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.
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 email@example.com or firstname.lastname@example.org.
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. 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.
The Ontario Telemedicine Network facilitates various telemedicine programs 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.
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. In tele-dermatology, a referrer (including a specialist) can send digital images to a consulting dermatologist and receive a response within five days. 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. 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. 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. 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. 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 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.
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.
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.
Watch this blog space for updates. If you have questions, contact the author: email@example.com.
 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.
 Telemedicine Policy. College of Physicians and Surgeons of Ontario. December 2014. Available at: https://www.cpso.on.ca/Physicians/Policies-Guidance/Policies/Telemedicine
 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.
 Such programs include teledermatology, telepyschiatry, teleophthalmology, telestroke, emergency services, critical care and others. More information about these program is available at https://otn.ca.
 See https://otnhub.ca/patient-care/#econsult
 See https://otnhub.ca/patient-care/teledermatology/
 See https://otn.ca/innovationcentre/teleophthalmology/
 Ontario Telemedicine Network 2017-2018 Annual Report. Available at: https://otn.ca/wp-content/uploads/2017/11/otn-annual-report.pdf
 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
 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).
 CPSO telemedicine policy. Supra note 1.
 CPSO telemedicine policy. Supra note 1.
 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