As a result of the COVID-19 pandemic, physicians have had to rapidly pivot their practices to include virtual care provision. In this podcast, Dr. Yolanda Madarnas, CMPA Physician Advisor, and Dr. Steven Bellemare, CMPA Director of Practice Improvement, identify key issues to consider for the provision of safe virtual care. Listen to them discuss how to include considerations around clinical judgment, standard of care, informed consent, and privacy to provide the best virtual care you can.
CMPA Perspective article:
Providing virtual care during the COVID-19 pandemic
Dr. Yolanda Madarnas: Hi everyone. Welcome to the fourth installment of our podcast series in the context of COVID-19.
Dr. Steven Bellemare: I'm Steven Bellemare, Director of Practice Improvement.
Yolanda: I'm Yolanda Madarnas, Physician Team Lead in Physician Consulting Services.
Steven: Today we thought we would talk about virtual care in the midst of a COVID-19 pandemic. You know Yolanda the medical community has been very agile in pivoting to the use of virtual care.
Yolanda: Not everyone is necessarily feeling agile. I know that in speaking with members on the phone, some tell us that they are struggling.
Steven: Yeah, for sure, for sure. But you know we have to give credit where credit is due. The majority of our members are telling us that they are actually using the phone to provide care. This isn't new, but they are using it more and more and you know, that is, technically, virtual care and that's an agile way to pivot to providing care.
Yolanda: That's true. That's true. Using the phone is indeed virtual care. Virtual care isn't just about using platforms with video links and formal telemedicine channels.
Steven: In fact you know, virtual care broadly speaking is simply the provision of medical care using technology with the provider physically separate from a patient.
Yolanda: So, in this podcast, we are going to try to address some of the medical-legal considerations when performing virtual care encounters.
Steven: Many provincial colleges have published standards related to virtual care. It's important to be familiar with these requirements as well as the many resources that are available to you to help you implement virtual care.
Yolanda: Indeed these standards and guidelines highlight the importance of considerations like consent, privacy, limits to care, and documentation.
Steven: So today as we normally do, we will have three take away messages.
Yolanda: Well, first and foremost let's state the obvious. Virtual care can't completely replace face to face encounters. We do need to use our clinical judgment to determine when a patient needs to be rebooked for an in-person assessment.
Steven: Second when it comes to virtual care visits, the standard of care should not be unduly compromised. Medicine is medicine and some conditions are not amenable to virtual care. Patients need to be redirected for appropriate in-person assessments.
Yolanda: Last but not least, not all virtual care platforms provide the same level of protection and security of patient health information. It's important that the patient understands and consents to moving ahead with a virtual care encounter.
Steven: Right. So, Yolanda let's jump to number one. Virtual care cannot completely replace face to face encounters.
Yolanda: Well, that's obvious and goes without saying. Virtual care encounters aren't the same as face to face encounters for many different reasons.
Steven: Of course. Especially when they are done over the phone. Assessments will be missing key pieces from physical examination and from all the nonverbal information we instinctively pick up on without consciously thinking about them.
Yolanda: Yeah. That makes information gathering and information delivery that much more important.
Steven: Right.
Yolanda: So while the medicine is the same, a virtual encounter may require you put more effort into certain aspects. For instance, the pertinent negatives and pertinent positives and discharge instructions.
Steven: Right. What do you mean by that though?
Yolanda: So, our differential diagnosis and management plan is only as good as the information we receive. Perhaps more so in a virtual care encounter than a face to face encounter. We need to be careful to gather all of the information that we need.
Steven: Right. So garbage in, garbage out.
Yolanda: Kind of and similarly our discharge instructions need to be very clear, almost directive. For example, whether another virtual encounter is appropriate or whether that patient should go to the Emergency Room in the event of the situation not resolving.
Steven: You know we are hearing in fact from our members that virtual care is not unanimously embraced just because, in fact, it can be somewhat awkward.
