Dr. Eileen Bridges: Welcome to our CMPA Webinar on virtual care. The first in a two-part series.
But before we begin, we would like to acknowledge the CMPA offices, located in Ottawa, are on the unceded, unsurrendered territory of the Anishinaabe Algonquin Nation, whose presence here reaches back to time immemorial.
We honor and pay our respect to these lands, to all First Nations, Inuit and Métis Peoples throughout Turtle Island.
I'm Eileen Bridges, a senior physician advisor at the CMPA in Safe Medical Care - Learning.
Dr. Cheryl Hunchak: And I'm Cheryl Hunchak, also a physician advisor in the CMPA Safe Medical Care - Learning.
Dr. Bridges: Both Cheryl and myself are paid employees of the CMPA, and otherwise we have nothing else to disclose.
Here are the steps we take to mitigate any potential bias in these webinars.
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Mitigating Potential Bias:
- The Scientific Planning Committee (SPC) is comprised of Physician Advisors who are employees of the CMPA; its composition is common for all of the CMPA's Practice Improvement workshops or courses.
- The SPC has a process in place to manage identified conflicts of interests:
- All SPC members have completed and signed conflict of interest (COI) disclosure forms.
- The SPC has reviewed all COI forms and indicated that none of the relationships disclosed pose a potential conflict of interest.
- The SPC was involved in the planning and development of the content of this program to ensure that the educational activity is evidence-based and has scientific validity, integrity, objectivity.
- The CMPA is a not-for-profit organization and this CPD activity has been developed without external support.
Dr. Hunchak: So, Eileen, the technology to provide virtual care has existed since the telephone was invented. But, for a variety of reasons, it's remained on the periphery of Canadian healthcare.
Until, of course, the COVID pandemic came along and literally changed that almost overnight.
[Content of on-screen slide, representing a cartoon where five people are sitting around a conference table in a high-rise building, and where one of them is saying “Digital transformation is years away. I don’t see our company having to change any time soon.”, while a wrecking ball with “COVID-19” written on it is swinging towards them]
Dr. Bridges: It's incredible, isn't it Cheryl, to look back and reflect on that.
Dr. Hunchak: It really is. You know, the medical community has been very agile in pivoting to the use of virtual care.
[Content of on-screen slide, representing an infographic taken from a Statistics Canada survey titled “Health care workers’ experiences providing virtual care during the COVID-19 pandemic”]
Image depicting a woman talking on the phone with her physician, with the mention “87% Phone” appearing underneath
Image depicting a woman sitting at a computer terminal and videochatting with her physician, with the mention “47% Video” appearing underneath
Image depicting a man texting over the phone with his physician, with the mention “26% Text/email” appearing underneath
Dr. Bridges: Well, you know what, not everyone has necessarily felt that agile. Change is really hard and some members have shared with us that they've struggled with this transition.
Dr. Hunchak: It definitely is not all easy and it's still very much in transition.
Let's talk about the kinds of virtual care that are currently in use.
The majority of our members have told us that they're using the phone more often than video and messaging modalities to provide care.
Telephone-based care isn't new, but we are using it more often and for more aspects of care these days and that has been an agile way of providing care.
Dr. Bridges: So, in this webinar, we're going to describe physicians obligations related to virtual care.
We're also going to identify some common medico-legal considerations relating to virtual care and then we'll talk about documentation and communication best practice tips.
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What is virtual care?
Telehealth
Remote care
Telemedicine
E-health
Virtual Care
Digital health
Dr. Bridges: So, when we think about it, virtual care, very broadly speaking, is simply the provision of medical care using technology with the provider physically separate from the patient.
There are a number of related terms used to describe what we're talking about here today.
All of these terms, shown here on this slide, are considered to be virtual care.
However, two things that we're not going to address today include remuneration models for virtual care and advice regarding specific platform choices.
If you do have questions relating to these topics, organizations like the Canadian Medical Association or your provincial medical association are best equipped to help answer these questions.
Dr. Hunchak: We also know that many members have questions about licensure regarding when patients may be located in a different province and other related scenarios, and there's a lot to cover around virtual care, to be sure, so that's why this is a two-part series and those types of questions will be addressed in part two.
Dr. Bridges: There's so much to cover.
Dr. Hunchak: This webinar today will review foundational considerations for physicians when providing various forms of virtual care.
Some will apply more to a video-type platform and others will apply whether you're using the phone, video or email communications.
Dr. Bridges: So, these considerations include what the standard of care is and how it might be determined, the privacy issues that might arise because of it, the necessary consent discussions, some documentation pearls, as well as the concept of virtual side manner, for want of a better word, and some communication tips to help build this.
