Safety of care
Telemedicine — Opportunities, challenges, and obligations
Originally published September 2013 / Revised March 2015
The digital revolution is profoundly changing how doctors and patients interact and the ways in which healthcare is delivered. Telemedicine has moved beyond the telephone and email, videoconferencing and web portals, and now includes a myriad of mobile apps for smartphones and tablets.
While telemedicine offers benefits for individual patients and is viewed by some governments as a way to improve access to care and control healthcare system costs, licensure and regulatory challenges continue to be perceived as barriers to achieving its full potential. Meanwhile, jurisdictional issues may complicate medico-legal matters for physicians.
Benefits and limitations
Telemedicine has been shown to help patients be more engaged in their health and enable better management of chronic diseases, resulting in fewer and shorter hospital stays, fewer emergency room visits, less severe illness, and fewer deaths.1
Telemedicine services are widely available in most Canadian provinces and territories. In Ontario, for example, the Telehomecare program provides remote monitoring and health coaching of patients with congestive heart failure and chronic obstructive pulmonary disease (COPD). Other examples include accepting cardiograms sent by patients to doctors via smartphone,2 and smartphones being used to capture and transmit blood pressure and lung function readings.
Existing legal, professional, and ethical obligations of practising medicine are not altered when telemedicine is used as opposed to in-person care. Medical regulatory authorities (Colleges) generally advise physicians to use their professional judgment to determine whether telemedicine is appropriate in a particular circumstance, and whether telemedicine will enable physicians to meet the standard of care. For example, prescribing opioids and medical marijuana via telemedicine might best be avoided in most cases when a physician’s ability to identify drug-seeking behaviour may be limited. The College of Physicians and Surgeons of British Columbia advises physicians in that province to “avoid completing a medical document for a patient to use medical marijuana by telemedicine.”3
Jurisdictional licensing and standards
In the absence of a national framework for telemedicine, the licensing requirements for physicians vary for each province and territory. Physicians should therefore be familiar with the requirements of each province and territory in which they practise and their patients reside. The issue over where the telemedicine encounter occurred may also be relevant in the event of a legal action.
The Colleges in British Columbia, Alberta, Manitoba, Saskatchewan, Ontario, Québec, New Brunswick, Nova Scotia, and Newfoundland and Labrador have published telemedicine bylaws or policies. Other Colleges may impose requirements that have not been formalized in a bylaw or policy. As well, legislative requirements are imposed by the Act Respecting Health Services and Social Services for physicians practising telemedicine in Québec.
Some physicians practising telemedicine might need to be licensed in both the jurisdiction in which they are located and the jurisdiction where the patient is located. Some Canadian jurisdictions may also require special registration, or they may place conditions on the provision of such services, or both.
As an example, a physician from outside of Alberta who provides telemedicine services to patients in Alberta may need to be licensed in and adhere to the policies of both jurisdictions depending on the type and frequency of the telemedicine services provided. The College of Physicians and Surgeons of Alberta regards the patient's location as the determining factor of where the telemedicine encounter occurs. For this reason, the College in Alberta requires physicians from other provinces to register with it unless the consultation is for an emergency assessment or treatment or the physician provides telemedicine consultations in Alberta less than six times a year.4
Similarly, the College of Physicians and Surgeons of Ontario (CPSO) expects physicians licensed outside Ontario to comply with its expectations when providing telemedicine services to patients in Ontario. As well, the Ontario government has said it wants to create standards and accredit telemedicine practitioners through the Ontario Telemedicine Network (OTN), thereby helping to reassure patients that online medical consultations are both convenient and safe.
Privacy and information security
The Canadian Medical Association's Code of Ethics requires physicians to "protect the personal health information of [their] patients."5 In addition, privacy legislation in every province and territory generally stipulates that personal information cannot be collected, used, or disclosed unless the individual has provided consent or the activity is otherwise permitted by law. When providing telemedicine services across provinces and territories, physicians will want to take appropriate steps to comply with the privacy legislation that applies in each jurisdiction.
Physicians would be prudent to confirm, to the extent possible, that both the patient and the physician are in physical settings that are appropriate for the encounter and permit the patient to share personal information in a reasonably private manner. Physicians should be satisfied that reasonable and legally compliant security protocols are in place to adequately protect patient information being transmitted via electronic means.
Patient consent in telemedicine
As with any non-emergent medical care, patients must receive adequate information about the benefits and risks of the proposed treatment so they may provide their informed consent. Telemedicine may present additional challenges in this area. Consequently, it may be prudent to also request that the patient read and accept standard terms and conditions for the telemedicine service, and such consent and any related discussions with the patent should be noted in the patient's medical record.
Some Colleges impose or recommend additional consent requirements for telemedicine. For example, the College of Physicians and Surgeons of Nova Scotia suggests that patient consent for telemedicine services should include “where the physician is located and licensed to practice medicine [and] how the privacy of the patient’s personal health information will be managed.”6
For the purposes of determining whether the CMPA will assist members with an issue related to telemedicine, the CMPA deems the location where care is provided to be the patient's location at the time of the telemedicine encounter. If the patient is located in Canada, CMPA members will generally be eligible for assistance in the event of medico-legal difficulties. However, members will generally not be eligible for CMPA assistance with medico-legal problems arising outside of Canada or that result from care provided to patients located outside of Canada. Nevertheless, when a patient is outside of Canada temporarily and contacts the member physician concerning an existing condition, the member would generally be eligible for CMPA assistance provided that the legal action is initiated in Canada.
- Rashid L. Bashshur, et al. “The Empirical Foundations of Telemedicine Interventions for Chronic Disease Management”, Telemedicine and e-Health. Sept. 2014, Vol. 20, No. 9. P.769-800 Retrieved Jan. 28 2015 from: http://online.liebertpub.com/doi/pdfplus/10.1089/tmj.2014.9981
- Lynda Sea ,“Q&A with Eric Topol: How the digital revolution will change medicine,” Utoday, University of Calgary, Sept. 20, 2013. Retrieved Jan. 29, 2015 from: http://www.ucalgary.ca/utoday/issue/2013-09-20/qa-eric-topol-how-digital-revolution-will-change-medicine
- College of Physicians and Surgeons of British Columbia, Professional Standards and Guidelines, “Marijuana for Medical Purposes”, April 2014. Retrieved Jan. 29, 2015 from: https://www.cpsbc.ca/files/pdf/PSG-Marijuana-for-Medical-Purposes.pdf
- College of Physicians and Surgeons of Alberta, “Telemedicine or Teleradiology.” Retrieved Aug. 2013 from: http://www.cpsa.ab.ca/services/Registration_Department/Alberta_medical_licence/Telemedicine.aspx.
- Canadian Medical Association, “Code of Ethics,” 2004. Retrieved Feb. 2, 2015 from: https://www.cma.ca/En/Pages/code-of-ethics.aspx#
- College of Physicians and Surgeons of Nova Scotia, Guideline for the Provisions of Telemedicine Services, Dec. 2013. Retrieved March 2015 from: http://www.cpsns.ns.ca/DesktopModules/Bring2mind/DMX/Download.aspx?PortalId=0&TabId=129&EntryId=46