Yolanda: But the reality is that it has an important role to play and it can be a valuable tool provided we recognize its limits.
Steven: True. Virtual care cannot replace face to face encounters entirely but many conditions can safely be managed through virtual care, would you not say?
Yolanda: That's true and it does take clinical judgment though to decide which ones can or should not be managed with this modality. Which takes us to key message number two: the standard of care.
Steven: Right. So, the colleges and courts expect that physicians won't unnecessarily or unduly compromise the standard of care. They will take into account the context in which the care was provided. We talked about that in podcast number one and in a pandemic situation a court or a college is likely to allow somewhat more latitude for virtual care than in a non-pandemic situation. Context does matter but judgment is critical.
Yolanda: Absolutely. So, while colleges acknowledge that these are unprecedented times it is essential for any physician going to use virtual care to consider just how suited virtual care is to assess any given patient.
Steven: For instance if you need to perform a specific physical exam maneuver for instance.
Yolanda: Yeah.
Steven: You may need to see a person in person.
Yolanda: Sure. Some elements of a clinical exam can be done via a virtual care modality if a camera is present. So a video may help you assess a rash or range of motion of a joint but it's not going to allow you to palpate an abdomen.
Steven: By and large most people tell us the phone is a good enough starting point. There may not be a need to go to a complicated series of web visits and platforms just so you can see a person.
Yolanda: Of course it's important to remember that everyone's practice is unique. So we each have to ask ourselves what problems can we safely assess and treat virtually and which ones can we not.
Steven: And not hesitating if the patient's condition is not amenable to being addressed virtually to rebook them for an in-person assessment either with you, a colleague, or sending them to an emergency assessment center.
Yolanda: Yeah. Let's restate the obvious, that standard of care should not be unduly compromised by virtual care. Medicine remains medicine and we need to offer our patients the best care possible under the circumstances.
Steven: You know speaking to the colleges again, they are aware of this. They have stated, a number of them have stated, that they will assess potential complaints in the context of how the care was provided.
Yolanda: Which is reassuring. But Steven, two situations come to mind where we might stumble.
Steven: Okay.
Yolanda: Take, for example, a patient who insists on being seen in person when they are offered a virtual care encounter. The flip side, a patient who we have asked to come in for a face to face encounter but refuses to come and be seen in person.
Steven: Well, you know what Yolanda, those are good points. We have heard from members about those issues, both of them, and the reality is that, with regards to the patients being concerned that they won't be satisfied with virtual visits, the rapid uptake of virtual care would actually suggest otherwise, that people are actually embracing this and finding it actually rather convenient. The biggest problem is in fact your second situation. It's that people who are seen virtually may in fact refuse to come in for a more in-depth assessment and that can cause a problem for the treating physician.
Yolanda: Absolutely. So, in both situations taking time to explore the issues is a great starting point. So, for example for the patient who insists on coming in, are their unmet expectations. What is the underlying need? Perhaps explaining that there is a risk of contracting COVID if they come in and trying to balance that against their wishes.
Steven: So, that might actually help them understand why a virtual visit may be appropriate despite some apprehensions around that. You know similarly when you do need to see someone for a more in-depth evaluation and they refuse, taking the time to explore their concerns is again a great place to start.
Yolanda: So perhaps there is a misunderstanding or an overestimation of the risk of contracting the virus that in fact needs to be addressed.
Steven: You know what we've seen this with people.
Yolanda: Absolutely.
Steven: Not wanting to go to Emergency Rooms. People are saying Emergency Rooms are empty compared to what they were before because there is that fear of the virus and conveying that information, that no, this is still a safe place to come and you really do need to do that is important. We are hearing from patients, from members I should say, that they are seeing, some patients that are more critically ill than they were before.
Yolanda: Because they delayed.
Steven: Yeah, exactly because they delayed attending the Emergency Room. So, you know in those cases where patients are hesitant to go see someone in person, it's important to document the advice that you give and your plans to comply with the standard of care. To do what the standard of care would call for.