Dr. Hunchak: So first, Eileen, what is the standard of care when it comes to virtual care? It's a big question.
Dr. Bridges: It's a great question, Cheryl, and, remember, it's not the CMPA's role to set standards of care and, therefore, these comments that we're going to make are based on expectations set by Colleges and the courts.
Dr. Hunchak: Absolutely, yeah, thanks for clarifying that.
So, we're going to move into a case example to illustrate this.
So, Dr. Swift, an internist, had been following an 80-year-old female with various comorbidities for years. The patient phoned Dr. Swift and expressed concern about a persistent cough which had recently worsened.
She requested to see Dr. Swift in person, but he declined, explaining there were no staff scheduled to work at his clinic that day.
Instead, he ordered a chest X-ray for her and advised her to go to the emergency department if her condition did not improve by the end of the week.
The patient, in the end, complied with the chest X-ray, but her daughter later complained to the College stating that Dr. Swift was dismissive of her mother's concerns.
Dr. Bridges: You know, these are really unfortunate situations for everybody involved, Cheryl. So, what do you think? How might the colleges generally view this?
Dr. Hunchak: Let's return to Dr. Swift, after reviewing some standard of care considerations that will help inform this.
So, to state the obvious, virtual care cannot completely replace face-to-face encounters. We need to use our clinical judgment to determine when a patient needs to be booked for an in-person assessment.
Dr. Bridges: Right.
Dr. Hunchak: Physicians are ultimately responsible for determining the appropriateness of providing virtual care in the circumstances, and it's important to remember that the standard of care must always be met.
Again, that's a standard by the College.
There are many patients for whom the standard of care cannot be met in a solely virtual care environment.
Dr. Bridges: Yes. Colleges and courts expect that physicians will meet the standards of care, regardless of whether care is provided virtually or in person.
So, clinical judgment on a case-to-case basis is crucial.
And while the Colleges acknowledge that the last few years have been unprecedented, it's still essential to consider just how appropriate virtual care is to give... to assess a given patient or a presenting complaint.
Dr. Hunchak: If you're wondering when it may be appropriate to offer virtual care, it can be helpful to remember the general standard of care that we're all held to, which is what a reasonable physician would have done in similar circumstances.
Reasonable care is actually determined by peer experts. It means you don't necessarily have to have gotten a diagnosis right, for instance, but that your clinical decision should be based on a sound reasoning process that considers the conflicting priorities and always keeps the patient's best interest in mind.
Dr. Bridges: Right.
Dr. Hunchak: In the virtual context, this means asking yourself whether you're able to obtain the necessary information required to make a reasonable clinical decision.
Dr. Bridges: So, Cheryl, how do you know after the fact if your care was reasonable?
Dr. Hunchak: Right, well, your documentation of the care including the information you gathered and the factors you considered to arrive at your clinical decisions are evidence of your reasoning and essentially are your intellectual footprint in the medical record.
This is what peer experts will review and base their decisions on.
Dr. Bridges: It's really not easy to navigate virtual care in such a rapidly changing environment.
So, to help you, there are some published guidelines on which clinical problems can be safely assessed using virtual care, especially by videoconferencing since this is a relatively newer tool than the telephone.
In particular, we'd like to highlight the CMA Virtual Care Playbook, which is available open access, online, to help guide physicians across Canada.
It covers key practical areas, including how to fit virtual care into your practice, workflow, and your technical requirements. It's been endorsed by the CMA, the CFPC and the Royal College, so it's an excellent place to start.
Dr. Hunchak: Yeah. Additionally, all physicians need to be familiar with their own province or territory's College policies regarding virtual care, as well as guidelines specific to your own clinical practice with respect to what can be safely assessed virtually.
So, here is a list of specific College policies for virtual care depending on your province or territory of practice.
Bottom line, there is one where you practice, so just be sure to familiarize yourself with it if you haven't already.
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College Guidelines and Standards
CPSBC, Virtual Care Practice Standard
CPSA, Virtual Care Standard of Practice
CPSS, Policy on Practice of Telemedicine
CPSM, Standard of Practice on Virtual Medicine
CPSO, Policy on Virtual Care
CMQ, Guide d’exercice : Le médecin, la télémédecine et les technologies de l’information et de la communication
CPSNB, Guidelines on Virtual Medicine
CPSNS, Professional Standards Regarding Virtual Care
CPSNL, Standard of Practice: Virtual Care
YMC, Standard: Telemedicine (Virtual Care)
Dr. Bridges: All right. So, let's look at another case, for an example here.
A family physician provides virtual care over the phone for a seven-year-old male. He's accompanied by his parents, and the parents explain that the boy has a tender left wrist after he fell on his outstretched hand while running in the park yesterday.
