Consultation 021 - Virtual Care

Virtual Care has a valuable place in my practice for my stable patients to come in person every other visit and a phone call check up in between and for my patients from rural areas in inclement weather in a pinch and a few other scenarios. Virtual Care as a type of telephone or video walk- in clinic with a doctor from anywhere in the country or in the world has very little to no added value to a patient versus the patient going to an ER or walk- in in their own community who understands the region.

I appreciate the need for the text: "Explicitly stating that ordering investigations under another healthcare provider’s name is inappropriate". One exception to this would be if my office partner is out of the office and I provide a virtual visit to one of his patients who requests a new standing order for their INR test, I'm going to have the EMR generate the requisition in my partner's name, not my own.

Congratulations on the modernization of this document. I would like to request further clarification of the cross border care standard item 1. As it reads it is a bit unclear what the implications are, for example, if a patient I have a prior therapeutic relationship with is temporarily located outside Alberta. If they are a resident of Alberta I am a bit unclear what the issue would be even if they happen to be for example "wintering" in California. Further clarification would be helpful to the provider.

As a consultant(surgery), I feel that virtual care cannot meet the necessary requirements for referral of a patient who has a medical issue(e.g. a hernia) that requires a physical examination for diagnosis. As a result our group is sending back virtual medicine referrals that do not fulfill this requirement. These patients must be examined by a physician in person in order to make an appropriate referral. Anything less than this is inappropriate and in no better that healthlink and algorithmic triage.

There are special circumstances which I hope the various Colleges will consider. I practice addiction medicine - and am seeing a number of patients who are unable to travel to see me as they would ordinarily in pre-Covid times. For instance I have two aboriginal patients in Northern Ontario who cannot travel easily - Zoom has been a huge benefit in continuing to care for them. This is not opportunistic or "cherry-picking" - in fact it is challenging to do good care - but myself and my therapeutic team have been able to via virtual care.

In another issue - (although this is third-party and not public healthcare system billable - it still pertains to professional ethics and cross-border medicine) - I have two helicopter pilots who needed aviation medicals - they are currently trapped in Borneo and unable to fly out due to pandemic restrictions. We were able to complete these exams via Zoom. Ordinarily they would have physically travelled to Alberta to see me.

Thank you to all who worked on this document as it brings many improvements. I see value in giving leeway to out-of-province physicians treating their own patients when that patient happens to be in Alberta. For example, a patient living in Ontario speaks with their Ontario psychiatrist once a month. If that patient happens to be in Alberta at the time of their monthly visit, technology could allow that beneficial care to continue even if it is not an emergency. If the CPSA allows this, then other provinces might reciprocate, allowing us to continue care on our patients when they travel.

It’s great not to arrive on Time for an appt only to sit and wait an hour plus while a sour receptionist glares at you for asking for and eta of when you will get in as you sit sandwiched between other sick people! Plus the care I get has been better then those who live in my rural community’s - they actually listen

I am a generalist In Mental Health (GP psychotherapy). I have been doing virtual counselling just by phone since Feb 2020. I provide continuity of care in regards to counselling. The vast majority of clients have accepted and thrived with this model of care. I have been pleasantly surprised at the depth of connection that we establish despite no physical contact.
Many clients enjoyed the freedom of not having to travel to the office. Others have expressed missing the in-person contact
I recommend for the future beyond the pandemic a mixed model of counselling that includes virtual and in person

I am not clear on why the emergency-care exemption from holding a CPSA license is needed. Surely any telehealth / virtual care service requires setup and provisioning, and obtaining a CPSA license is an essential part of that process. Are we so desperate that we need to allow unlicensed providers in any setting at all?

My concern is that this is a wedge or slippery slope which could allow unlicensed providers to provide large amounts of loosely-interpreted 'emergency' care in Alberta.

I would prefer to remove this exemption.

