Dr. Lisa Thurgur: Hi everyone. Good morning or good afternoon, depending on where you're joining from. And welcome to our webinar entitled Providing Safe Virtual Care: A Deeper Dive. So, this webinar, as I'm sure you figured out, is an extension of our virtual care webinar that we produced in 2023. And we'll take a closer look at some topics that our members have been asking us about.
But before we begin, I would like to acknowledge the land that we are presenting from today. The CMPA offices are located in Ottawa, and they are on the unceded, unsurrendered territory of the Anishinaabe Algonquin Nation, whose presence reaches back to time immemorial. Now, this photo that you see is actually taken by a CMPA member and is of the land directly across from the CMPA offices.
I also want to recognize that today we have participants learning with us from all other areas across Canada, and I would like to honor and pay respect to these lands that you are on, and to all First Nations, Inuit and Métis people throughout Turtle Island. As an organization, the CMPA recognizes all First Peoples who were here before us, those who live with us now, and the seven generations to come. I would like to start with introducing our panel today for this webinar. So, Dennis Desai is a general surgeon and he’s practiced in various sites across Canada as well as internationally. He joined the CMPA in 2008, so he's been with us for quite a while, and he is a special advisor for medico-legal services, at the association here.
And Dennis speaks to members daily about their medico-legal concerns in all areas. And we're thrilled to have him with us. Welcome, Dennis.
Dr. Dennis Desai: Well, thanks for inviting me, Lisa, and I look forward to our discussion.
Dr. Lisa Thurgur: Excellent. So do I. And now Martin Lapner. He's a partner at the Ottawa law office of Gowling WLG. He practices in health law and privacy, including as counsel to the CMPA and to physicians. Marty practices with an emphasis on professional, regulatory and civil liability matters. And he's here today to share a wealth of medico-legal knowledge on the topic of virtual care.
Welcome, Marty.
Mr. Martin Lapner: It's a pleasure to be here. Thank you.
Dr. Lisa Thurgur: Great. My name is Lisa Thurgur. I'm an emergency physician, and I am a physician advisor at Safe Medical Care here at the CMPA. And I am thrilled to be hosting our webinar today. Later at the end, for our question and answer period, you will meet Élisabeth Boileau. She is our moderator. Élisabeth is also an emergency physician, and she is a physician advisor in Safe Medical Care-Learning as well.
And like I said, you'll get to meet her later during the Q&A session. Now, as a panel, we have no conflicts of interest to disclose, except that both Dennis and I are paid employees of the CMPA, and Marty is retained counsel for the CMPA. All right, let's talk virtual care. Now, virtual care has become part of many physicians’ practices, and I think that both patients and physicians would agree that it has its pros and its cons, and we're going to talk about that. The Virtual Care Part One webinar that aired live last year, if you've missed it, or perhaps you just want to watch it again as a refresher, you can find it on our website under the Education and Events section.
You scroll down to CMPA webinars and it is appropriately called Providing Safe Virtual Care. Now in that webinar, we addressed physician obligations and common medico-legal issues related to virtual care. We discussed in detail several topics, topics like consent, documentation, standard of care, which is very important. And we also spoke a bit about etiquette for using virtual care, because it was a bit of a newer topic about a year ago.
Now, this second webinar today is intended to complement Virtual Care Part One, and it's intended to take a bit of a deeper dive into the topic in order to assist all of you, our physicians, with your inquiries about the professional and the legal obligations and your medico-legal risk when you are providing virtual care. Now, you can see from the objectives that are shown on this slide here that we will be reviewing some key concepts from Virtual Care 1.
And then we will focus on licensing concerns and limitations that exist for providing out-of-country virtual care, because we've had quite a few questions and calls about that. And then finally, to wrap it up, we will discuss the concept of virtual care for involuntary psychiatric assessments. But I'd like to start with reviewing the concept of standard of care when it comes to virtual care.
So, let's start with a scenario that perhaps people can relate to. All right, Dennis, I'm going to throw a scenario out to you. Let's say that you're a physician running an urgent care clinic, and that that clinic serves northern communities. And in this clinic, you see patients both virtually and in person. And say, you have a 65-year-old female patient, known COPD, and she has a new cough.
She's phoned the clinic that morning and asks for an appointment. She let the receptionist know that she does have some travel limitations for the next, say, 2 to 3 days, so she's specifically requested a virtual appointment for that reason, which is perfectly in keeping with what your clinic is able to do. So, Dennis, what is the standard of care in this scenario, and would a virtual visit allow enough of an assessment to meet the standard of care?