Yolanda: In essence, this really is informed refusal. Patients can refuse to be seen, can refuse to follow our recommendations but as a physician, we do need to make sure they do understand those risks. Okay. So let's move to key point number three Steven.
Steven: Are we there already? Informed consent then.
Yolanda: Alright. So, consent for virtual encounters isn't really implied by simply participating in the encounter and it does need to be addressed.
Steven: This is really consent around the potential inherent security issues. The threat to personal health information that comes with virtual care.
Yolanda: It's important that we help our patients understand that privacy and security risks vis-a-vis their health information exist with the use of any platform, be it telephone, telehealth, video conference, email.
Steven: Security is a huge issue. We could spend a few podcasts talking about security but basically the big concern here is that the health care information can be intercepted by a third party.
Yolanda: That's where encryption of the platform is important.
Steven: Simply put, encryption means that the information is scrambled and it's indecipherable for anyone who doesn't have the access key.
Yolanda: Specifically it's important to understand there is a difference between encryption at large and end-to-end encryption.
Steven: Okay, that's going to need a little bit more explanation.
Yolanda: Yeah. It is complicated indeed and I'm going to do my best to try to explain it. So, an encrypted platform doesn't allow anyone but the two users to see the data. The data is scrambled in transit, but it isn't scrambled when it sits on a provider's server. There, it's not encrypted and that could potentially allow the technology provider, that company that sold you the platform, to mine your data while it sits on their servers. Without end-to-end encryption, they could theoretically access the content of that visit and figure out for instance that I'm an oncologist, that I specialize in breast cancer, that I connected with 10 patients in three regions between the hours of 9:00 and 3:00 and they can start building a profile that uses that information about my virtual care consults. Not the actual information but use it for non-healthcare purposes.
Steven: So that's where end-to-end encryption comes in. In end-to-end encryption, the platform company can't even access the content of the virtual care visit. That type of information is completely blocked off to them. It's definitely more secure and those issues whether or not you're platform provides encryption or end-to-end encryption is usually found in the small print, the fine print of your contract.
Yolanda: Something most of us are not trained to understand, know about, or even know to look for, but many provincial medical associations, colleges, and health authorities have actually come out with recommendations on which platforms they deem appropriate for use. Some have even bought licenses for all of their physicians and some have services that can help you sort this out.
Steven: Right. So, Yolanda, if I was to work in a clinic or a hospital and use a virtual care platform for instance that's provided by my provincial government, could I as a physician be held to account for something that I have no control over if there was to be a privacy breach?
Yolanda: Yeah. That's a good question. I mean, generally, physicians are allowed to rely on the systems provided to them by an employer, by an institution, a clinic, a hospital.
Steven: That said, it's also a good idea, to point out privacy concerns that you may have about your systems if you suspect or know about them. Even better for you to do it in writing so you can demonstrate your diligence.
Yolanda: Yeah. That's a great point and in fact, in most of these facilities, there are privacy officers whose job it is to look after that.
Steven: Yeah, you can't just use a patient's consent to use the platform to "wash your hands" of the security issues if there were to be any. In fact, one of the other issues to consider is that patients should avoid using a computer or device that doesn't belong to them, that belongs to someone else. Their employer for instance because some elements of their health care visit information, could be accessed through things like cookies, for instance.
Yolanda: Yeah. So, let's use this as the springboard to talk more about the consent issue. So, are physicians expected to get consent each and every time they conduct a virtual visit?
Steven: Well, it would be the prudent thing to do for sure.
Yolanda: Wow. So, each and every time they see the same patient, or can they just do it the first time?
Steven: Well, you'll see me coming here again, I'm sure. Ideally, you want to do it every time and that's because the issues may be different from visit to visit and the privacy concerns for one type of problem may be more acceptable to a patient then they are for another.
Yolanda: Yeah. So, I guess, generally speaking, it's best to assume that patients haven't even considered the security issues associated with virtual care and so it behooves us to point them out.
