Third Party Medical Reports

Shelves of medical charts

Physicians play an important role when conducting independent medical examinations (IMEs), and providing third party medical reports and testimony. A policy has been approved for the purpose of setting out obligations for physicians who take on this role.

The Third Party Medical Reports policy, which consolidates CPSO’s Third Party Reports and Medical Expert: Reports and Testimony policies, contains expectations reflecting the range of physician involvement in third party matters — from treating physicians filling out forms for their patients to physicians providing testimony as experts.

At its June meeting, CPSO Council approved the new policy, which was updated to reflect the feedback received during the draft policy’s external consultation.

Overall, feedback on the draft policy was largely positive. Most respondents found it clearly written, easy to understand and comprehensive, and feedback around the draft expectations was largely supportive. However, some respondents expressed concern regarding some of the new expectations. The provisions that generated the most feedback pertained to the requirements to have an active certificate of registration and be actively practising in order to accept a request to conduct an independent medical examination (IME) and/or act as a medical expert.

The Policy Review Working Group considered the feedback and decided to only require an active certificate of registration for IMEs. They replaced the active practice requirement with the expectation that physicians only accept requests to conduct IMEs and act as medical experts if the matter falls within their scope of practice and area of expertise, and they have the requisite knowledge, skill and judgment.

“We believe the change regarding active certificate of registration addresses the concerns raised by consultation respondents about the appropriateness of requiring licensure for medical experts when it may not be relevant in all cases, and it is ultimately up to an adjudicative body to determine whether or not an expert is qualified,” said Dr. Keith Hay, a CPSO Medical Advisor and member of the Policy Review Working Group.

Guidance provided in the companion Advice to the Profession document can help physicians determine whether they meet the new policy requirements when accepting requests to conduct IMEs and act as medical experts, said Dr. Hay. For example, physicians who are asked to conduct IMEs may want to consider whether they have proficient knowledge of the relevant practice guidelines, and whether they have current or recent experience practising within the scope of practice the matter requires.

What to Know

The updated policy also requires that:

  • Treating physicians provide testimony when ordered (e.g., by subpoena or summons);
  • Express consent be obtained to collect, use or disclose the subject’s personal information to a third party, and conduct an IME — although the policy acknowledges that obtaining consent may not be possible in a narrow category of circumstances;
  • Physicians be transparent about who assisted them with the IME and third party medical report, and ensure any statements and/or opinions expressed are their own;
  • Reports be completed in a timely manner. Outside of legal proceedings, third party medical reports that require IMEs must be completed within 60 days and third party medical reports that do not require IMEs must be completed within 45 days;
  • Requests for observers for IMEs be permitted when physicians are of the view that the observer’s presence will not impact the examination; and
  • Physicians who become aware of a clinically significant finding while conducting an IME take some form of appropriate action.

What to Document

Physicians must document the following for all professional encounters or services provided for a third party or third party process, where applicable:

  • Identification of the subject and their contact information;
  • Identification of the requesting party;
  • Date of professional encounter or service;
  • Consent that has been obtained for the collection, use and disclosure of information;
  • Consent that has been obtained for examinations;
  • Information regarding the IMEs that have been conducted;
  • Consent that has been obtained with respect to the presence of observers and/or recordings of examinations; and
  • Any clinically significant findings and any action taken with respect to the findings.