Dr. Dennis Desai: Well, I'm really glad you started with this, Lisa, because it is so important to always consider what the standard of care is, and the standard of care varies with the circumstances, not the communication channel. So what are the circumstances? Are there travel issues? Is there an urgency to deal with this problem or can it wait for a couple of days? Are there other options available locally?
So, in this case that you mention, this patient is unable to travel for a couple of days. So given what you're suggesting, it may be appropriate to do virtual care to at least get a sense of it, and at least get the history to decide if she then needs to be seen in person or not.
One thing I would like to mention is that you should document your thoughts, and the circumstances, when you're dealt with a virtual care situation, to suggest that you're choosing virtual care because you feel it's in the patient's best interests, because there are limited other options.
Dr. Lisa Thurgur: Okay. So, in line with our discussion about standard of care, we know that at the CMPA, the courts expect physicians to also exercise reasonable care, skill and judgment. So, can you tell us what that means, Dennis?
Dr. Dennis Desai: Yes. I mean, we get that question a lot: Can I do X or treatment Y? Would that meet the standard of care? And the standard of care is not set by the CMPA or even by our CMPA lawyers. Standard of care is set by Colleges which will have expectations or obligations. Sometimes professional organizations say, you know, this is a standard. And really it relies on your peers.
The guideline you may want to use, if you wonder, is this going to meet the standard of care, is: what would a reasonable physician with similar training and experience do under similar circumstances? Really, the standard of care is, what would the majority, or at least a respectable minority, of your colleagues do in that situation?
Dr. Lisa Thurgur: Okay. I like this, Dennis. So if you find yourself wondering, when is it appropriate to offer virtual care, it may be helpful to remember the general standard of care we are held to is what a reasonable physician would do, or what they would have done under similar circumstances. Is that right?
Dr. Dennis Desai: That’s correct.
Dr. Lisa Thurgur: Okay. That's a great message.
Now what about this scenario? Say you have the same patient, your COPD patient with a new cough. And this patient is at a northern nursing station, and you're seeing them virtually there. So quite far away. As you know, one of the limitations or one of the problems with virtual care is not being able to examine the patient.
So, in this case, not being able to listen to her lungs or do a full assessment. But what if the northern nursing station has a new electronic stethoscope? And the nurse who was there at the northern nurse's station says that they know how to use the electronic stethoscope. Would that suffice? And could the nurse use this to examine the patient while you're on the virtual call with them?
Could the physician use that information? And how can they rely on their findings?
Dr. Dennis Desai: So now you've packed in two questions there. One is the use of an electronic tool, like a stethoscope. And also about delegation to another health care provider, which comes into play when we're dealing with virtual care. So, when you're using technology, I think it assumes that you are familiar with that technology, be it through your training, through a previous experience, maybe through a course, and that you know the risks, the benefits, and the limitations of that tool.
So, preferably in advance, you have researched that tool and you are aware. And then the second thing is the delegation to another. Now the courts accept that you can rely on other providers to practice within their scope of practice. And a regular stethoscope or a blood pressure cuff is definitely within the scope of practice of a nurse.
But is an electronic stethoscope in the scope of practice of a nurse? That's not clear. And it would be up to you to determine that, preferably in advance. The nurse may say that he's available to do the stethoscope, but is he really trained? Is he capable? And if you are delegating something you should be also aware of the technology, how to use it, so there's still an onus on you, and aware of the provider's limitations and skills. So, two things to know.
Dr. Lisa Thurgur: Two things to know. And that's important because there's a lot of new technology, coming our way as physicians, and we have to take that into consideration with all new technology. Okay. Now what if the patient is so remote, that there's no way you can see them in person. Now, does the standard of care take this into account, Marty? And what do the Colleges say about that?
Martin Lapner: Yeah, that's a good question. I think I'll start by repeating something that Dennis said, and it might be repeated a few times during this webinar. The Colleges say the standard of care is the same, regardless of whether the care is delivered virtually or in person. That said, the Colleges and the courts may consider extenuating circumstances that would prevent seeing a patient in person.
And that's reflective of the definition for the standard of care, which says, what would a reasonably prudent physician do in the circumstances? So, some College policies expressly refer to the remoteness of the patient as a relevant factor for considering whether in-person care is required and is in the best interests of the patient. For example, this may involve consideration of whether the benefits of providing virtual care outweigh the risks, or if a failure to provide care virtually will actually hinder the patient's access to care because they are so remote.
Dr. Lisa Thurgur: Okay. That's interesting. Now, what if the patient has no travel limitations, Dennis? What if they just would prefer to have a virtual appointment for convenience rather than attend in person? I know this happened a lot during COVID, so why not continue this now if the patient prefers it?
