Clinical Guiding Principles for Virtual Care

A written statement by UHN's Chief Medical Officer and Chief Medical Information Officer regarding the continued practice of virtual care at UHN.

October 18, 2021

Posted on behalf of Dr. Brian Hodges, Chief Medical Officer & Dr. Peter Rossos, Chief Medical Information Officer

Re: Virtual Care at UHN

Dear colleagues,

Many of you have read the recent joint position of the Chief Medical Officer of Health, Ministry of Health and the College of Physicians and Surgeons of Ontario which states that "in-person care can now be provided safely and appropriately", and that "it is expected that all physicians are providing in-person care based on clinical needs and patient preference".

Questions have been raised as to whether this will change our approach to in-person and virtual care at UHN – the answer is that it will not, because this joint position is consistent with our Clinical Guiding Principles for Virtual Care. The UHN principles were developed and are maintained by UHN's Virtual Care Clinical Advisory Panel, which is composed of interprofessional care team members and UHN Patient Partners. In the creation of this "living" document we referenced and communicated with organizations including the CPSO and CMPA. The overarching clinical consideration is that care providers should consult and practice within the virtual care standards or guidelines defined by regulatory bodies and/or associations of their profession.

The letter from the Chief Medical Officer of Health, Ministry of Health and the CPSO also states that "There are limits to what can be done virtually and the standard of care is often difficult to meet in a virtual care environment." If the selection criteria identified in the UHN Clinical Guiding Principles for Virtual Care are followed, physicians at UHN will most certainly be meeting the standard for patient care.

Since 2003 we have provided and pioneered virtual care to improve access, timeliness and safety for patients and caregivers requiring our expertise and services. UHN continues to fully support the delivery of care through virtual means including by videoconference and telephone when it is in the best interests of patients, meets the standard of care, and is clinically safe. Through Virtual Care at UHN we are dedicated to improving and innovating technologies and processes for seamless transitions between in-person and virtual care delivery.

Thank you for your ongoing commitment to A Healthier World in these challenging times. At UHN, the needs of patients come first, above all else.

Please feel free to contact us with questions, concerns, and suggestions.

Brian Hodges MD, PhD, FRCPC
EVP Education and Chief Medical Officer, UHN
Professor, Faculty of Medicine, University of Toronto

Peter G. Rossos, MD, MBA, FRCP(C), FACP, CAGF
Chief Medical Information Officer, University Health Network
Professor, Faculty of Medicine, University of Toronto

Care providers should consult and practice within the virtual care standards or guidelines defined by regulatory bodies and/or associations of their profession.

Care providers who practice telemedicine must continue to meet the standard of care and the existing legal and professional obligations that apply to care that is provided in person.

Care providers (including learners) must be prepared with the necessary competencies and supports required to deliver virtual care (e.g., digital literacy, equipment, physical space).

Out of Province Patients

For some provinces, there are specific licensing requirements for care providers to complete. Please contact UHN's Virtual Care Team (VirtualCare@uhn.ca) to assist you with this process. In addition, physicians may also wish to consult the CPSO and CMPA for further information.

1. Urgent virtual care may differ from planned virtual care visits and should only be provided when appropriate expertise, workflows, and supporting resources have been defined (see Appendix A for examples). Supporting resources may include, but are not limited to:
   1. Appropriate staffing model
      