Yeah, your typical FOOSH.
So, we need to understand the limitations of the tools that we and our patients are using before we can reach a decision about the appropriateness of providing virtual care in this instance, right.
So, for this pediatric patient with a tender wrist, the physician needs to consider whether they will be able to gather the necessary information to assess the degree of injury over the telephone.
Dr. Hunchak: In other instances, some presenting complaints may be assessed by photo submission.
So, for skin lesions, which is a very common presentation, you may wish to consider the quality of photos submitted and whether you have all the necessary angles captured, for instance, to arrive at a reasonable clinical decision.
You may also consider whether the photos that a patient provides to you are timely depending on the nature of the concern.
With respect to photo submission compared to video conferencing in real time, sometimes photos submitted in advance via secure messaging provide a resolution that is much better than the resolution of even a high-quality webcam.
In these two common examples, and of course there are many more, the quality of the information obtained in a virtual care encounter depends on the equipment itself, the virtual modality being used, as well as the clinical circumstances.
Dr. Bridges: Yeah, so many things it depends on.
Dr. Hunchak: Yeah. With the limitations of technology, you may not be able to physically examine patients, of course, as you otherwise normally would.
This is generally true for phone encounters, which do represent the vast majority of virtual care in Canada at present, and also a key consideration for video encounters, depending again on the patient and the presenting complaint.
The CMA Virtual Care Playbook suggests that the scope of virtual practice with video conferencing is presently limited to encounters that require only history, gross inspection, and/or data that patients can gather with cameras and common home devices like glucometers, home blood pressure machines, thermometers and things like scales.
For telephone encounters, this scope can be further limited by the lack of ability to visualize your patients.
Dr. Bridges: So, it's also important to note, Cheryl, you know, that as we may have experienced during the pandemic, the requirements for a physical exam can sometimes be waved, you know, if it's truly in the best interest of the patient, such as during a pandemic, contagious disease outbreak, or when the patient has had a temporary loss of mobility, limited mobility, or lack of transportation.
But ultimately, it's about using our clinical judgment and weighing the best risks and benefits of the decisions that we're going to make, and communicating the decision clearly to our patients and documenting, you know, when relevant, right?
Dr. Hunchak: So, what should we do if we determine that virtual care cannot facilitate the provision of adequate care or the level of exam that the patient requires?
Dr. Bridges: As with other clinical situations that we're used to, we need to have a plan B or this corridor of care when providing virtual care.
This means if you are unable to see a patient in person but think they need to be seen in person, then you should have some kind of alternative plan to refer them to a place you know or someone else who can see the patient in a timely manner.
Dr. Hunchak: Yes, and ideally this should not be the local emergency department for non-emergent concerns, as this can contribute to ED overcrowding.
Depending on where you work, this may be unavoidable, but it would be advisable to proactively establish local care networks that can accommodate patients in need of non-emergent inpatient… in-person care without relying on the nearest emergency department.
Dr. Bridges: And, in fact, many colleges have stated just this, that except in cases involving a true emergency, physicians should refrain from referring patients to emergency departments as a de facto backup to virtual care or as a replacement for in-person appointments.
And if you haven't already established this, think about what your patients’ corridor of care will be when providing virtual care visits, and take steps to ensure these are in place when you and your patients need them.
Dr. Hunchak: Let's return for a moment to our first case. You'll recall the case of Dr. Swift who received a College complaint from his 80-year-old patient's daughter after he declined to see her in person for a worsening cough.
When the patient phoned Dr. Swift and expressed concern her cough had… about her cough and had requested an in-person visit, he had explained that no staff were scheduled to work that day.
After that, he had ordered a chest X-ray and asked her to seek care in the emergency department if her condition did not improve before the end of the week.
You can likely now appreciate there are a few important considerations here, including whether the College may view Dr. Swift as having met the standard of care in addressing her cough.
Generally speaking, Dr. Swift is responsible for ensuring he's familiar with the College policies in his province or territory regarding virtual care, and for providing reasonable care in accordance with these policies.
We truly can't overemphasize the importance of being familiar with these.
Dr. Bridges: Yeah, the policies, isn't it? And that's right, you know, and the second consideration is that the patient's right to request an in-person visit and at the very least to understand Dr. Swift's clinical decision regarding whether a virtual or in-person visit is felt to be the most appropriate for the clinical concern that's described.
We don't know what Dr. Swift documented in his record and we will review the documentation tips for virtual care encounter shortly, we'll get to that, but it would be important for Dr. Swift to inquire about the reasons for the patient’s request for an in-person visit, to explain his next availability for an in-person patient care, and to discuss reasonable options for obtaining care under these particular circumstances.