Dr. Dennis Desai: Well, I mean, you're still left with the standard of care. And I guess I may sound like a broken record or I guess these days, a skipped CD, but the standard of care implies that you have a fiduciary duty to proceed in the best interests of the patient. So, not just follow their preferences. So, medically speaking, is virtual care appropriate if there are no travel limitations? You go back to what would a reasonable physician do or your colleagues do under similar circumstances. Would they just proceed with a virtual care appointment? Or would they say: “You know, I probably should really see you for that. I realize you'd prefer that”. But let's say, all things being equal, if you think that it may be appropriate, do you have to go with patient preference?
And I don't know, Marty, is there any legislation or College expectation on that?
Martin Lapner: We actually see – that's a good question. We see a lot of complaints, about patient preference not being accommodated. But it's important to remember that it still needs to be clinically appropriate. So, the Colleges say, yes, you should accommodate and you should prioritize patient preference, but do so where it's clinically appropriate and available.
In COVID times, there were different circumstances to consider, which in a sense changed the standard of care. For example, during COVID, one: there may have been a provincial health directive to keep offices closed or College policies setting out broader expectations to prioritize use of virtual care as a first option. And second, and this underlies the first reason, there were much higher risks for patients with comorbidities to rely on public transportation and wait in waiting rooms.
So, at that time, it could have been in a patient's best interest to have a virtual appointment. In some cases where it would not be now, and in those cases, you treat empirically, then follow and see if an in-person assessment would be necessary.
Dr. Lisa Thurgur: Okay. But in these times, you would have to ask yourself whether or not a virtual appointment is in the patient's best interests. Would you agree with that, Marty?
Martin Lapner: Yeah, absolutely.
Dr. Lisa Thurgur: Okay. All right.
Martin Lapner: In some cases, you may not actually know, just to add to that. You may not actually know until you assess the patient whether they need to be seen in person or whether they should attend the hospital. But it's important for you to make that determination as soon as you're in a position to do so.
Some Colleges, sorry, some clinics have policies to help and advise patients of the types of issues that are appropriate for virtual care, which can be helpful. And they'll also clarify for patients that virtual care appointments are not a substitute for attending the emergency department in the case of emergency, for example.
Dr. Lisa Thurgur: Excellent. All right, what about documentation for consent to use virtual care? Let's review this briefly. Now, do I need to get a signed consent form to have a virtual appointment, Dennis?
Dr. Dennis Desai: Well, let's start at the beginning. Consent is obligatory whenever you're treating a patient. Absolutely.
Dr. Lisa Thurgur: I thought you might say that.
Dr. Dennis Desai: But, now, when we're treating a patient in person, everybody understands the circumstances about privacy and what you can see and what you can assess. It's not as clear with virtual care. There are special risks: privacy with the platform, privacy with the technology, and even the fact that you can only do a limited assessment.
Patients may not realize that when you can't see them set up and stand up and so on and so forth, you are missing part of your assessment, so you are doing it under limited circumstances. And given that patients may not understand that, the Colleges, for instance, often obligate you to get written consent, especially with the first virtual care visit.
Now, I want to mention that the CMPA actually has a template consent form, Use of Virtual Tools, online that any member can access. And it not only gives you a framework for how to put the consent, but it also has appendices which discuss some of these risks and limitations in more detail, because I want to stress that consent is a process. It's not just a signed form. If there were challenges in the future, it would be ideal to have the patient say: Yes, she did discuss it with me, and I felt a go ahead. Versus a patient saying: I don't know, I just had to sign a form before they started the virtual visit. So, it's a process, and it's important to document.
The other thing you may want to document, along with the consent, is why you're choosing virtual care. And I know I'm repeating myself a little bit, but sometimes the circumstances which are obvious to you now may not be as obvious later on. As Marty was saying, provincial directives, or restrictions, or the evidence of the flu right now and whether they can wait in a waiting room.
So, it would be ideal if that was documented, for future reference.
Dr. Lisa Thurgur: Okay. That's a great tip about the template for the consent form that's on the website for physicians who are doing a lot of virtual care. I think that would come in really handy for them. That's great. Thanks, Dennis. Now, documentation is a topic all in itself. At the CMPA, we love to talk about documentation and for good reason.
But, now, are there differences between provinces in terms of the way virtual care should be documented? What about different expectations in terms of other issues like selecting platforms or privacy requirements? Can you comment on that, Marty?
