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Advice to the Profession: Telemedicine

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Advice to the Profession companion documents are intended to provide physicians with additional information and general advice in order to support their understanding and implementation of the expectations set out in policies. They may also identify some additional best practices regarding specific practice issues.

Telemedicine can play an important role in the health-care system for both patients and physicians by improving access to care and increasing efficiencies in the way it is delivered. As technology continues to evolve, it will bring new opportunities and advancements in the delivery of care via telemedicine.

At the same time, this option may not be appropriate in every instance. This advice document is intended to help physicians interpret and understand the College’s expectations regarding the appropriate use of telemedicine, as set out in the Telemedicine policy.

Can I provide care to patients exclusively via telemedicine?

It will depend on the circumstances of each case, including the specific care being contemplated. As noted in the policy and this advice document, you must use your professional judgment to determine whether telemedicine is appropriate for every patient and in each instance its use is contemplated for patient care. Some situations may be inappropriate for telemedicine, such as cases where an in-person physical assessment is required.

Can I delegate controlled acts via telemedicine?

When practicing telemedicine, you must continue to meet the same legal and professional obligations that apply to care that is provided in person, including the expectations set out in the Telemedicine policy and other College policies like the Delegation of Controlled Acts policy.

The Delegation of Controlled Acts policy outlines expectations for physicians about when and how they may delegate controlled acts. These include (among others) ensuring that:

  • the best interests of the patient are the primary consideration in every instance of delegation, and that controlled acts are not delegated solely for monetary or convenience reasons;
  • delegation only occurs in the context of an existing physician-patient relationship, unless patient safety and best interests dictate otherwise; and
  • the delegatehas the appropriate knowl­edge, skill, and judgment to perform the delegated act and is able to accept the delegation.

In addition, you must ensure that any adverse event that occurs will be managed appropriately, which may involve specific considerations if the delegation has taken place via telemedicine.

Can I prescribe medication (e.g. cannabis, Botox) via telemedicine?

Before authorizing a prescription via telemedicine, you will need to consider whether you are able to meet your legal and professional obligations and the standard of care in relation to the specific patient and the specific care being provided, in the absence of physical interaction with the patient.

With specific reference to prescriptions, you will need to take into account the expectations contained in the College’s Prescribing Drugs policy. This policy expects (among other things) that the physician will have current knowledge of the patient’s clinical status, obtained through an appropriate clinical assessment, which will include an appropriate patient history and appropriate physical examination (and/or any other relevant examinations or investigations).

What should I know when considering opioid prescriptions or treatment via telemedicine? 

In addition to the general expectations regarding prescribing, the Prescribing Drugs policy also contains expectations specific to prescriptions for narcotic and other controlled substances which must be complied with.

With respect to Methadone Maintenance Treatment (MMT), telemedicine may work best for patients who have achieved stability with their treatment plan and who have already developed a good working relationship with their MMT physician. While telemedicine can support treatment in communities where no other options exist for MMT, it should not generally be viewed as a replacement for in-person interaction where this can be facilitated. 

I work in a walk-in clinic where telemedicine is available to patients who self-identify with specific complaints and presentations. What should I keep in mind in these situations?

As in all cases, you need to be alive to the possibility that the specific interaction may be inappropriate for telemedicine. Where a clinic permits patients to choose a telemedicine option based on a self-identified concern, you should be aware that new or additional considerations could arise in the course of the patient interaction that change the nature of the investigation, potentially making telemedicine inappropriate. There may also be situations in which the self-identified complaint presents issues or complications that cannot be completely assessed through telemedicine technology.

Where you feel that telemedicine is inappropriate for the specific patient interaction, or has become inappropriate in the course of the interaction, an in-person consultation should be considered.   

Can I use videoconferencing apps such as Skype or FaceTime to provide patient care via telemedicine?

Videoconferencing can be a convenient way to remotely connect to patients, particularly those patients who may be located in rural or remote areas. While videoconferencing apps like Skype and FaceTime are readily available, you will need to assess in each instance whether videoconferencing is appropriate in each patient’s particular circumstances, including whether patient privacy and confidentiality can be adequately protected. Relevant considerations may include:

  • the privacy (or lack thereof) offered by the physician’s and the patient’s physical locations,
  • any technical limitations (such as low bandwidth, poor screen resolution, or unsecure networks or portals) that may affect the quality of care provided, and
  • whether the technology meets appropriate security standards.

If patient privacy cannot be adequately protected, an in-person consultation or alternate technology should be considered – in particular, telemedicine technology available through the Ontario Telemedicine Network.

Further information may be found in the College’s Confidentiality of Personal Health Information policy and the CMPA document Videoconferencing consultation: When is it the right choice?