And this conversation should then be documented in the record, including the advice he provided, the plan that followed, and the rationales for his plan.
Having these conversations and documenting them in the record promotes patient safety for his patient with the worsening cough, and explains the rationale for his care and decisions should, you know, his care ever be called into question and a College complaint be filed.
Dr. Hunchak: Exactly! Finally, if Dr. Swift was unable to assess his patient in person, in a timely fashion, and felt this was required, referring the patient within his established corridor of care rather than to the emergency department, if he felt it was non-emergent, would be in the patient's best interest.
Dr. Bridges: Great summary. Thank you so much for highlighting all these points for us.
OK. So, so far, we've discussed considerations regarding the appropriateness of virtual care when it comes to the need for physical examination. Now, let's talk about another limitation of technology that we need to consider, and that's our ability to communicate effectively with these modalities.
Dr. Hunchak: Yeah. Great point. Virtual care can eliminate some or nearly all of the non-verbal cues we may use to help confirm understanding or satisfaction with an encounter.
This may require extra effort and explicit verbal communication to fill in those gaps of the non-verbal nuances that we lose in virtual care.
Dr. Bridges: And that may make information gathering and delivering that much more important in these circumstances.
While the clinical medicine is always the same, the virtual encounter may require more effort and attention paid to certain aspects of our assessment, for instance, the pertinent positives and negatives.
Our differential diagnosis and management plans are only as good as the information we solicit and receive.
So, just as in face-to-face encounters, it's prudent to consider whether we've gathered all the information necessary to arrive at a reasonable differential diagnosis and plan.
So, here's some tips to help improve your communication during virtual care encounters, and these are when using a video platform, and some of these are going to sound really obvious but being intentional about them makes a huge difference.
Dr. Hunchak: It really does. So, you'll want to confirm that patients can adequately see and hear you, and you'll want to speak slowly. And this would apply to phone encounters as well as video encounters.
Ask questions and allow time for patients to ask theirs. And it's quite easy to inadvertently speak over one another and interrupt each other without the visual cues that we're all usually used to.
Certainly, we've had that experience in virtual meetings in the past.
Dr. Bridges: It can definitely be a bit chaotic at times. So it's important not to make certain assumptions, especially when providing care over the phone.
Now, we're talking about phone, a little bit.
Assessments will be inherently missing key pieces from the physical exam and from all the non-verbal information that we instinctively pick up on without unconsciously even thinking about it during face-to-face encounters.
Dr. Hunchak: For video-based care, make sure you place your web camera at eye level and look at it to simulate eye contact as much as possible.
If you're using a separate webcam, which is recommended, position it so that the camera is directly above your patient's video image.
It helps to really exaggerate non-verbal cues to some degree like nodding and facial expressions and, where relevant, clearly explain and demonstrate how you would like patients to do certain physical maneuvers to help with the assessment.
You can really see how this may require some extra patience and will be easier in some circumstances than in others.
Dr. Bridges: Absolutely. The last, and last but not least, of the challenges we're talking about today is ensuring privacy.
Privacy and security are major considerations, and we could spend a few webinars just talking about this, so, we'll stick to the basics for now, today, Cheryl.
Firstly, we need to ensure that patient health information cannot be intercepted by a third party.
This is most relevant obviously for video and electronic forms of virtual care, but it's also a consideration for phone interactions depending on the background environment.
For video conferencing and electronic messaging systems, platform encryption is important.
Do you want to explain just a little bit about that, Cheryl?
Dr. Hunchak: Sure, I mean, simply put, encryption means that the information is scrambled and it's indecipherable for anyone who doesn't have the access key.
Text messages, emails, photos, shared files, etc. relating to patient care are all considered part of the medical record and should be protected with encryption.
Although the CMPA does not advise physicians which specific virtual platform to use, many provincial or territorial medical associations, Colleges or health authorities have come out with recommendations about which platforms they deem ideal for use.
Generally speaking, the safest virtual platforms are ones created for medical use in Canada.
So, you'll want to inquire whether the data captured can be used by a third party and whether there is end-to-end encryption present. This means that the platform company cannot access the content of your virtual care visits to mine the data for non-healthcare purposes.
Experts stress that some consumer video conferencing platforms may not offer those features.
Consider also where the information gets stored and, again, whether it remains in Canada or elsewhere. You should be aware of your provincial and territorial privacy legislation, as well as the College's policy on how personal health information must be managed and protected.
Dr. Bridges: That's a lot of information.
Dr. Hunchak: It is, yeah.
Dr. Bridges: Once you're satisfied with the platform that you're using, consider the privacy of the space your patient is in during a visit.