Martin Lapner: Documentation is one of the things that hasn't really changed just because the care is virtual or in person. You document as you normally would, being diligent about your assessment, about your decision making and your follow-up plan. One thing and I'll reiterate what Dennis said, again, is you may want to document, and it's a good idea to document, why you decided virtual care or in person was appropriate.
And that can be helpful down the road if there is any medico-legal incident. In terms of the platform, one issue to consider, particularly when providing care across provinces or territories, is privacy. There may be requirements to consider in your home province or territory, and in the jurisdiction where the patient is located. For example, physicians should generally consider whether the tool they intend to use is compliant with the privacy laws in those jurisdictions.
In some jurisdictions, a privacy impact assessment may be required before using a platform. And that could be important if that legislation applies in the province where the patient is located.
Dr. Lisa Thurgur: Okay. And that is helpful. Now at the CMPA, we hear from a lot of physicians who are providing virtual care, and they're wondering if they have to have a backup or an option B if in-person care cannot be… you know, if it's required, if the patient actually requires in-person care. They're calling in and wondering, do I have to have a backup or a plan B or an option B?
So, what are the expectations of the Colleges on this, Marty?
Martin Lapner: Yeah, that's a good question that comes up fairly often. Many Colleges require physicians to be able to assess patients in person when it's required or to have an arrangement in place with another provider who can deliver timely in-person assessment or see them in person. Colleges generally don't allow you to use the emergency department as a de facto backup or a walk-in clinic as a replacement for in-person appointments, with one caveat that if the patient's so remote and there really are no physical locations for the patient to see, then the hospital may be the only option.
Dr. Lisa Thurgur: Okay. And are there any other different requirements that are unique to virtual care?
Martin Lapner: Yeah, that's a good question. It's also a key pointer I think that you should review the virtual care policies of the relevant Colleges. Some of the standards and guidelines have some unique requirements for virtual care that are different from what you might expect for in-person care. So many Colleges, for example, require physicians to advise the patient of their location and licensure status.
You generally wouldn't do that for an in-person appointment because it's obvious. For other issues, again, while there is some consistency, there's a fair bit of consistency between the Colleges. It's a good idea to review the virtual care policies in jurisdictions where you're practicing, just to ensure you're compliant.
Dr. Lisa Thurgur: Okay. Going back to consent for a minute, we often get questions about, consent requirements for minor patients and who should be present for a virtual care appointment. So, if a virtual care video appointment is occurring with a child, do the parents need to be there? Does someone supervising that appointment need to be there, Dennis?
Dr. Dennis Desai: Well, I'm glad you brought that up. The age of consent hasn't changed because the standard of care hasn't changed. So, you can generally follow your usual practice. But the point with virtual care is it may not be obvious to you about parents’ attendance with a virtual appointment. It depends on the room and where they're located. So, especially with a mature minor, a physician should take extra care to consider that minor's right to privacy and whether they need to actually consent to have the parents present at that appointment.
Dr. Lisa Thurgur: Okay. Thanks for clarifying that. I'd like to switch gears now and talk about licensing concerns for virtual care. So, before interacting with patients in a different jurisdiction, what should physicians consider in order to meet the applicable licensing requirements? Marty, can you tell us a little bit about that?
Martin Lapner: Yeah. So, licensure is another key issue for virtual care. The requirements really vary from one province to another or territory. There isn't a pan-Canadian approach to virtual care licensure. Some Colleges require physicians to be licensed fully, to have a full independent license in the jurisdiction in which the physician’s located and the jurisdiction where the patient is located.
Other Colleges require special registration or they place conditions on the provision of certain services. For example, prescribing some controlled substances or the number of patients that are seen virtually. And then there are some exceptions for follow-up of existing patients who are temporarily in other jurisdictions. The bottom line is it's a good idea to ask the College in the relevant jurisdictions about their requirements for licensure, just to ensure you're on side. Another key issue is billing. And while the CMPA doesn't generally provide advice with respect to billing, it's important to confirm with your billing authority whether you can bill the provincial plan if the patient's not physically located in your province at the time of service, and the extent to which the care will be provided virtually.
And if you have questions about this, you can also ask your provincial or territorial medical association.
Dr. Lisa Thurgur: Great. Thanks, Marty. All right, let's talk about out-of-country scenarios. Okay. So, let's talk about CMPA assistance for when either the physician or the patient is out of the country. And I'm going to throw another scenario at you, Dennis. Let's say there's a 75-year-old male patient, who suffers from hypertension and diabetes, and he's followed by his family physician for both of these and sees the physician, say, monthly for blood pressure checks and discussions about his glucose control.
