Understanding the Regulatory Framework of OTN’s eConsult

The use of virtual care, also called telemedicine, is growing in Ontario. The June 2019 Devlin Report on Ending Hallway Medicine referred to the Ontario Telemedicine Network’s eConsult program as a success story that could be built upon in the pending realignment of the healthcare system.[1]

What is telemedicine? How are electronic consultations remunerated? Do these services meet regulatory requirements? If you need advice about the practise of telemedicine, or related privacy issues, please contact spalter@ddohealthlaw.com or sgrauer@ddohealthlaw.com.

This blog explores telemedicine, electronic consultations and related regulatory issues.

What is telemedicine?

Telemedicine is the use of communications technology to provide clinical patient care, or to assist in the provision of such care, at a distance. Various technologies may be used, including telephones (land lines and mobile devices), electronic mail, video-conferencing, audio-conferencing, remote monitoring and telerobotics.[2] The improvement of access to medical services for patients in rural communities, via telemedicine services facilitated by the Ontario Telemedicine Network (OTN), has been reported in the literature.[3]

The Ontario Telemedicine Network facilitates various telemedicine programs[4] including:

  • eConsult – electronic consultations between primary care providers and specialist physicians in respect of a specific patient
  • eCare – applications or devices that monitor patients, or to allow patients to self-monitor in their own homes
  • eVisit – real-time video visits with patients.

This blog entry will focus on e-Consult, electronic consultations between health care providers.

Electronic consultations

The OTN eConsult is a service that lets a referring provider, such as a family physician or nurse practitioner, consult with a specialist physician over a secure hub provided by OTN, without requiring the patient to visit the specialist (in person or virtually). The referring provider sends the clinical question, along with relevant patient information such as patient/family history, history of the presenting complaint and (where indicated) laboratory and diagnostic test results, to the specialist. The specialist reviews the records and answers the clinical question, provides a consultation report and may request that the patient be referred.[5] In tele-dermatology, a referrer (including a specialist) can send digital images to a consulting dermatologist and receive a response within five days.[6] In tele-ophthalmology, patients are referred by their family physician to an OTN tele-ophthalmology site where their retina is scanned and the image is uploaded to an ophthalmologist for assessment, diagnosis and/or treatment recommendations while the referring provider coordinates follow-up care.[7]  Physicians can apply for access to the secure OTN hub and the eConsult service at https://support.otn.ca/en/form/otnhub-sign-form-ocfp-members.

The Ontario Telemedicine Network’s 2017-2018 annual report indicates that during that time period 33,643 electronic consultations took place, including tele-dermatology and tele-ophthalmology, and resulted in 78% referral avoidance.[8] Electronic consultations save time and money for patients who avoid a visit to the specialist.

Who pays for electronic consultations?

Under the eConsult program, there is no charge to the patient. Both the referring physician or nurse-practitioner, and the consultant physician, can bill OHIP for telemedicine services if certain conditions are met.[9] All physicians billing OHIP for telemedicine are required to complete a form to be registered as a telehealth provider with the Ministry of Health. The OTN website also indicates that consultants may be remunerated through another route via funding provided by the Ministry of Health.[10] Physicians are permitted to bill for services provided at sites outside the OTN network but only if the service is eligible for remuneration through OTN/the provincial telemedicine program and the site has been certified by OTN; it is unclear whether this remuneration occurs through OHIP or otherwise through the Ministry.

Regulatory requirements

Regulatory requirements for physicians providing medical services to patients vary somewhat across provinces and territories. Similarly, the requirements for physicians providing telemedicine services also vary across Canada. The College of Physicians and Surgeons of Ontario’s telemedicine policy states that it applies to CPSO-registered physicians, regardless of where the physician or patient is physically located when the telemedicine service is provided.[11]

Under the CPSO telemedicine policy, CPSO-registered physicians providing medical services via telemedicine, including consultations with other providers, are required to ensure that telemedicine is in the best interests of the patient, and that the physician’s regulatory and legal obligations, including the standard of care, can be met. Physicians are also required to ensure that the patient is accurately identified, and that the patient information obtained via telemedicine is reliable and of sufficient quality. Providers must also protect the privacy and confidentiality of their patients’ personal health information and ensure that the technology platform is secure.

How does a physician ensure that such security and technical requirements are met? According to the CPSO policy, physicians can do so by using the sites in the OTN network, or OTN certified sites, or by checking with a privacy expert.[12]

What happens if a physician is located outside of Ontario?

Under the CPSO telemedicine policy, if the consultant is outside of Ontario, but the referring provider is inside of Ontario, the Ontario referrer is expected to take reasonable steps to ensure him/herself that the consultant is appropriately licensed in his or her jurisdiction of practice and should alert the patient, via the use of a form, that the consultant may or may not be licensed to practise medicine in Ontario. If the referring provider is located outside of Ontario, and is not registered with the CPSO, the CPSO may report that provider’s actions to his or her local medical regulator, and reimbursement from OHIP may not be available to the provider.

A national telemedicine framework?

