Physicians who are closing their medical practice often contact the College to seek guidance about the measures they should take before they close their medical practice. The College also receives calls from patients asking how they can obtain their medical records, obtain outstanding prescriptions, or laboratory reports because their physician has closed their practice.

This document is intended to help physicians interpret their obligations as set out in the Closing a Medical Practice policy and provide guidance around how these obligations may be effectively discharged.

Notification

The policy requires that physicians notify patients whose care is being actively managed. What does “actively managing care” mean?

There are straightforward examples where it is clear that a physician is actively managing a patient’s care.  For example, you are seeing the patient on a regular basis or even only annually.  In addition, actively managed would include patients who are rostered with your practice and being counted as part of your contract, or where you are writing or renewing prescriptions or being kept informed about care provided to patients by other health care providers even though you may not be personally seeing them regularly.

Similarly, there are straightforward examples of when physicians are not actively managing care. For example, where a specialist’s involvement with a patient has already reached its natural or expected conclusion prior to the practice closure, or episodic care that is being provided in an emergency room or walk-in clinic. In these situations, neither the patient nor the physician is likely to have an expectation of an ongoing physician-patient relationship and so would not be captured by the policy.

However, there are many more examples and case specific scenarios where professional judgment comes into play in determining whether or not notifying patients is required by the policy.

In addition to notifying patients directly, what other steps can physicians take to help ensure patients are aware of the practice closure?

While direct notification is required to ensure that patients are personally informed about a practice closure, direct notification can also be supplemented by the following methods of notification:  

• Printed notice, posted in the office;
• The outgoing voicemail message;
• A notice posted on a website; and/or
• Newspaper advertisement.

Who else should I be notifying (in addition to patients, the CPSO and hospitals) about my practice closure?

The policy states that physicians must use their professional judgment to determine whether other health care providers involved in the patient’s care would benefit from notification. This could include other physicians, pharmacies or laboratories that patients frequently use.  As well, there may be others who would benefit from notice of a practice closure, such as the Ministry of Health and Long-Term Care.

Arranging Ongoing Care

How can I help my patients find another physician to take over their care?

The policy requires physicians to take reasonable steps to facilitate ongoing care. Recognizing that what is appropriate will depend on the reason for the practice closure, the needs of the patient, and the risks to them if ongoing care is not arranged, as well as the system resources that are available in the physician’s community. For example, what steps are reasonable would look different for a family physician in a well-resourced community compared to an underserviced community or when planning well in advance of an upcoming retirement when compared to an unexpected closure due to an illness.

Generally speaking, it’s considered best practice for physicians who are retiring or relocating their practice outside their current community to try and arrange for a successor to take over the entire practice or at least a part of the practice. However, the College recognizes that this will not always be possible for a number a different reasons.

In those instances where it’s not possible to arrange for a successor or where patients opt not to go with the planned successor, physicians can still provide some assistance to patients in finding a new health care provider.

For many patients, it will be sufficient to provide them with information about how they can access ongoing care, using the resources listed on the College website. However, patients who may be categorized as higher-need, marginalized and/or complex¹ may require additional assistance in order to arrange for the ongoing care of these patients.

Records

If I am arranging for a successor to take over my practice can I provide them with information about patients in my practice?

The Personal Health Information Protection Act, 2004 (PHIPA) permits physicians who are custodians of the medical record to disclose patients’ personal health information to a potential successor for the purpose of allowing the potential successor to assess and evaluate the physician’s practice as long as the potential successor enters into an agreement to keep the information confidential and secure.²

What happens to my patient records if I die?

If a physician dies, the estate trustee of the physician is deemed to be the custodian of the records until custody and control of the records passes to another person who is legally authorized to hold them.³

Where there is uncertainty about who is responsible for the medical records of a deceased physician, a call to the CMPA or the College’s Physician Advisory Service can help. More information about medical records and practice closure can be found in the resources listed below.

I am relocating my practice, what are my record retention obligations?

When you relocate your practice, you are still responsible for meeting records retention requirements, whether or not you will be providing ongoing health care to your patients.  If you are transferring custody of records for patients you can contact the CMPA to ensure that the arrangements you make for record transfer and retention comply with your obligations under the Medicine Act, 1991 with respect to records and PHIPA.

It is good practice when you transfer medical records to someone who is legally authorized to hold them, to document record transfer arrangements in a written agreement. An agreement can address the following:

• The location of the records;
• The requirement of the receiving physician to notify the transferring physician if the records are moved to a different location or transferred to a different physician;
• The transferring physician’s right of access to the records in the event of a civil claim or College complaint;
• The patients’ right of access to the records;
• The length of time for which the records must be retained;
• The obligation to protect the confidentiality of the records; and
• The destruction of the records.

Limitations following a resignation, revocation or suspension

The policy does not discuss new prescriptions written before a physician resigns, or is revoked or suspended  — are they valid?

The policy requirements focus on informing patients about the most likely scenarios they are liable to encounter. The Ontario College of Pharmacists also provides guidance on these issues, and their Fact Sheet notes that the decision to dispense a prescription or refill after a prescriber’s registration status has changed and the patient is no long under their care should be made on a case-by-case basis. Therefore, a pharmacist will need to exercise their professional judgment when faced with a prescription from a physician whose certificate of registration is no longer valid, even if it was valid at the time of writing the prescription.

Resources

The information below provides additional guidance for physicians with respect to closing a medical practice.  Information includes: planning for an unexpected closure (i.e. unexpected death or illness), planning for an expected closure, what to do about patient medical records, sample notification letters to patients, privacy obligations and other office management considerations.

Canadian Medical Protective Association

The CMPA is a national organization and provides broad advice about a number of medico-legal issues.  For Ontario specific information physicians are advised to look at the CPSO policy and advice document regarding medical office closure issues. However, the CMPA has a number of resources on the issues generally that physicians may find helpful.

For example:

• Closing or Leaving a Practice: Tips for Primary Care Physicians
• Winding Down Your Practice
• Electronic Records Handbook

Ontario Medical Association

• Closing a Practice: A Guide for Physicians (includes sample patient notification letters)
• Closing your Practice Due to Retirement?

Information and Privacy Commissioner of Ontario

• Succession Planning to Help Prevent Abandoned Records
• Avoiding Abandoned Health Records: Guidance for Health Information Custodians Changing Practice
• Frequently Asked Questions: Personal Health Information Protection Act, What are the requirements for the treatment of personal health records in the event of a change in practice? (p. 15)

Ministry of Health and Long-Term Care

• HealthForceOntario: Transition Out of Practice: A Guide for Physicians  

Endnotes

^1. These patients include those requiring urgent access to care, those with chronic conditions, an activity-limiting disability, mental illness, or other socio-economic factors.

^2. PHIPA, s. 42 (1)

^3. PHIPA , s. 3 (12)