He has decided that he'd like to go to Florida for four weeks for vacation. So, can the physician continue to see this patient remotely to follow his hypertension and his diabetes? And will the CMPA assist if the physician encounters any medico-legal difficulties?
Dr. Dennis Desai: Well, again, you've packed two questions into one. So, let me start with: Can the physician see the patient? Obviously, the physician can treat the patient. “Does it meet the standard of care?” was probably implied in your question. Standard of care: unchanged. Not a surprising answer. So, virtual care may be appropriate if you can get the readings you need, do the assessment you need.
So, virtual care may be, medically speaking, fine for this patient. However, the big question is: Will the CMPA assist you? Now, our assistance is always discretionary, and it's done on a case-by-case basis. And fundamentally, the CMPA is set up to assist physicians practicing in Canada, treating patients in Canada. So, when you talk about our extent of assistance for situations out of the country, if it's an existing patient and an existing issue and the patient is temporarily out of the country, for instance, a vacation or studying abroad or maybe working on a short work term, then generally the physician will be eligible for assistance, assuming that the medico-legal action is brought in Canada.
Still, though, it'd be prudent for the physician to consider getting local follow-up to examine the patient if they require it. If this is a new patient, though, or a new issue, or the patient is residing outside of Canada for any prolonged period, then generally the CMPA is not structured to assist that physician, even if a medical action starts in Canada. I mean, there are many nuances to a physician providing care outside of Canada, and I'm just speaking to one as extent of assistance. I'm sure there are other issues. Maybe Marty, you can…
Martin Lapner: Yeah, I'm just going to go back to an issue I've brought up before. In addition to liability protection considerations, again, the physician may need a license in the jurisdiction in which the patient's located. In this scenario, for example, the state medical board may consider the provision of care in Florida as the practice of medicine. A complaint or a concern could end up being raised in that jurisdiction, or it could be brought back to your own College, which could be critical.
Dr. Lisa Thurgur: Okay. Very helpful. But I'm going to reverse the scenario now, Dennis. So, what if the physician wants to go to Florida, for the winter, and run their clinic virtually from outside of Canada? Will the CMPA assist?
Dr. Dennis Desai: Well, it sounds appealing. And, we have had calls of physicians that would like to do things like that, but I want to make it clear that the CMPA is there really to assist physicians practicing in Canada. And so, where a physician resides outside of Canada, they're generally not eligible for assistance, either for a medico-legal action in Canada or in a foreign jurisdiction.
Dr. Lisa Thurgur: Okay. Well, I'm gonna throw in another twist then, just to make it interesting. What if the physician is out-of-country at a conference? And perhaps they get a call from the office. An urgent call, about a lab test to follow up on. This lab test requires their attention. It was something that wasn't planned.
It's a little different than the physician heading off to Florida for the winter, right? It's temporary. It's something that wasn't planned. Would the physician be eligible for assistance in this scenario?
Dr. Dennis Desai: Good question. And, you know, we're a membership-driven organization, so we try to do what we can for members. And now, you're considering an existing patient, an existing issue, and the physician is just out for a vacation or a conference. They have no plans to work there. Our assistance is always discretionary. And in those situations, the guidelines are that we would consider protecting that physician should a medico-legal action occur in Canada.
But I want to stress some of the points that you mentioned there, which is that we're really talking about a temporary absence. So, a few days, a week or two, but definitely less than a month. And, you know, I want to also reinforce Marty's point about, what about licensing? And that’s something you may want to consider even if you're there for a short term.
So, again, our assistance is discretionary. If you have a challenging circumstance, you can definitely contact us for more definitive thoughts on your specific situation.
Dr. Lisa Thurgur: Okay, great. Well, thank you both for clarifying out-of-country assistance. As the webinar is heading to sort of the halfway mark, and before it concludes, I do want to discuss if virtual care can be used to complete applications for involuntary psychiatric assessments. Certainly, since the pandemic and the increase in popularity of virtual care, physicians have been asked to complete involuntary psychiatric assessments on patients through virtual platforms.
We're hearing a lot more about this. So, is this allowed now that the pandemic is over, Dennis?
Dr. Dennis Desai: Well, you know, we have the standard of care on one hand, but we also have statutes and legislation and what you're obligated or expected to do. So, my reading of the mental health statutes are that a physician signing an application for involuntary assessment should have personally examined the patient. Now that, of course, assumes that the physician has done a thorough and careful inquiry into all the facts and circumstances necessary.
But does “personally examine” mean examine in person? I mean, that's going to be a detailed reading of the legislation or knowledge of the case history. So, I'll turn to our legal beagle again.
