ALERT CONTENT PLACEHOLDER
​​​UHN Virtual Care: A Healthier World is in Our Reach
Introduction

Reason for Action: It was identified that TeamUHN requires a resource to support assessment of when virtual care is suitable for a patient. The Clinical Guiding Principles for Virtual Care were developed to meet this need.

Purpose: This document is a guide for TeamUHN, including care providers, administrative staff, and learners, to enhance the patient care experience through virtual care. It was developed and is maintained by UHN's Virtual Care Clinical Advisory Panel. Comments and suggestions are always welcomed (contact details below).

Consider clinical, psychosocial, socioeconomic, cultural and social identity needs and preferences when determining suitability for virtual care. As with any important decision, ensure that all available options are provided to and understood by patients so that they may have the opportunity to consider their options and participate fully in shared decision-making.

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

  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
  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 vs 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.
  3. Access and Equity

    A literature review on access and equity barriers to participating in virtual care amongst particular populations has been initiated (April 2021). This document will be updated to include findings of the literature review.

  4. 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
  5. 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
  6. Other Considerations

  7. 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.
  8. 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
  9. Digital literacy and access to technology and safe, private space. 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.

Virtual Care at UHN is committed to working with patient partners, clinical teams, Social Medicine Program, and groups across UHN to creatively and effectively meet the evolving needs of our patients and TeamUHN.

We always welcome comments and suggestions to improve the Clinical Guiding Principles for Virtual Care.

Please contact Jennifer Catton, Director, Outpatient Strategy & Diagnostic Performance.


Appendix A: Examples of Urgent Virtual Care

Examples of urgent virtual care programs with appropriate expertise and supporting resources.

  • UHN Telestroke Program
  • Rapid virtual access clinics for post emergency department discharge patients
  • Crisis hotlines
  • UHN Connected Care COVID Clinic
  • Proactive monitoring on cancer treatment
  • Post-surgery care
  • UHN Virtual Emergency Department

1 High risk prescribing: Prescribing of high-alert medications. High-alert medications are drugs that bear a heightened risk of causing significant patient harm when they are used in error. Harm is defined as a temporary or permanent impairment in body functions or structures. Includes mental, physical, sensory functions and pain. Institute for Safe Medication Practices (2018, 2005).