In most provinces, practising telemedicine across borders requires that the practitioner confirm that s/he is complying with the licensing requirements of one or both jurisdictions. Given that Canada has provincial regulatory requirements for the practice of telemedicine by physicians that are not harmonized, the Federation of Canadian Medical Regulatory Authorities is exploring a national telemedicine license for physicians to support the provision of telemedicine across all Canadian provinces and territories.[13]

Watch this blog space for updates. If you have questions, contact the author:  spalter@ddohealthlaw.com.

 

[1] Premier’s Council on Improving Healthcare and Ending Hallway Medicine, A Healthy Ontario: Building a Sustainable Health Care System, June 2019, available at https://files.ontario.ca/moh-healthy-ontario-building-sustainable-health-care-en-2019-06-25.pdf, pages 20-21.

[2] Telemedicine Policy. College of Physicians and Surgeons of Ontario. December 2014. Available at: https://www.cpso.on.ca/Physicians/Policies-Guidance/Policies/Telemedicine

[3] O’Gorman, L.D., Hogenbirk, J.C. and Warry, W. Clinical Telemedicine Utilization in Ontario over the Ontario Telemedicine Network. Telemed J E Health. 2016 Jun 1; 22(6): 473–479.

[4] Such programs include teledermatology, telepyschiatry, teleophthalmology, telestroke, emergency services, critical care and others. More information about these program is available at https://otn.ca.

[5] See https://otnhub.ca/patient-care/#econsult

[6] See https://otnhub.ca/patient-care/teledermatology/

[7] See https://otn.ca/innovationcentre/teleophthalmology/

[8] Ontario Telemedicine Network 2017-2018 Annual Report. Available at: https://otn.ca/wp-content/uploads/2017/11/otn-annual-report.pdf

[9] See the Schedule of Benefits, March 1, 2016, available at http://www.health.gov.on.ca/en/pro/programs/ohip/sob/physserv/sob_master20181115.pdf

[10] According to the OTN website, supra note 4, remuneration is available through the Ontario eConsult Centre of Excellence, which is housed at the Ottawa Hospital, in partnership with the Bruyere Research Institute and various regional and delivery partners including the OTN, OntarioMD, eHealth Ontario, the South East Academic Medical organization and the Champlain BASE (Building Access to Specialists through eConsultation).

[11] CPSO telemedicine policy. Supra note 1.

[12] CPSO telemedicine policy. Supra note 1.

[13] College of Physicians and Surgeons of British Columbia. Registrar’s message: Telemedicine and licence portability―the future of medical regulation in Canada. College Connector Volume 7. No. 2. March/April 2019.    https://www.cpsbc.ca/for-physicians/college-connector/2019-V07-02/01

 

DDO Health Law Update

July 26, 2019: A weekly scan of new legislation and regulations important to the Ontario health sector, as well as articles of interest.

 

Bills

The Ontario Legislature has adjourned until October 28, 2019.

 

Proposed and Approved Regulations

No new and approved regulations of interest.

 

Ontario Newsroom

Ontario investing in new long-term care beds in Mississauga

Ontario investing in new long-term care beds in Brampton

Supporting seniors and their families through consultations across Ontario

 

Articles of Interest

Ontario Health Teams

Barrie healthcare group given green light to submit an application to form an Ontario Health Team

Southlake, partners get thumbs up to continue Ontario Health Team application

Province approves new Ontario Health Team for Windsor-Essex

Focus of Ontario health care restructuring shifts to the community

 

Health Care

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BHATIA: The future of health care is digital

Hospital ‘black boxes’ begin providing data that will help reduce distractions, errors in operating room

 

Cannabis

Ontario First Nation divided over fate of legal cannabis grow-op on its land

Flavonoids are the next big thing in marijuana research

 

Public Health

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Things to do

30 things to do in Toronto this weekend

What is Virtual Care?

Virtual care, or telemedicine, is the use of communications technology to provide clinical patient care, or to assist in the provision of such care, at a distance. It includes communications technologies such as telephones (land lines and mobile devices), electronic mail, text messaging, video-conferencing, audio-conferencing, remote monitoring, internet-based tools and telerobotics. The June 2019 Devlin Report on Ending Hallway Medicine referred to several of the Ontario Telemedicine Network programs as innovative successes that could be built upon in the pending digitization and realignment of Ontario’s health care system.[1]

 

The Ontario Telemedicine Network website[2] provides or links to many different types of virtual care, which can be broken down into 3 basic types:

  1. eCare: applications or devices used to monitor patients, or to allow patients to self-monitor; such applications or devices may be sourced via innovative procurement together with the MOHLTC and the LHINs
  2. eVisit: real time video visits with patients, usually initiated by the health care provider
  3. eConsult: secure electronic consultations between health care providers about a specific patient

 

Virtual care services require registration by the physician to use OTN infrastructure.  Other infrastructure may be used if approved by OTN. The following chart identifies different types of virtual care solutions, most of which are provided by OTN or available through the OTN website.

[1] Premier’s Council on Improving Healthcare and Ending Hallway Medicine, A Healthy Ontario: Building a Sustainable Health Care System, June 2019, available at https://files.ontario.ca/moh-healthy-ontario-building-sustainable-health-care-en-2019-06-25.pdf, pages 20-21.