Martin Lapner: That's a good question. And we receive it periodically. There's no express requirement in the legislation that physicians must be in the same location, same physical location, as the patient. The terms “examined” and “personally examined” are not generally defined in the Mental Health Acts across the country. And we're not aware of any court that has commented on whether or not these terms expressly permit the use of virtual care to conduct examinations for the purpose of completing these applications for involuntary psychiatric committal.
At the same time, in some jurisdictions, larger telemedicine networks have, for several years now actually, provided physicians with the ability to conduct examinations for the purpose of completing these forms. And there's commentary from certain healthcare organizations that telemedicine is appropriate for this purpose. And we've also seen some jurisprudence where these examinations have been upheld without strictly being considered by the decision makers.
But the examination was done by virtual care and it was tacitly accepted.
Dr. Lisa Thurgur: Okay. So, from what I understand, the takeaway message or the teaching point is that regardless of the medium, whether it's virtually or in person, what is really important is that there's a careful assessment done. Is that right?
Martin Lapner: That’s right.
Dr. Lisa Thurgur: Okay, excellent. Well, I would like to thank both of you for joining us for the panel today, and clarifying many issues around virtual care. Perhaps you might agree with me that, you know, given the context of both the healthcare human resource crisis that we are currently facing and the wake of the COVID-19 pandemic, that virtual care can certainly play a role in improving access to health care.
As physicians who will be potentially using virtual care, we urge all of you to think about what we discussed today to better understand, not only patient safety, but also your medico-legal risks, related to virtual care. I actually think back and reflect that since the start of the pandemic, there really has been a flurry of activity with College standards and policies on virtual care.
However, now it seems, speaking with both of you, that things have sort of stabilized in terms of regulatory expectations, and when to use virtual care. Would you say that's right, Marty?
Martin Lapner: Yeah, absolutely. I'd say that's right. And with some exceptions, there appears to be a general recognition of the benefits of virtual care, particularly in the context of the pandemic or for patients in remote locations, and to better accommodate patient or provider preference, where clinically appropriate, of course. But virtual care, seems to be, or it seems to be said by the Colleges that virtual care should be blended with in-person care and not used exclusively.
Dr. Lisa Thurgur: Okay. And there is also an understanding that the standard of care has not changed, whether it's virtual or in-person. Is that right, Dennis?
Dr. Dennis Desai: Absolutely.
Dr. Lisa Thurgur: Excellent. Thank you for clearing that. Dennis, maybe you could tell us and tell the participants what's coming down the pipe with virtual care. What might we see?
Dr. Dennis Desai: Well, I wish I was 100% good at predicting, but at least I can take some guesses at what we might see. I think we might see an increasing use of virtual care. Especially in certain niches, like maybe follow-up appointments or certain monitoring appointments where it's not as critical to do that in-person assessment and there's a limited scope of that particular visit.
At the same time, there may be incorporation of a lot of mobile health apps or electronic tech into that virtual care, to allow the physician to do a slightly better assessment than they could simply other than through a camera. The other thing I wonder is if AI is going to have an influence: AI in ability to triage incoming virtual care, mobile health applications, or simply in triaging patients themselves.
So, it's hard to know.
Dr. Lisa Thurgur: Okay, interesting. You heard it here. Dennis has predicted what's coming and what will be new with virtual care. Thanks for that. And as participants, you should also remember that if questions arise in your daily practice, we urge you to go to our website. We have many, many resources there that are focused on the everyday needs of the physicians.
On the website, under the Education and Events section, you'll find the Good Practices section. There are podcasts. There's our other webinars that we've done. There are numerous e-learning activities. Really the possibilities for learning about topics, areas in your practice are endless. So, do check it out.
And of course, if you do have a medico-legal challenge that cannot be addressed by our website, then please know that we are here to protect you.
We're here to support you. And we strongly encourage you to contact the CMPA (you'll get to speak with people like Dennis) if you have questions that can't be answered from our website.
We would like to give you a chance now to ask your questions. So, we're going to move to our Q&A period. Our moderator, as I mentioned previously, is Élisabeth Boileau who is a physician advisor in Safe Medical Care Learning at the CMPA. Welcome, Élisabeth. Now, to have your questions answered during this Q&A session, please use the Q&A button that's in the toolbar situated at the bottom of your screen to submit your questions. They will go to Élisabeth and she will pose them to our panel.
Take it away, Élisabeth.
Dr. Élisabeth Boileau: Thank you. Yes. People are asking all sorts of questions since the very beginning of the webinar, so I think people are very engaged in this topic. I'm going to address the first question that we got to Marty. What if the patient refuses to come in for an in-person visit, and I don't think I can provide an adequate assessment virtually? What would you say?