Ask your patients who's with them or near them and what's going on in their environment. Consider “Hey, who may be listening in or watching?” And knowing this may help tailor your encounter accordingly.
And consider any possible limitations due to lack of patient privacy.
It's also important to ask your patient to confirm where they're physically located, so you know where to send help in case of an emergency.
It happens more often than people think, right?
More commonly, it's important to confirm that they're located in Canada, in the jurisdiction in which you have licensure, and we're going to talk more about this in part two of our video webinar series.
Dr. Hunchak: OK, so that all makes sense, but what do we do when patients think that taking our virtual care call in a coffee shop or on a busy bus is a good idea?
Dr. Bridges: Yeah, we've heard that from members a lot. This can be a real challenge.
So, consider advising patients that this is not ideal and why it's not ideal.
Sometimes, they may not realize that this is not in their best interest or even safe.
For example, you may not be able to gather the necessary information you need to provide reasonable care, if patients are worried about strangers, or family members, who may be listening in to the conversation.
And this may impact your clinical evaluation, which could lead to serious consequences for the patient.
Advise patients of these risks and remember, if, in your judgment, you feel you cannot complete an adequate assessment, you may request that the patient attend an in-person assessment or reschedule the appointment for when they're in a private environment.
Dr. Hunchak: Also, for our part, it's important to protect patient privacy by holding virtual care encounters in a location where family members or others in our environment can't overhear or oversee the encounter.
This does actually also include ensuring that there are privacy screens on your windows, where relevant.
And sometimes we actually may protect… forget to protect ourselves, as well.
Dr. Bridges: Yeah. We're aware of members who have experienced medico-legal problems because they were not careful about protecting their own privacy during virtual care video encounters.
Here's some tips to safeguard against this.
So, first, blur your background or use a virtual background for video encounters. It's advisable to avoid disclosing personal photos or personal details about your home environment, and don't give out your personal email, phone numbers, or address.
Now, for telephone encounters, ensure that your personal phone number is blocked. And, in these instances, it can be helpful to alert patients ahead of time to expect a call from a blocked number during their virtual care appointment time.
Dr. Hunchak: Thanks, Eileen. Yeah, those are definitely easy, practical ideas to put into practice, especially for members who may not have… have conducted virtual care before.
Dr. Bridges: Absolutely. Now, let's talk about a patient who we've asked to come in for a face-to-face encounter, but they refuse to come, and they want to have their appointment virtually, instead.
Dr. Hunchak: Yes. We have also spoken with members about this issue.
Commonly, patients who have been receiving virtual care may decline to come in for an in-person assessment, and, sometimes, this can create an issue for the treating physician, depending on the clinical circumstances.
Dr. Bridges: Absolutely. I think it's so important to take the time to explore the underlying issues, you know, that's a good starting point, right?
Perhaps there's a misunderstanding that can be addressed.
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Benefits and challenges are relative…
- Safety
- Access
- Engagement
- Convenience
- Resource allocation
- Confidentiality
- Jurisdiction
- Regulation
Dr. Hunchak: Yes, and it's helpful to keep in mind that the benefits and challenges of virtual care are relative depending on the patient's and the physician's circumstances.
So, for example, some patients with disabilities have experienced improved access to care because they don't have to travel to see their physician.
Virtual care does have many benefits and certainly these are not limited to only a pandemic setting.
Most colleges recognize that virtual care may improve access to care, especially for patients in remote and underserviced areas, for patients with disabilities, for patients in institutional settings, and for patients who have limited psychosocial supports or economic means to travel to their care.
Dr. Bridges: Exactly, right? So, consider exploring the underlying causes and clearly explain the risk associated with not receiving in-person care, and what aspects of in-person care you believe to be in their best interests.
It could be that our patient's embarrassed, right, to tell you that he can't pay for a taxi to come and see you at the clinic, or he's got kids at home and nobody to babysit.
Dr. Hunchak: Yes, that could be the case. However, if in your judgment you feel you do need to see the patient in person to perform an adequate assessment, you have a duty to inform them of their health condition, the risks and benefits of the treatment, and the possible outcomes of refusing in-person care.
Then, physicians should document the patient’s refusal and the information provided to them in the medical record in a factual and objective manner.
And this actually leads nicely into our next subject, which is that of consent.
Dr. Bridges: OK. Consent for virtual encounters isn't implied by simply participating in the encounter. It does need to be explicitly explored and obtained.
And, so, one helpful way to educate patients about virtual care is to direct them to a website or a document with a clear explanation of the benefits, limitations and the risks of these virtual visits.
The open access CMA Virtual Care Guide for Patients is available online and it's one option for you to use, to present to your patients.