Virtual care ought to made permanent and on par in every way with face to face consultation

Some primary care physicians still struggle with provision of care virtually because of the limitations to the amount of information we can get without a physical examination component in an encounter.
Some clinical presentations still require in-per examinations to be able to correctly diagnose and provide proper care.

I was confused by the direction not to "cherry pick" or refuse patients for virtual care based on complexity but at the same time needing to assess whether a patient is appropriate for virtual care based on their complexity. I am thinking about services whose physicians may live in urban areas but that offer virtual care to patients in rural areas where there is a physician shortage. In my mind, the service is only appropriate for less complex patients but at least that offloads those patient who are less complex but do not have access to a local family MD from having to go to ER. If that is considered a benefit, how can the physicians providing the service make pre-arrangements for patients to receive care other than at the ER if there are no local physicians accepting patients for primary care?

Thank you for bringing up the concept of Virtual Care. I thinks it would enhanced the continue care of our patients in the current situation.

This is still early days in regard to virtual care. Progress will largely depend on big bussiness. The CPSA should help guide the profession down the path, and refrain being prescriptive.

The proposed Virtual Care standards do not deal with a few important issues:

1. It should be explicitly stated that virtual care can only be provided to patients who are physically within Alberta. Virtual care is not meant to be for Albertans travelling within Canada or for patients out of country as those patients should seek local medical care for their concerns. There should be some sort of standard protocol in place to verify patient location prior to the virtual visit being initiated.

2. Physicians offering Virtual Care while physically located outside of the province should be required to have an established relationship with a local clinic in the same city as the patient (at least for major urban centres where care is abundant). Many patients attempt to seek virtual care for issues that are inappropriate for Virtual Care. In these cases, there should be a pre-arranged or designated clinic or physician who can see the patient in person, who can physically examine the patient and who has access the visit notes from the Virtual Care physician.

3. Physicians practicing Virtual Care should be required to be on-site in Alberta for at least a few weeks per year in order to understand the local style of medical practice. This will ensure the highest standards of care and reduce the chance for over investigation and over referral. In other specialties (ex. Diagnostic Imaging), AHS has a requirement that physicians practising remotely should return to Alberta for approximately 2 weeks for every 8 weeks they work abroad. A similar requirement should be considered for primary care.

4. There is a double standard between other provinces (ex. Ontario) as other provinces require both the physician and patient to be located in their home province in order to bill for the visit (ex. OHIP). With an uneven playing field, it will be harder to attract physicians to Alberta as physicians may elect to live elsewhere and practice “virtually”. In am not sure this is in the best interest of Albertans, especially in urban centres where care is abundant. Are other provinces going to open up their patients to being seen virtually by docs physically located in Alberta (of course with the required provincial license)?

Virtual Care

QUOTE:

GLOSSARY

Appropriate assessment: includes, but is not limited to, taking a patient history, visual inspection (if applicable) and performing/ordering any necessary diagnostic tests, investigations or procedures that are required to help establish a diagnosis and/or guide management. Commented [CD16]: Added to address a common issue/query. Commented [CD17]: From CPSBC. Commented [CD18]: Added to address common issue/query.

Virtual Care Appropriateness, limitations and privacy risks: virtual care is appropriate when it will facilitate a good outcome and, in some cases, may be the best option; however, some health concerns cannot be managed virtually (e.g., the patient requires in-person assessment).