[2][2] https://otn.ca/


How DDO Can Assist Your Ontario Health Team

In the Second Report from the Premier’s Council on Improving Healthcare and Ending Hallway Medicine, the Premier’s Council offered 10 recommendations on how Ontario might achieve a healthcare system that is modern, sustainable, integrated and centred on the patient. It will be incumbent on Ontario Health Teams (“OHTs”), as the primary providers of front line health care services, to be examples of how the Council’s recommendations can be put into practice.

Our Experience & Expertise

DDO Health Law has the experience and expertise to help OHTs implement many of these recommendations in practical, effective and cost efficient ways.The

The Premier’s Council Recommendations

1. Integration

Recommendations 1-3 are focused on creating a healthcare system that is integrated around patients and across providers. The system should provide (i) more accessible and effective information to patients, families and caregivers and (ii) health services providers that can guide patients through a full continuum of health care services.

DDO can assist OHTs with:

Accessible and Effective Information

  • Obtaining patient consent
  • Disclosure of information to family and caregivers
  • Sharing of information across health care providers
  • How patient information may be made available for research purposes
  • Policies and procedures related to consent and handling of personal health information
  • Template documents for obtaining consent and for protecting and sharing information
  • Training staff on consent and privacy requirements 

Integration of Health Service Providers

  • Collaborative governance mechanisms, e.g. multi-organization steering committees
  • Moving towards long-term integration, e.g., shared committees, boards or full-on merger/amalgamation
  • Contractual arrangements for shared services and collaborative initiatives
  • Sharing of electronic health records between health services providers

2. Innovation

Recommendations 4 and 5 are attempts to modernize the healthcare system to better use current technology and to expand on the pathways by which healthcare has traditionally been provided.

DDO can assist OHTs with:

  • Providing virtual health care in accordance with applicable laws
  • Creating inter-professional care teams
  • Seeking required approvals for the provision of home and community care services
  • Providing home and community care services in accordance with applicable laws (including privacy and consent requirements)
  • Purchase and use of innovative software and equipment for patient care

3. Efficiency and Alignment

Recommendations 6-8 propose means of creating a healthcare system that: (i) strategically collects and uses data in a manner that will improve health outcomes and (ii) coordinates services to allow for increased value for taxpayer dollars.

DDO can assist OHTs with:

  • Sharing data and electronic health records
  • Using data for research and quality improvement purposes
  • Methods of collaborative governance
  • Co-location options
  • Sharing of management and front-line staff
  • Integration of administrative and procurement services
  • Integrating health services through services agreements and inter-professional care teams
  • Electronic referral processes

4. Capacity

Recommendations 9 and 10 consider how short- and long-term capacity issues might be better addressed by maximizing assets and skills that are currently available. The recommendations propose that collaborative leadership and integrated care are keys to maximizing the benefits of available assets.

DDO can assist OHTs with:

  • Shared governance models
  • Inter-professional care models
  • Data sharing
  • The procurement and use of innovative tools that allow for integrated care

For more information, please contact mgleeson@ddohealthlaw.com.

DDO Health Law Update

July 19, 2019: A weekly scan of new legislation and regulations important to the Ontario health sector, as well as articles of interest.

 

Bills

 

The Ontario Legislature has adjourned until October 28, 2019.

 

Proposed and Approved Regulations

 

No new and approved regulations of interest.

 

Ontario Newsroom

Ontario Investing in New Program to Support Seniors’ Mental Health

Ontario opening more transitional care beds in the GTA

 

Articles of Interest

 

Ontario Health Teams

Orillia group chosen to establish new Ontario Health Team

Hamilton and Burlington health providers apply to be first in Ontario to reinvent care

 

Cannabis

Retail cannabis company wants to see store open in Kitchener

Cannabis sales jumped $11M in May as more stores open

Who’s really behind Toronto’s chain of illegal pot shops that won’t quit?

 

Health Care

Ontario hospital visits related to sexual assault much higher than previously thought: study

4 in 10 deaths avoidable in northern Ontario First Nation communities: report

 How one Ontario town is luring young doctors – and keeping them there

 

Privacy

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‘Just walk away from it’: The scary things companies like FaceApp can do with your data

 

Physicians

Nearly 53, 000 sexual assault cases treated by Ontario doctors over 15 years: study

 

AI

Former Vector Institute VP Darin Graham to lead LG’s Toronto AI Lab

 

Things to do this Weekend

35 things to do in Toronto this weekend

Update on Ontario Health Teams: The Self-Assessment Process is Complete

On July 18, 2019, Ontario’s Minister of Health and Long-Term Care hosted an audio webinar to announce that the Ministry has completed its review of the first phase of self-assessments to become Ontario Health Teams. Before the end of July, the Ministry expects to make public the list of applicants that have been identified as ready to proceed to the Full Application portion of the approval process.

During the webinar, the Ministry announced that 31 applicants will be invited to submit Full Applications. Full Applications are to be submitted for review in October of this year. The Ministry will soon make available online materials that will describe the processes and requirements for completion of a Full Application.

The Ministry hopes to provide final approval for the first wave of Ontario Health Teams before the end of the calendar year.