Martin Lapner: We've seen this question before, and many Colleges require physicians to consider patient preference, and we touched on this during the webinar a bit. But they also expect physicians to decline to provide a virtual assessment if they feel inadequate information is available or for physical examinations required to provide the appropriate advice. This is similar to care that would be provided before the pandemic.
If a patient needed to come in to be seen, you would explain to them why they needed to come in to be seen. And if they continued to refuse, you'd want to carefully document that and the efforts you made to encourage them to come in.
Dr. Élisabeth Boileau: Absolutely. Thank you for that. Then I will address the next one to Dennis. So, an audience member is asking: My patient has moved from Kelowna in BC to Canmore in Alberta, but they want to stay my family medicine patient and attend virtually. How to manage that?
Dr. Dennis Desai: Happy to take the question. I mean, it's challenging with the health and human resource problem out there. I can understand why patients may want to stay attached and why you may feel obligated to try to help out, but, boy, there's a lot to unpack there. You now have a patient that's quite remote from you.
Do you understand the local referral patterns? Where you get a chest X-ray, even bloodwork? If you have to refer to a surgeon or an oncologist, where would you go? Generally, a lot of Colleges, Marty mentioned, suggest that you have a backup plan. An option B. An in-person assessment is required, it would be ideal. And that you set that up ahead of time.
Would you have that in Canmore? And so that would be a major sticking point. And then finally, of course, there's licensing provisions that I think Marty has mentioned a couple of times. So, we would strongly recommend you check with both Colleges, to make sure that you are fulfilling the requirements you need to do if you're going to provide this patient with ongoing medical care.
You know, in the short term, maybe you could provide a bridge until that patient is able to set up some contacts locally. So, there may be some other options you could look at. And one thing I would like to mention is that you should inform the CMPA, our membership department, if you are going to be working in multiple provinces, because it may affect how we administratively set that up on our side.
Dr. Élisabeth Boileau: Right. And the next one I'm going to give to you, Lisa. So, the member is asking: What should I do if my patient is on the bus and insists on continuing with the virtual assessment instead of being in a private place?
Dr. Lisa Thurgur: All right. Thanks for that one, Élisabeth. I’d first like to say that I can relate with this member. I also like to multitask and do things on the go. I mean, my initial thought on that, even though it seems very simplistic, is that probably the best advice for this patient and the physician would be to reschedule the appointment.
The biggest issue for me in this scenario is privacy concerns. So even though the patient might feel that they can speak freely, that they could be frank or honest and answer questions, often they don't know what types of questions might be asked. I feel as though privacy would be the biggest concern. I mean, this relates a little bit also to patients who might want to take a virtual call while driving themselves as well.
So, not only is distraction a bit of a key, but you're never really sure who else is in the car. So, although it's often troublesome to reschedule appointments because everyone's time is very, very valuable, I do feel that privacy is the biggest concern there, and that the safest solution to that scenario would be to reschedule the appointment.
Dr. Élisabeth Boileau: Our next question: If I perform a virtual assessment and am concerned the patient requires an in-person assessment or emergent care, yet they refuse to go to the ED, what do I do?
Dr. Dennis Desai: Tough situation. And I speak from, you know, personal experience being stuck in that. Sometimes you can help them problem-solve. They may be sick or injured, or their family member is sick, and they just can't problem-solve how to get to in-person care. So, you may help to determine the barriers and help them overcome it.
If, on the other hand, intentionally, they just have no intention of coming in then, maybe, an informed consent. It's your obligation to make sure that they understand the risks that they undertake and the problems that could occur, if they really decide not to come in, because many patients don't realize how bad the situation can get.
Again, being a CMPA employee, I would stress the importance of documentation, so that you can explain the circumstances and that what you told the patient that could happen, and their responses, to show that you took every effort to provide this patient with the best care you could. These situations are challenging, and again, if there's any questions or concerns, feel free to contact us at the CMPA, because we're always here to help you.
Dr. Élisabeth Boileau: The next one I will give to Marty. What if the patient insists on an in-person visit, and I don't think it's necessary? For instance, for follow-up of test results or anything that wouldn't require a physical exam, for instance.
Martin Lapner: Yeah, that's a good question, and it's one that comes up a lot or we see a lot in complaints to the regulators. Patients sometimes want to be seen, and they expect their physician to see them. I think it's worth having a discussion with the patient about why they want to come in, and maybe you can explain to them why it may not be necessary in that circumstance. Colleges have differing requirements on this issue, but several require prioritization of patient preference where appropriate and available. And some Colleges expressly say if the patient wants to be seen in person, then you should see them in person. So, it's two things. Mainly, you should have a discussion, and if it's clinically appropriate and available, you should prioritize their preference.