My humble opinion:

In the above paragraph, the "HOWEVER, SOME HEALTH ISSUES CANNOT BE MANAGED VIRTUALLY (e.g., THE PATIENT REQUIRES in-person assessment)" might not be well formulated, and might lead to confusion and misunderstanding. Shouldn't it be: "however, some health concerns cannot be managed virtually (e.g." THE PATIENT"S MEDICAL ISSUE requires in-person assessment)" instead ?
There are those issues that cannot be managed virtually: e.g, looking for a hernia, checking a prostate, examining a patient in-person because of the presence of red flags symptoms...
But to say that "some health concerns cannot be managed virtually (e.g., the patient requires in-person assessment)" .might make people erroneously think that " I want in-person visit, so the doctor has to oblige"...
I am thinking about those situations we had when a patient (who does not believe in Covid, is against masking, against self distancing …) asks to be seen in-person to be able to vent "in-person" their anger against an employer, … or to rant "in-person" about public health measures, about governments conspiracies... Supportive listening and finding a way to help those patients can take 30 min to 60 min a visit …even more. Might be not a big issue, pre-Covid era. But in this Covid era, how would you feel, stuck for 30 min in the tiny exam room, not optimally ventilated, with the patient standing at less than 3 feet from you, blocking the door, talking loudly and relentlessly, and projecting visible droplets of saliva onto your face because his mask (if he agrees to wear one), loosely worn, has dropped to his chin... You are scared, you feel "ambushed" ( as a colleague of us put it) because those peoples are the most at risk peoples, are the ones who do not care about contracting the virus ("it's a hoax"), do not care about spreading it to other people, other patients ( "it's just a bad cold, why are you so scared?"). One of our poor staff was on the brink of tears on that evening, and she was so traumatized she asked not to be put at the front desk the following days...

Wouldn't it be clearer to say "however, some health concerns cannot be managed virtually (e.g." the patient's MEDICAL ISSUE requires in-person assessment)" instead ?

Just an humble opinion

Any chance of changing the name to "Care Provided Virtually"? Maybe just me, but "virtual care" always sounds a bit like "not-really-care" or "not-as-good-as" care, when in some circumstances care provided virtually could be more appropriate than in-person care!

The issue of cross-border virtual care is confusing. I'd suggest it's quite different for a CPSA-regulated Alberta doc to provide care virtually to an Ontario resident living in Ontario, than it is for an Alberta doc to provide virtual care to an Alberta patient, with whom they have an existing relationship, who's travelling in Ontario. Yet the draft SoP treats both the same. (Interestingly, the doc is allowed to be out-of-province, but not the patient).

Presuming the point is to regulate cross-border "dial-a-doc" operations primarily, would it make more sense to tell docs who don't have a CPSA practice permit - get an Alberta license if you want to treat patients in Alberta, "unless it's a patient temporarily/newly-arrived in Alberta with whom you have an existing physician-patient relationship"? And tell Alberta docs the same thing for caring virtually for patients outside Alberta? And it doesn't really make sense to tell out-of-province docs they can only provide virtual care "in emergencies, where no other options exist" - there's always an Alberta ER open, but why load them up with patients needing a prescription refill from their regular doctor in New Brunswick, or advice about their peritoneal dialysis from their home team? Unfortunately, a "dial-a-doc" company could probably argue that Alberta patients called in BECAUSE they couldn't access other care options when they wanted it!

By definition, virtual care can't be provided "in the same manner in which they apply to care provided in person" - paragraph 7.

Reading through paragraph 9, it's clear this is aimed at episodic virtual care, not virtual care "thoughtfully used to promote continuity of care within the context of a therapeutic relationship". Doesn't make sense to require me to tell my patient my "name, location, and licensure status" every phone visit.

I'm not at all clear on what's meant by paragraph 12, in the context of virtual care? What parts of the "full scope" of the prescribing-related SoPs can I dispense with? When can I just fire off a Rx for someone else's patient? It would help to clarify what this is addressing...

"Appropriate assessment" is defined in the Glossary as no-physical-exam, which is generally felt to be the sticking point re. whether virtual assessment is appropriate. However, the SoP (paragraph 8) states the doc "must consider whether virtual care allows appropriate assessmentG of the presenting problem and, if it does not, must personally arrange for a timely in-person assessment..." If the glossary definition is used, there would never be a time when virtual care wasn't fine! 🙂 Suggest maybe removing that definition from the Glossary altogether?