However, it's also not enough to simply refer them to a website, right, Cheryl?
Dr. Hunchak: Right, yeah, absolutely. Consent does need to be explicit, and some colleges impose or recommend additional consent requirements for virtual care. Other colleges expect physicians to explain the limitations of virtual care services, and any extra risk that may arise from that.
Some colleges require a process to verify the identity of the patient or the physician, or both, and this underscores the importance of being familiar with the College policies for virtual care in your own province or territory.
Generally speaking, there are three main topics to be discussed.
So, first, consent should be obtained after disclosing the known risks and limitations of a virtual visit. Your patient should understand that their medical issue may not be manageable by virtual care and they may be asked to be assessed in person or, again, that there may be limits to what advice you can provide.
Second, patients should be advised about reasonable, available alternatives for care when it's relevant.
And, thirdly, patients must be advised about the privacy and security risks that we've outlined that exist with the use of electronic platforms for care.
Dr. Bridges: So, Cheryl, I can hear our members saying this right now: “If I work in a clinic or a hospital and use a virtual care platform that's provided by my provincial government or the institution that I'm working in, could I, as a physician, be held accountable for something that I have no control over if there were a privacy breach?"
Dr. Hunchak: Yeah, it's a great question and, generally, physicians may rely on the systems provided to them by an employer, an institution, a clinic or a hospital.
But, that being said, it's also possible, it is possible that in the event a patient commences a legal proceeding alleging harm suffered as a result of a privacy breach, all those involved, including physicians relying on that virtual care platform, could potentially be named as defendants.
Dr. Bridges: All right. So, overall, as a physician user of electronic platforms that you did… you didn't personally select for virtual care, it's a good idea to identify and communicate any privacy concerns that you may have about your systems, if you suspect or know about them.
And even better to put your concerns in writing to your institutional leaders so that you can demonstrate your diligence, if required.
Dr. Hunchak: Yeah, great point. And, in fact, most facilities have designated privacy officers whose very job it is to solicit and address these.
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Verbal disclosure for virtual care
Virtual care has some privacy and security risks that could allow your health information to be intercepted or unintentionally disclosed. We want to make sure you understand this before we proceed.
In order to improve privacy and confidentiality, you should be in a private setting and should not use an employer’s or someone else’s computer/device as they may be able to access your information.
If you want more information, please [ask and/or check the link on our website/confirmation email, etc.]. If we determine during the visit that you require a physical exam you will need to be assessed in person. You should also understand that virtual care is not a substitute for attending the emergency department if urgent care is needed.
Are you OK to continue?
Dr. Bridges: So, here's an example of a verbal disclosure suggested by the Doctors of BC for a virtual care encounter in a consulting practice.
This can be used to obtain verbal consent at the beginning of a consult, and it's prudent to document the consent conversation you had with your patient in the medical record.
Clinics and hospitals usually also have their own consent forms that they use.
[Content of on-screen slide]
CMPA Consent Form
- Covers video, audio and messaging communication
- Suitable for continuing care practice
CONSENT TO USE VIRTUAL CARE TOOLS
This template is intended as a basis for an informed discussion. If used, physicians should adapt it to meet the particular circumstances in which virtual care tools will be used with a patient.
Consideration of jurisdictional legislation and regulation is strongly encouraged.
PHYSICIAN INFORMATION:
Name: click here
Address:
Email (if applicable):
Phone (as required for Service(s)):
Website (if applicable):
The Physician has offered to provide the following means of virtual care (“the Services”):
(Yes/No) Email
(Yes/No) Videoconferencing
(Yes/No) Text messaging (including instant messaging)
(Yes/No) Website/Portal
(Yes/No) Social media (specify):
(Yes/No) Other (specify):
PATIENT ACKNOWLEDGMENT AND AGREEMENT: I acknowledge that I have read and fully understand the risks, limitations, conditions of use, and instructions for use of the selected Services more fully described in the Appendix to this consent form. I understand and accept the risks outlined in the Appendix to this consent form, associated with the use of the Services when interacting with the Physician and the Physician’s staff. I consent to the conditions and will follow the instructions outlined in the Appendix, as well as any other conditions that the Physician may impose in relation to patients using the Services.
I acknowledge and understand that despite recommendations that encryption software be used as a security mechanism for virtual care tools, it is possible that interacting with the Physician or the Physician’s staff using the Services may not be encrypted. Despite this, I agree to interact with the Physician or the Physician’s staff using these Services with a full understanding of the risk.
I acknowledge that either I or the Physician may, at any time, withdraw the option of using the Services upon providing written notice. Any questions I had have been answered.