Steven: I think that's certainly very diligent, right? Every time.
Yolanda: Every time. People forget, people change, circumstances change.
Steven: Right.
Yolanda: There is more to consent then the security platform. Another important aspect is the limitations of the care when done virtually.
Steven: That's right. Does the patient actually understand that their issue may not be manageable by virtual care or that there are limitations in what you'll be able to say to them or the advice you will be able to provide?
Yolanda: By that, if a physical exam is deemed to be necessary that they are going to need to rebook for an in-person assessment or present to ER.
Steven: Right. In the end, these consent issues, Yolanda, the good news about those is that they can be delegated to someone else. You, the physician, don't necessarily have to do it yourself every single time.
Yolanda: Yeah, that's right. You can delegate that first step of consent to a practical nurse, a nurse working with you, your medical office assistant, a clerk. As long as you are confident that they have enough knowledge to explain things well and to address any questions that the patient has.
Steven: That confidence comes with you actually having had that discussion with them and training them how to do it, right? Then that way, once they have that consent discussion with the patient, all you would have to do is confirm with the patient when you log on that they are in fact okay with proceeding as you are checking their identifying information.
Yolanda: That's another important point, isn't it?
Steven: Right.
Yolanda: Checking that you are actually speaking with the right person.
Steven: Imagine that. I mean it's kind of intuitive in person but and its perhaps it's less of an issue when you are dealing with a lot of follow up of people that you know but certainly when are seeing someone for the first time, it's a good idea to check that you are indeed speaking to or seeing the right person.
Yolanda: That can be a simple as asking them to hold up their health card to the camera or asking them for their address, date of birth to correlate with the information that you have on file. I mean, you know when I call the credit card company, these are the questions that they ask me to make sure they are speaking to the cardholder.
Steven: Exactly. Speaking about knowing who you are talking to, consider the privacy of the space that you are in.
Yolanda: That's right. You know many of us are providing virtual care from our homes and it's important that our spouses, children, for instance, can't overhear or see what's going on during our consults.
Steven: Yeah, that might be easier said than done.
Yolanda: I know but we do need to do our due diligence and do our best. The kitchen table is probably not a good place.
Steven: I think that would be safe to say, yeah. You know, I add that it might be wise to ask your patient who at their end, may be listening in or watching as well. That way you will be better able to tailor your questions and conversations.
Yolanda: Remember to document these aspects as well.
Steven: Okay, Yolanda there is so much to cover but I think we need to wrap up on this issue.
Yolanda: I know time flies once we get going.
Steven: Right. Could we provide at least a take-home message for members who are exploring this brand new virtual care environment?
Yolanda: So as with all things, focus on your communication skills. Take time to understand your patient's concerns and their expectations.
Steven: Ask questions but let patients ask theirs as well. It's easy to speak over one another and to interrupt each other without visual cues that we are used to having.
Yolanda: For sure. Virtual care can eliminate some or even all of the nonverbal cues that we usually use to help us confirm understanding or satisfaction with an encounter. So, we need to make extra efforts to use explicit verbal communication to fill in those gaps of the nonverbal nuances that we lose with virtual care.
Steven: Let's not assume anything. You don't want to be filling in those gaps based on your own unconscious biases. You may interpret or believe things to have happened that in fact haven't.
Yolanda: So we know this is a lot. Please don't hesitate to call us to discuss your specific concerns or issues with virtual care.
Steven: Certainly these podcasts are not meant to be all-encompassing deep dives into anything in particular. They are meant to be an overview.
Yolanda: And food for thought. So, a reminder to have a look at the COVID—
Steven: The COVID-19 hub on our website.
Yolanda: On our website.
Steven: Lots of frequently asked questions. Chances are if you are asking yourself the question we've heard it before and it might be on our website. That said, don't hesitate to call us. We are always happy to talk to you in person.
Yolanda: Thanks again for joining us today.
Steven: Have a good day everyone.
Yolanda: Bye-bye.
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