   2. Defined workflows to address evolving urgency
   3. Patient support
2. Virtual care may be effective for many patient encounters including:
   1. Assessment, consultation, diagnosis, and treatment of conditions that are manageable through virtual care, including outpatient rehabilitation
   2. Review of laboratory results, pathology, imaging, and consultant reports
   3. Assessment, planning and coordination of in-person diagnostic and therapeutic care
   4. Chronic disease monitoring and follow-up
   5. Review of patient monitoring, patient-reported outcome and experience measures
   6. Counselling
   7. Patient and family education
   8. Research study visits, referral for clinical trial eligibility
3. If physical examination is required, consider:
   1. Whether the patient must be evaluated in-person either directly or in coordination with other appropriate care providers.
   2. Whether physical examination can be effectively conducted virtually (e.g., visual inspection, range of motion, tenderness to palpation, sensitive exams, etc.). If yes, consider whether the patient requires specific preparation (e.g., informed of requirements, appropriate space available, access to required equipment, etc.).
4. Leverage virtual care to minimize the need for repeat in-person visits. This may include coordination of clinic visits, diagnostic studies and therapeutics.
5. Carefully assess the use of virtual care to provide "bad news" or new diagnoses. Please consider:
   1. Timelines:
      • Results may be available immediately through myUHN Patient Portal and require explanation and support.
      • Treatment decisions may require expedited communication and planning.
   2. Sensitivity of diagnosis: consider the dignitary component of relaying the news and inherent privacy concerns with virtual care.
   3. Support and comfort: in-clinic versus in-home environment, whether or not presence of family and caregiver is desired, etc.
   4. Complexity: patients may prefer in-person for more in-depth discussions.
6. Virtual high risk prescribing¹ must be carefully considered, especially with initial virtual consultations. Examples may include, but are not limited to:
   1. New prescriptions for narcotics, benzodiazepines, stimulants, and/or cannabis.
   2. Prescriptions for patients with a history of substance use disorder.

Access barriers must be considered in clinical decision making regarding virtual high risk prescribing. High risk prescribing should be practiced in environments where the goals of therapy are clear and patients receive ongoing interprofessional care (e.g., Palliative Care, Chronic Pain Management and Addiction Medicine).

Patient preference regarding virtual or in-person care must be always be considered. If the patient and provider decide on virtual care, it is important to also establish the most effective modality (e.g., telephone or videoconference). The following principles are intended to support patient-centred care and UHN's primary value of "the needs of patients come first" (see UHN's Patient Declaration of Values).

Patient Preference

1. Patients require the necessary information to make an informed decision regarding preference. In addition to identifying patient preference, informed consent must be documented (see Consent and Privacy Protection for Virtual Care).
2. Care teams must have capacity to provide both telephone and videoconferencing visits. Videoconferencing visits are preferred by many patients especially when meeting providers for the first time.

Access and Equity

Results of a literature review (initiated April 2021) on access and equity barriers to participating in virtual care have been incorporated into this release of the Clinical Guiding Principles for Virtual Care. As a next step, peer-led focus groups are to be conducted in collaboration with UHN's Social Medicine Program and community partners, as a part of UHN's Outpatient Care Strategy. This document will be updated to include learnings from these engagements.

3. Consider physical challenges to in-person care:
   1. Travel distance
   2. Ability to travel independently
   3. Mobility
   4. Patient safety
   5. Hospital and clinical capacity for physical distancing
   6. Inconvenience
4. Economic considerations:
   1. Lost wages
   2. Travel expenses and parking
   3. Childcare, elder care, etc.
   4. Economic considerations for patients, families, caregivers, and/or support
   5. Other patient responsibilities
5. Language and communication requirements must be anticipated and optimized for virtual or in-person care. Patients should not be disadvantaged owing to limited English language proficiency. Consider strategies such as using Interpretation and Translation Services or aphasia-friendly services.
6. Virtual care can allow for the inclusion of family, caregiver, and/or support person during the virtual visit, if desired and consented to by the patient (virtually or co-located with the patient). Consider how the selected virtual care platform may affect:
   1. Family, caregiver, and/or support person experience
   2. Burden to family, caregiver, and/or support person
7. Digital literacy and access to technology. Effective videoconference visits require reliable secure internet access, an email address and device(s) with video and audio capabilities. Consider strategies such as:
   1. Using technology that the patient is comfortable with such as telephone where the platform will not impact quality of care.
   2. If appropriate, inclusion of family, caregiver, and/or support with adequate digital literacy and access to technology.
   3. Device loaning programs if available (e.g., videoconferencing enabled tablet, home blood pressure cuffs, etc.)
   4. Hosted virtual visit if available (i.e., at a telehealth centre closer to the patient's home).

Please note, Virtual Care at UHN is working towards developing patient resources to build digital literacy skills and outline device requirements. Additional resources will be linked to this document as they become available.

8. Access to safe and private space. Consider factors that may prevent a patient from communicating openly and privately during virtual care (e.g. housing status, domestic circumstances).