Originally published September 2017
A busy professional tells his family physician about a rash on his back that is not getting better. After detailing his family history of skin cancer, he describes his growing anxiety. All he can think about is how would he, as a single parent, deal with a serious health problem?
After examining the rash, the family physician decides to consult with a dermatologist. However, the patient lives in a rural area that is two hours from the nearest dermatologist’s office, which has a 6–9 month wait for non-emergencies. There is another option—a remote consultation using technology to connect with a specialist, otherwise known as an eConsultation.
The physician informs the patient about the technology used for an eConsultation and, in particular, any risks to privacy and the confidentiality of personal health information. With the patient’s consent, the physician photographs the rash. She logs into the secure electronic consultation website, clicks on the drop-down list of available specialties, and selects "dermatology." She fills in the form, gives the patient’s history, uploads the photograph, and submits the request for a consultation.
Within a few days, the family physician receives a secure email from a dermatologist. The specialist doesn’t see a need for a referral visit, but does suggest a biopsy. The family physician calls the patient and arranges for the procedure, which is performed locally. The rash, diagnosed as early skin cancer, is treated quickly and effectively. The family physician summarizes the care process in the patient’s record.
Technology enhancing patient care
Across Canada, individuals and groups are using new technology to improve consultations and referrals. These initiatives are generally referred to as eConsultation and eReferral services.
While the services can be diverse in the technology used and the features offered, they share a common goal: to streamline consultations and referrals, giving patients and primary care physicians more effective and efficient access to specialist care.
eReferral services generally allow primary care physicians to request a referral to a specialist electronically, rather than by fax or mail.1 eReferral services can involve migrating relevant patient information already contained in the physician’s electronic medical record systems into an electronic referral form that is sent to the specialist and also saved in the patient’s electronic record.
eConsultation services typically connect primary care physicians with specialists using information and communication technology. They allow physicians to have an electronic dialogue to manage patient care, without requiring a face-to-face visit with the patient. 1
eConsultation and eReferral services vary
eConsultation and eReferral services vary widely. Some use the Internet, while others use traditional technology. For example, the Champlain BASE (Building Access to Specialists through eConsultation) eConsult Service is a web-based service primarily available in parts of Ontario.2 In British Columbia, the Rapid Access To Consultative Expertise (RACE) eConsultation service uses the telephone.3 Some are developed by public organizations and are provided without charge,2 while others are created by private groups and charge users a fee.4
"eConsultations and eReferrals are exciting because of their potential benefits," says Dr. Dennis Desai, CMPA’s Senior Physician Advisor, Quality Improvement and eHealth. "There is real potential for patient care to be enhanced because wait times for specialist care may be reduced and the barriers that prevent patients from accessing care may be removed."
Before participating in this type of service, physicians should be satisfied that it would serve their patients’ needs, and also support them in meeting their legal, professional and ethical obligations.
What are physicians’ legal, professional, and ethical obligations?
Duty of care
In an eConsultation and eReferral situation, primary care physicians have a doctor-patient relationship with the patient, which creates a duty of care.
That duty may also extend to consulting physicians who have been involved in the patient’s care, even if they have not seen or interacted directly with the patient. The law continues to evolve in this area, but it is probable that discussing a patient’s care through an eConsultation would establish a duty of care. And, at least one Canadian court has suggested that a physician may owe a duty to patients even in the absence of a doctor-patient relationship.5
Standards of care
When evaluating an eConsultation or eReferral service, physicians should question if it supports them in meeting their obligation to treat patients according to current and applicable standards of care.
Some medical organizations and specialty societies, and all regulatory authorities (Colleges) have established standards for in-person consultations and referrals. It is likely that those would apply equally to eConsultations and eReferrals.
In general, referring physicians should be able to provide necessary information about the patient’s problem; the clinical question to be answered; patient details; and relevant investigations, treatments, and medications. Consulting physicians should have sufficient details about the patient’s condition to be able to provide answers to specific questions and give appropriate advice.6
Specialists should generally decline to provide an eConsultation if they feel that the available information is inadequate or a physical examination is needed to provide the appropriate advice. A physician who proceeds with an eConsultation that does not meet the standard of care may be subject to disciplinary proceedings by the physician’s College and may be liable in a civil action for any injury the patient suffers because of that failure.
