Virtual Care Expectations

Virtual care improves access to care and increases efficiencies, but it is not appropriate in many instances

After an extensive consultation, Council has approved expectations for physicians about the appropriate use of virtual care. A companion Advice document helps physicians interpret their obligations as set out in the policy.

The Virtual Care policy recognizes the important role virtual care can play in the health care system by improving access to care and increasing efficiencies in the way it is delivered. But the policy also recognizes that virtual care is not appropriate in many instances and emphasizes the core expectation that physicians meet the same standard of practice as though the care was provided in-person.

“Generally, virtual care is not meant to replace but to complement in-person care as there are real limits to what can be done virtually. Not all conditions can be treated virtually and not everyone has equal access to or is comfortable using technology,” said Dr. Sarah Reid, a member of the Policy Review Working group.

The document was informed by consultation feedback and by perspectives shared during our Virtual Care Symposium in which we brought together patients and physicians to discuss what quality virtual care looks like.

During the consultation, there was broad support for the draft policy with most survey respondents agreeing the draft was clear, easy to understand, and the expectations reasonable. Accordingly, many of the expectations in the draft were retained in the approved policy.

Physicians will need to consider what is in their patient’s best interest and find a solution that balances the need for access, safety, quality care, and, where possible, patient preference

Given the dramatic transformation in the delivery of health care that has occurred during the COVID-19 pandemic, the consultation feedback was strongly informed by respondents’ experiences. While many respondents championed virtual care in terms of its potential to promote access, convenience, and safety, significant concerns were raised about virtual care inappropriately being prioritized over in-person care. The consultation also heard concerns from key stakeholders regarding the proliferation of virtual walk-in clinics and substandard virtual care more generally.

The policy’s expectations related to scenarios requiring in-person care were updated and strengthened. In particular, the policy continues to require physicians be mindful of the limitations of virtual care and take appropriate action when the physician determines that in-person care is required. Appropriate action is now specified as informing patients of the urgency with which in-person care should be sought and providing or assisting patients in accessing in-person care in a timely manner (e.g., through coverage arrangements or by directing patients to local in-person options.)

The policy reminds physicians the standard of care remains the same and must always be met whether care is provided in person or virtually. Meeting the standard of care in a virtual environment includes: continuing to obtain a relevant history, conducting appropriate examinations, ordering diagnostic tests, and making diagnoses and/or differential diagnoses, as appropriate. It involves explaining the benefits and risks of treatment options, providing suitable treatment plans, and ensuring necessary follow-up. It also includes ensuring that patients referred to specialists are appropriately investigated, examined and treated before a referral is made.

“If a physical examination is required in order to appropriately assess or treat the patient, then virtual care will not enable you to meet the standard of care in that instance,” said Dr. Reid, who practises as a pediatric emergency physician in Ottawa.

However, she said there are limited exceptions, such as during contagious disease outbreaks, or for a patient whose access might be otherwise limited to the point of risking patient harm. A risk-benefit analysis can help physicians determine whether the standard of care can be met with a virtual encounter. As part of the analysis, a key factor is the platform under consideration. Video-based platforms may allow for a modified physical examination, while telephone-based encounters are very limited in their scope are much more limited in terms of what can be done.

The consultation feedback made clear that not all patients have access to technology, are comfortable using technology, or are able to receive care virtually. At the same time, not all patients have equal ability to make themselves available for in-person care or have the same access to local in-person options. “Physicians will need to consider what is in their patient’s best interest and find a solution that satisfies the need for patient access, safety, and quality care, as well as patient preference, where possible,” said Dr. Reid.

Although physicians are ultimately responsible for determining which modality will result in the best outcome for patients, effective and sensitive communication in these instances can go a long way towards resolving any disagreements, she said.

CPSO recognizes the provision of virtual care will continue to evolve with the development of clinical practice guidelines by other organizations and specialty associations. Our policy approach supports that ongoing work by anchoring our core expectations to the standard of care.

4 things to know about the policy

1. Physicians must only provide virtual care if the standard of care can be met and existing legal and professional obligations can be met.
2. If during an encounter, it’s determined that in-person care is needed, physicians must take appropriate action, including providing or assisting patients in accessing appropriate in-person care in a timely manner.
3. Consider patient preferences and accommodate where clinically appropriate and available.
4. Physicians must use technology is that is fit for purpose and facilitate a quality encounter.