New Virtual Care Policy Approved by the College of Physicians and Surgeons of Ontario
Introduction
The COVID-19 pandemic has drastically transformed the delivery of healthcare. In recognition of these changes, the College of Physicians and Surgeons of Ontario (“CPSO”) recently drafted a new Virtual Care policy (“Policy”), with an accompanying Advice to the Profession document ("Advice document”). After receiving feedback from consultation and engagement activities, the CPSO revised the draft policy. It was granted final approval and came into effect in June 2022.
The Policy replaces the previous Telemedicine policy and provides expectations and guidance for physicians to promote the delivery of high-quality virtual health care. The Policy has introduced several significant changes to physicians’ obligations with respect to the delivery of virtual care. The new guidelines clarify when virtual care is appropriate, what disclosure of information is required during a first virtual encounter, the appropriate technology and setting for virtual care, and consent and confidentiality requirements, among other additions. It is important that those providing virtual care review their requirements under the Policy to ensure compliance.
A Need for Change
The previous Telemedicine policy was first approved by the CPSO in 2007 and was last revised in 2014. It provided physicians with general expectations, including how to decide when telemedicine is appropriate, the types of care that can be provided at a distance, the quality of care required, privacy and confidentiality requirements, as well as guidelines for practicing across borders.
As we all know, the COVID-19 pandemic prompted a pronounced change to the healthcare landscape. While virtual care was in many cases the only option, as many patients became accustomed to accessing their physicians virtually, it was apparent that virtual care could promote accessibility, convenience, and safety. However, the swift shift to virtual care posed new challenges that the Telemedicine policy was not designed to address.
After extensive research, consultations, and discussions with physicians and patients, the draft Policy and Advice document were developed and approved for external consultation in September 2021. Key stakeholders and internal CPSO groups were consulted, such as the Canadian Medical Protective Association (CMPA), Ontario Health, and the Inquiries Complaints and Reports Committee. Despite the issues raised, there was widespread support for the new Policy. Nearly 400 feedback responses, mainly from physicians, were received and considered during the revision stage. Virtual care was praised for its accessibility and convenience, while at the same time concerns were raised regarding the inappropriate prioritization of virtual care over in-person care and the proliferation of virtual walk-in clinics and inadequate virtual care more broadly. The aim of the updated Policy is to mitigate these challenges and enhance the delivery of virtual care.
The Virtual Care Policy
Virtual care is described as “any interaction between patients and/or members of their circle of care that occurs remotely, using any form of communication or information technology, including telephone, video conferencing, and digital messaging (e.g., secure messaging, emails, and text messaging) with the aim of facilitating or providing patient care.” This means that virtual care comprises of all medical services to patients (e.g., assessing, diagnosing, giving advice, teleradiology, telemonitoring, etc.) as well as inter-professional and intra-professional consultations (i.e., remote consultations between providers).
Under the Policy, physicians providing virtual care are required to meet the same standard of care, competency, and the existing legal and professional obligations as in-person care. Virtual care is to be centered around patients’ best interests and physicians are required to be mindful of the limitations of virtual care.
During the development and revision stages of the Policy, important factors were taken into consideration. For example, requiring in-person services could inadvertently lead to the limitation of virtual services in areas that are already experiencing access issues. On the other hand, accessing in-person services could become inaccessible to some patients as a result of the virtual-first approach and resistance from some physicians to return to in-person care.
Th new requirements introduced by the Policy are noted below. It is vital that health care providers promptly adjust the delivery of their services, if needed, to ensure compliance with the new requirements.
A. Patients’ Best Interest, Standard of Care and Limitations of Virtual Care
Patient preference for in-person or virtual care should be accommodated where appropriate. Physicians are ultimately responsible for making a final decision that will best serve the patient’s interest. A variety of factors must be considered when making a decision.
Virtual care is meant to complement, not replace, in-person care. Physicians are required to be mindful of the limitations of virtual care and must take appropriate action when it is determined that in-person care is required.
If during a virtual encounter the quality of care becomes compromised and a patient’s best interest is no longer respected, a physician must take appropriate action.
When the standard of care is difficult to meet in a virtual environment, physicians will generally be required to provide in-person care. Fully virtual practice might only be possible in limited circumstances.
The draft Advice document explains ways to meet the standard of care in a virtual environment, including continuing to obtain a relevant history, conducting appropriate examinations, ordering diagnostic tests, and making diagnoses and/or differential diagnoses, etc.
B. Establishing a Physician-Patient Relationship and Appropriate Setting and Technology
During virtual encounters, physicians and any other parties present are required to disclose their identity, contact information and licensure status (where they are licensed) to all new patients.
In cases where virtual interactions are synchronous, physicians must confirm that the physical setting where the patient is receiving virtual care is appropriate and safe in the circumstances. If it is not appropriate to proceed, alternative action, such as rescheduling, is required.
Virtual care can take a variety of forms including interactions by video, telephone or digital messaging. What is appropriate in terms of the patient’s setting is dependent on the nature and purpose of the interaction.
Physicians providing virtual care must use technology that is appropriate for care, can facilitate a quality encounter, and allows the standard of care to be met.
C. Confidentiality, Privacy and Security
All physicians must take reasonable steps to protect personal health information (PHI), including protection against theft, loss, and unauthorized access, use, and disclosure of PHI.
If using less secure technology (e.g., unencrypted platforms), physicians must obtain and document the patient’s express (i.e., verbal or written) consent to do so.
D. Informed Consent for Virtual Care
Consent must be obtained during the initial virtual encounter and each time the benefits, limitations, and potential risks change. Consent can be obtained by someone working on behalf of the physician and documentation of consent for virtual care is not required in every instance of virtual care.
E. Licensing Requirements and Care Across Borders
Where a physician is providing virtual care into another jurisdiction, they must comply with the requirements for licensure in that jurisdiction.
Physicians must ensure they have appropriate liability protection if they provide care into other jurisdictions.
Ontario physicians can provide necessary virtual care to Ontario patients even when one or the other is temporarily out of the province.
Physicians providing virtual care to Ontario patients located in Ontario must hold a valid and active certificate of registration with the CPSO, unless the provision of virtual care from a physician licensed elsewhere is in the patient’s best interest (e.g., care that is not readily available in Ontario).
Conclusion
The Policy and companion Advice document promote consistency, clarity and accountability for health care professionals facilitating virtual care. Physicians must seriously consider whether virtual or in-person care will better meet the needs and preferences of their patients. During virtual encounters, important steps must be taken to preserve the quality of care, such as acquiring patient consent, disclosing physician information, and protecting PHI. As more patients access health care from a distance, this Policy will be influential in guiding the delivery of virtual health care in Ontario.
With the Policy now in effect, it is crucial that health care professionals immediately comply with the new measures. For more information, assistance or advice regarding the new Policy or the Advice document, please contact us.