As physicians have ethical and legal obligations to keep their patients’ personal health information private and confidential, they should be satisfied that any eConsultation or eReferral service they rely on has adequate security and privacy protocols to protect patient information.
Physicians should ask the service provider to confirm that the service has the appropriate privacy safeguards. When practising within a healthcare facility that has adopted an eConsultation or eReferral service, physicians may wish to speak with their administration to ensure similar steps have been taken by the facility.
To learn about specific safeguard requirements, physicians can look to applicable federal or provincial or territorial privacy legislation, or College guidelines or standards of practice. More information about privacy considerations for eReferrals or eConsultations is available from provincial and territorial privacy commissioners, Colleges, and the CMPA.
In investigating an eConsultation or eReferral service, physicians should consider if the service allows them to meet their legal and professional responsibilities to maintain proper medical records for patients.
Primary care physicians should document in the patient’s medical record the information that would normally be expected with any consult or referral request including the patient information provided to the specialist, details of exchanges with the specialist, the specialist’s recommendations, and the reasons for following the specialist’s recommendations (or not). A consulting physician providing treatment recommendations to a primary care physician through an eConsultation should document the information provided by the treating physician, the substance of any exchange with the treating physician, information considered in the course of the consultation, and their recommendations to the treating physician.
These records can provide invaluable evidence in case a question arises later about the information provided or advice given. Legal proceedings often start long after a referral is made and consultation provided, and these records may be physicians’ only source of information to refresh their memory.
Before participating in an eConsultation or eReferral with physicians located in a different province or territory, doctors should consider whether they have met applicable licensing requirements.
Some eConsultations may be considered telemedicine, which can have specific licensing requirements. The Federation of Medical Regulatory Authorities of Canada defines telemedicine as "the provision of medical expertise for the purpose of diagnosis and patient care by means of telecommunications and information technology where the patient and the provider are separated by distance. Telemedicine may include, but is not limited to, the provision of pathology, medical imaging and patient consultative services."7
Telemedicine licensing requirements vary for each province and territory. Some physicians practising telemedicine might need to be licensed in both the jurisdiction in which they are located and in 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. So, physicians should be familiar with the requirements of each province and territory in which they practise and the patients are located.
Moving forward with care
eConsultations and eReferrals represent an exciting and promising new frontier in medical care. They offer great potential for remotely connecting referring and consulting physicians, and enhancing patient care. Before participating in such a service, clinicians should carefully examine it to satisfy themselves that it will also allow them to meet their legal, ethical, and professional responsibilities.
Some eConsultation or eReferral services may allow physicians to offer medical advice for patients living outside of Canada. For the purposes of determining whether the CMPA will generally 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. While CMPA members are generally eligible for assistance in the event of medical-legal difficulties if the patient is located in Canada, they are generally not eligible for CMPA assistance if the medical-legal problems arise outside of Canada or result from care provided to patients located outside of Canada.
- Canada Health Infoway [Internet]. Advanced clinical e-Functions and patient e-Services. Toronto (ON): Canada Health Infoway;[cited 2017 May 25]. Available from: https://www.infoway-inforoute.ca/en/component/edocman/2842-advanced-clinical-e-functions-and-patient-e-services-descriptions/view-document?Itemid=101
- The Champlain BASE eConsult Service [Internet]. Ottawa (ON): Champlain BASE eConsult; [cited 2017 May 25]. Available from: http://www.champlainbaseeconsult.com/
- RACE Rapid Access to Consultative Expertise [Internet]. Vancouver (BC): RACE; [cited 2017 May 25]. Available from: http://www.raceconnect.ca/contact-us/
- Consult conduit [Internet]. Toronto (ON): E-Consultations made easy; 2017 [cited 2017 May 25]. Available from: https://www.consultconduit.com/
- Crawford v Penney, 2003 CanLll 22314 (ON CA)
- Canadian Medical Protective Association [Internet]. Improving communication between physicians. Ottawa (ON): CMPA; June 2011 [cited 2017 May 25]. Available from: https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2011/improving-communication-between-physicians
- Federation of Medical Regulatory Authorities of Canada [Internet]. FMRAC Policy on Telemedicine. Ottawa (ON): FMRAC; June 2010 [cited 2017 May 25]. Available from: http://fmrac.ca/wp-content/uploads/2014/02/FMRAC_Policy_on_Telemedicine_June2010.pdf)