Dr. Lisa Thurgur: Can I just add, Élisabeth and Marty. I mean, just putting my emerg doc hat on a little bit. I think it's also important for physicians to ask themselves: Is there any other reason why the patient might want to come in person, right? So, you know, occasionally we see patients in the emerg, or anywhere really, who have another agenda or a hidden agenda that maybe they weren't comfortable requesting or telling you the reason why on the phone, when they're booking the appointment or when they come to the emerg in front of other people. It may be a sensitive issue. So, I think it's always important to also ask yourself: Why are they asking for that in-person appointment? There may be another reason that really is worth seeing them in person.
Dr. Élisabeth Boileau: Thank you for that. And we will go back to you, Dennis. So, we have a question from a psychiatrist who says: I would like to spend the winter in Arizona. My patients would like to keep seeing me as needed virtually. Is this okay?
Dr. Dennis Desai: Thanks for the question. Yes, we get that question a lot. Most of us would prefer to spend the winter in Arizona. I want to stress here, though, that the CMPA extent of assistance extends to Canadian physicians practicing in Canada. And so, there would be no protection for this physician should there be any medico-legal issues, both in Arizona and in Canada.
I just want to take the opportunity to also mention that the licensing issues that may occur, because now they are stationed in Arizona, and Arizona may expect them to have a license if they are practicing in Arizona. And then there's the College requirements, so that if your patients are in a certain province where that College says they need to be able to look to in-person follow-up if necessary, and you should have a hook-up with a local provider.
Have you made that determination, that junction. So, CMPA, no protection, and if you are going to do it, you can use an alternate liability protector. But consider these other things about licensure and College requirements.
Dr. Élisabeth Boileau: Back to you, Marty. If you deliver virtual care exclusively, meaning that you do not have a physical practice, is it acceptable to refer to a local walk-in clinic if a non-urgent in-person care is recommended? I know you've touched on this a bit in the panel already, so that's why I'm going to you.
Martin Lapner: Yeah. So, we did touch on that a little bit during the main portion of the webinar. And many Colleges have stated that physicians should generally refrain from referring patients to the emergency department or walk-in clinics as a de facto backup, or as a replacement for in-person appointments. Some Colleges expressly refer to this requirement and some prohibit virtual-only medical clinics, which touch on this issue.
For example, the Colleges in Nova Scotia and BC say that either you or someone with whom you have a formal arrangement in place has to be able to see your patient in person if required and within a reasonable timeframe. So, that's something to consider.
Dr. Élisabeth Boileau: Absolutely. Okay, so this next question I'm going to not assign to anyone. Anyone can take it. It's a question that's been recurring in the Q&A. So, I'll ask this version of the question, but it has come up quite a bit. So, just to clarify, when it comes to virtual care, does this only involve video, or a phone call as well?
I have seen healthcare professionals providing appointments on phone.
Martin Lapner: Yeah, that's a good question. And it actually raises a few issues. It's worth looking at the College policy definition. Most of them are quite broad and they would capture video and telephone. In fact, I think they would invariably capture both. Some also differentiate between synchronous or asynchronous communication. So, that would be electronic communications that are in writing, so they're not at the same time. And they're generally broadly defined to capture all of these. So, telephone or virtual, they would all be captured within this.
The second issue, which is a bit of a nuance that I wanted to raise, is that some College policies actually say: when providing virtual care, the preferred mode is to use video as well. So, you may want to look at the relevant College policies in your jurisdiction to see whether they're saying you should be using video as a preferred mode.
Dr. Élisabeth Boileau: Thank you, everyone, for all your answers. There are many more questions we're getting, but this is all the time that we have. So, I'm going to hand it over back to you, Lisa.
Dr. Lisa Thurgur: All right. Thanks very much, Élisabeth. It is too bad we are out of time, but I do want to thank our panel again and our expert moderator for being part of today's session. And I want to thank all of you for all of your questions. Now, my guess is that given the number of people who were on the webinar, that we probably didn't get to all your questions, and for that, I do apologize, but you should know that we read through all of the questions that come through the Q&A regardless, and we use those questions to help inform future content, so we really do appreciate them. We hope that you were able to take away a pearl or two about improving patient safety and reducing medico-legal risk when it comes to using virtual care in your practice. Thanks again for joining us and have a great rest of your day.