Patient name:
Patient address:
Patient home phone:
Patient mobile phone:
Patient email (if applicable):
Other account information required to interact via the Services (if applicable):
Patient signature:
Date:
Witness signature:
Date:
Dr. Hunchak: Yes, and here's another example.
This one is a PDF form available, open access, on the CMPA website.
It can be used for either video, audio and electronic messaging communications in virtual care.
And we have heard from members that they have found this useful and adaptable.
Dr. Bridges: All right. So, let's just clarify something and make sure we all understand: Are physicians expected to obtain consent every time they conduct a virtual visit?
Dr. Hunchak: That is the best way to minimize risk, yes.
Dr. Bridges: So, document patient consent for virtual care each and every time they see a patient? Or can physicians just, you know, obtain consent the first time round?
Dr. Hunchak: Well, ideally, you do want to obtain consent every time, and that's because the issues may differ from visit to visit. And, therefore, the privacy concerns for one type of problem may be more acceptable to a patient than they may be for another.
That's really the root of it.
Dr. Bridges: Right. I guess people forget, people change, circumstances change. Maybe they were okay talking about a runny nose today, but not about their sexual history tomorrow.
Dr. Hunchak: Exactly, yeah. And the good news is that some elements of consent can also be delegated. So you, as the physician, don't necessarily have to obtain consent yourself every single time.
Dr. Bridges: Yeah. You can delegate the first step of consent to someone working with you. So, your nurse working with you, your medical office assistant or a clinic for… a clerk for instance, right, as long as you're confident that the delegate has enough knowledge to explain things well, and to address any questions that the patient has, and then you can do this.
Written consent is ideal when possible, especially for longitudinal relationships, but documenting a patient's verbal consent can also suffice.
So, let's now review some documentation considerations specific to the virtual care environment.
Dr. Hunchak: OK. So, first, be sure to document how you identified the patient during the encounter.
This can be as simple as asking them to hold up their health card to the camera, in the case of a video visit.
Or, with telephone visits, asking them to provide you with their address or date of birth to correlate with the information you have on file. It's the same as being authenticated by a credit card company, really, and quite important to do each time for virtual care.
Dr. Bridges: Good point. With longitudinal patient relationships, this may feel a bit unnatural at first, but without the in-person setting, it's really an important practice to develop.
You'll also want to consider documenting any other individuals present during the encounter.
Now, second thing, is to be sure to document how you obtain that patient consent.
As discussed before, patients may not appreciate the limitations of virtual care and how they impact their care. And the alternatives that may be available to them. And all these relevant privacy considerations that we discussed.
You may also want to include the format of the virtual session, whether it was completed by phone, email or a video platform.
Dr. Hunchak: After that, consider documenting how you obtained the information used to formulate your diagnosis and plan.
So, for instance, did your patient take their own temperature? What was the source of that information? Did you look at a skin… a skin lesion via webcam or high-resolution photo? Was the assessment conducted through an intermediary? Like, for instance, a caregiver for patients with, for instance, a hearing impairment.
Your assessment will be supported by documenting how you verified pertinent negatives and positives.
Dr. Bridges: Additionally, documenting what other diagnostic possibilities were considered will frame your virtual clinic assessment, and help you demonstrate that your decision-making was reasonable under the circumstances.
Dr. Hunchak: Yeah, that's a good idea.
If you're watchful waiting rather than immediately arranging for a physical exam, an investigation or a therapeutic trial, document your clinical reasoning for this in the record.
It'll help explain your decision-making, as we've discussed, for everyone in the circle of care or if your care is ever later called into question.
Dr. Bridges: So, next, document the specific follow-up instructions that you provided to your patient.
Documenting this information in the medical record would not only help with the continuity of care, but will also help demonstrate that your follow-up plan was reasonable under the circumstances.
Dr. Hunchak: Yes. Documenting your follow-up plan is always important in day-to-day practice, but there are some additional considerations here.
So, therapeutic plans and follow-ups may require more details to be included, including using clear communication when you're talking on the phone or on camera, again, because of that lack of non-verbal feedback we're used to, and because our physical exam may have been limited.
Documenting these conversations may help clarify any potential misunderstandings about follow-up plans, as relevant.
Dr. Bridges: Now, it may be the case that you want to see the patient in person next week and not on the phone, and this can be confusing to some patients, as well.
How many times has a person shown up for an in-patient visit virtually and vice versa, right?
Dr. Hunchak: It definitely happens, yeah. So, here's some things that you can consider.
Have you provided a list of warning symptoms to prompt a call to your clinic or a visit to the emergency department?
Do you have a means to share your written discharge instructions with the patient or, for instance, a lab requisition? For example, messages via a secure portal in your EMR could be sent one way to their email address.
