In the wake of the novel coronavirus (COVID-19), health professionals are exercising all efforts possible to ensure that there is no disruption in service or breakdown in patient care. The Ministry of Health in Ontario has released health-sector specific guidelines to assist health facilities minimize the risk of infection within their respective practices.
Current public health directives advise against direct patient care in non-urgent situations. In these circumstances, health professionals may consider the delivery of health care via telemedicine.
Telemedicine - or virtual care - is the remote delivery of health care services using telecommunications technology. In appropriate circumstances, it can provide a mechanism for professionals to provide continued care while simultaneously limiting the potential spread of the virus. Telemedicine allows patients to be assessed and treated without attending in clinic. Of course, professional judgment must be exercised in order to determine whether telemedicine is appropriate for each patient. If telemedicine is not appropriate and in-person care cannot be provided, health professionals must institute plans with their patients to ensure appropriate continuity of care.
Health facilities and clinic owners should be aware of various considerations and potential risks, including the following:
- Which patients can you offer telemedicine services to;
- What permissions or insurance do you need;
- What platform can you use to deliver telemedicine;
- How do you communicate this optional service to your clients; and
- If telemedicine is not an option, how do you ensure continuity of care?
When considering whether you can offer telemedicine to your patients, you must consider the nature of the services you are providing, as well as their location and the location of their patients.
In terms of the nature of services, please consider the relevant standards, guidelines and practice directions concerning the modalities of services you are offering and exercise your professional judgment to determine whether these services can be provided without direct physical contact.
Regarding location, consider where you and your patients are located when the service is being provided. Given the changing travel restrictions and quarantines, it is possible that some health professionals and their patients may be offering or requesting care while outside of their province or territory and temporarily unable to return home. When providing telemedicine, it is important that you confirm both your and your client's location at the outset of each treatment session and that this information is recorded in your clinical records. When one party is out of jurisdiction, you must consider whether you need special permission from the foreign jurisdiction to provide the care, understand the guidelines, standards and legislation that apply in that jurisdiction and ensure that you are compliant with them.
Some health care professionals practicing telemedicine might need to be licensed in both the jurisdiction in which they are located as well as the jurisdiction where the patient is located.
While there is currently no national framework for telemedicine, a number of medical associations in Canada and the United States have released guidelines for the provision of telemedicine. For example, in 2006 the Canadian Psychological Association published draft ethical guidelines for psychologists providing psychological services through electronic means. In 2011, the Association of Canadian Psychological Regulatory Organizations published model standards for telepsychology service delivery. In 2015, the Ontario Psychological Association also published a best-practices guideline for the provision of telepsychology.
Prior to implementing telemedicine services, please ensure that proper insurance is in place to provide virtual care services. In doing so, make sure to ask your broker whether the insurance will provide coverage if you or your patients are outside of your home jurisdiction.
Ultimately, professionals are responsible for ensuring that the virtual services that they are offering can be provided in a manner that protects their patients' confidentiality and the security of their patients' personal health information.
While the use of readily available platforms like Skype for telemedicine can be appealing, Skype has been found not to be compliant with PHIPA. Health care custodians must carefully review user agreements for any program or application that they intend to use for the delivery of telemedicine. For instance, the Ontario Psychological Association recommends the use of platforms that offer bank-grade, end-to-end encryption for the provision of telepsychology.
In addition to ensuring that appropriate platforms are used to provide patient care via telemedicine, practitioners and clinics should make reasonable efforts to offer a complete and clear description of the telemedicine services they can provide. Amongst other things, these descriptions should include any user-end costs associated with virtual services, as well as the limitations of these services.
If telemedicine is deemed appropriate, health care facilities and professionals must obtain and document informed consent from patients who wish to opt in for telemedicine. Patients need to be advised of the benefits and risks of proposed virtual care so that informed consent can be obtained. A best practice would be for clinics to develop standard terms and conditions for telemedicine and have patients review and sign their consent to those terms. Additionally, consent and any related discussions with the patient must be recorded in the patient's medical record.
Communication with Clients
From the initial contact of proposing telemedicine services to the actual telemedicine patient visit, communication should be done through secured means.
While you may wish to email clients to communicate the options available to them, there are risks associated with email communication. For instance, one cannot guarantee that the intended recipient will receive and review the email once it has been sent. Additionally, there are risks of interception errors in sending emails. If you are unable to send secure encrypted email communication, then consent should first be obtained verbally (including over the phone) from patients before you communicate with patients through unencrypted email. Once consent is obtained, the amount and type of personal health information that is included in an unencrypted email should be limited. The simple identification of a patient as a patient can be a breach of applicable privacy legislation; therefore it is important that no patient identifiers (name, age, date of birth, address, etc.) be included in email communications.
Some public bodies, such as the Information and Privacy Commissioner of Ontario, also expect custodians to develop and implement a written policy for sending and receiving personal health information by email. In addition, they expect custodians to notify their patients about this policy and obtain patient consent prior to communicating via email that is not encrypted.
Continuity of Care
In considering your patient population and your obligations to ensure that your patients do not feel abandoned during this time when in-person care is not advisable, it is important to make best efforts to ensure that that your patients are left with as many options as possible.
This includes relaxing appointment rescheduling and cancellation policies, and coming up with a treatment plan and protocol - which may or may not include telemedicine - that can carry patients through this time. This plan may include providing patients with additional resources, contact information to use in times of crisis, referrals to other professionals available to provide emergency or ongoing care in your absence, and open dialogue to ensure continuity of care.
Most provincial Colleges that govern health professionals have continuity of care policies in place. For instance, the College of Psychologists of Ontario requires psychologists who may be impaired due to health reasons to ensure that their clients are notified and receive assistance in obtaining replacement services. Health care facilities should refer to these policies and standards if they anticipate a disruption in services. A number of Colleges have also recently released statements meant to assist and direct professionals with navigating the issues of patient care in the wake of COVID-19.
At the heart of these policies and statements is the objective of preventing breakdowns in patient care and providing patients with the tools they need to navigate the health care system.
 Ministry of Health and Long-term Care: http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/2019_guidance.aspx
 Canadian Psychological Association; Providing Psychological Services via Electronic Media; Draft Ethical Guidelines for Psychologists Providing Psychological Services Via Electronic; https://cpa.ca/aboutcpa/committees/ethics/psychserviceselectronically/;
 Ontario Psychological Association; OPA Communications and Member Services Committee, April 2015 : Guidelines For Best Practices in the Provision of Telepsychology: http://www.psych.on.ca/Policy-Public-Affairs/OPA-Guidelines
 Nicole Minutti, Health Policy Analyst, Information and Privacy Commissioner of Ontario; May 11, 2017: Electronic Communication of Personal Health Information, "A presentation to the Porcupine Health Unit (Timmins, Ontario).
 See for example the College of Nurses of Ontario: https://www.cno.org/en/trending-topics/novel-coronavirus/; the College of Physicians of Ontario: https://www.cpso.on.ca/Physicians/Your-Practice/Physician-Advisory-Services/COVID-19-Information-for-Physicians; the College of Psychotherapists of Ontario: https://www.crpo.ca/advice-to-rps-regarding-covid-19/