How are you sending information to their family physician, if you're not the family physician, to ensure continuity of care?
And have you specifically outlined how and where to seek additional care if their clinical status changes? And whether or not, as we touched on, whether that’s in person or virtual.
Finally, do you have patient care handouts or information sheets that your patients can access online or be sent electronically?
Dr. Bridges: OK. Let's switch gears a little bit now, and talk a bit about phone consults, right, or virtual consults.
When we're discussing with consultants, what should we document, right?
Dr. Hunchak: Right. So, when speaking to consultants over the phone, you'll want to document the time of call, who you spoke with, what information you provided, the advice received, and whether there was any patient safety concerns that were brought up.
It's also important to document the efforts you made to contact consultants and follow-up providers, or to arrange patient transfers, particularly when there may be a perceived or anticipated delay.
Remember that whether these communications take place by text, email, telephone or other electronic means, these are all considered part of the medical record and do need to be included.
This also applies to photos and other images or recordings that patients send in as part of their assessments.
Dr. Bridges: A lot of us have ordered... offered virtual care by now, either by phone or video, so let's cover some additional tips to help your virtual encounter go as smoothly as possible.
Dr. Hunchak: Right. So, here's some additional pearls from a systematic review that was published this year by Canadian researchers.
They reviewed 60 different guidelines for virtual care encounters. Shows you how much is out there, and you can scan this QR code to directly access the paper.
Dr. Bridges: There are really practical and helpful tips in this paper.
So, providing a checklist to the patient before an encounter can save a lot of time and help them prepare for the visit, especially considering that everyone's familiarity with the computer technology differs.
I don't know about your experience, but for some reason, there always seems to be something to fix before going online.
Dr. Hunchak: Yeah, that's true. Communicating a clear plan in case of technology failures, such as if a phone line drops or the video call stops, is important to stop you from scrambling and ensure that the patient receives the care they need.
Dr. Bridges: Another timesaver is to collect or create patient education texts and web links to share during or after the encounter, to replace what you might have previously shown patients in the office.
This can be a very helpful adjunct to the care provided during the visit.
Dr. Hunchak: You may also want to consider explaining to patients why you need to break eye contact during the encounter.
So, you might say something like acknowledging that you have two screens open and you may need to look away, because you're reading their record or looking up a guideline.
It's also helpful to explain why you're clicking and typing. It can be very distracting for patients and, again, you can say something like “You may hear me typing as I listen to you, I'm taking notes because I want to make sure I record everything accurately.”
Dr. Bridges: All right. So, in conclusion, be mindful of the limitations of virtual care.
Everyone's practice is unique, so we must consider what problems we can safely assess and treat virtually and which ones we can't.
If the patient's condition is non-amenable to being addressed virtually, consider booking them for an in-person assessment either with you, a colleague or, if they require emergent care, to the emergency department.
Communicate to your patients your rationale for which format of care is most appropriate for their condition.
And remember that the general expectation is that physicians meet the standard of care, regardless of whether the care is delivered virtually or in person.
Offering our patients care tailored to their circumstances will optimize patient safety and minimize risk.
Dr. Hunchak: As with all assessments, focus on your communication.
So, in virtual care encounters, be especially deliberate to help overcome those inherent lack of non-verbal cues and to optimize patient understanding. This will help clarify your patients' concerns and expectations, and avoid miscommunications.
Dr. Bridges: Our documentation is what will help communicate the rationale for our care to others and provide evidence that our care was reasonable under the circumstances.
So, some key areas to capture in the record relating to the virtual care include your patients consent to receive virtual care.
Consider documenting sources of data points, like home blood pressure machine readings, photos of lesions sent by patients, and how relevant elements of a physical exam were accomplished when possible.
And, finally, document a clear follow-up plan in your note. Consider how you will communicate blood and imaging requisitions to your patients and whether you'll make electronic references, like materials and handouts, available to them.
Dr. Hunchak: That pretty much rounds up the core essentials of providing a safe and effective virtual care, Eileen.
At this point, we're going to ask everyone watching to reflect on what your main takeaway is from this session today.
What's something you plan to put into practice or perhaps refine during your next virtual care encounter? So, just take a moment now, write it down for yourself and make a commitment to it.
We'd also like to remind you again that we will be following up this webinar with a virtual care, part two, session to address additional considerations in the new year.
Dr. Bridges: And thank you all for the incredible work you do on a day-to-day basis.
The last few years have been hard, and we continue to be challenged in many new and enduring ways.
Your work is vital, impactful and we're here to support you with educational content like this webinar and many other open access and accredited offerings, as well as one-on-one tailored advice when you need it.
So, here's some of those offerings and how to reach us, and thank you so much for joining us today.
