Organization
[November 24, 2021 6:11 PM]
Ontario College of Family Physicians (OCFP)
Response in PDF format.
Physician (including retired)
[November 22, 2021 3:51 PM]
The policy is good overall. My concern relates to patients who move provinces and it takes time to find specialist care and where primary care is not up to the care task / not up to the task without specialty support. The other concern relates to patients on holiday in another province who needs advice on their medication (not working or side effects)- would this be covered under urgent? They would not be able to find the same level of specialty care or have access to it. The policy might add a line about patients on holiday in other provinces- for example some of mine went to get practical support from family, a decision I supported. In the future, a national system fits more with the way our population lives and moves- this of course is a decision out of scope for now.
Organization
[November 22, 2021 2:57 PM]
OMA Section on Plastic Surgery
Response in PDF format.
Organization
[November 22, 2021 1:50 PM]
Association of Family Health Teams of Ontario (AFHTO)
Response in PDF format.
Member of the public
[November 22, 2021 12:50 PM]
My recommendation is that the CPSO speak clearly and permissively regarding the provision of health services across provincial borders for Ontarians who travel within Canada and new-Ontario residents who have moved from another province, There are several trends over the last decade that impact on portability and timely access to health services in Ontario. These are now permanent trends. 1. Increasing mobility of Canadians. More Canadians are moving residences, both within and between provinces. Many of these moves are temporary such as students attending university, temporary work assignments for seasonal workers, interim family rearrangements in response to work from home and homeschooling. This has a negative impact on the provision of health services. 2. Virtual care now allows many Canadians to continue to access their existing GP or specialty care for longer periods following their move. In other words, the need to find a “local” GP or specialist is no longer as critical because there is not a gap due to the ease of continuing the existing physician-patient relationship. This has a positive impact on the provision of health services. 3. Waitlists for GP or specialists has increased in many geographic locations in Canada. This has a negative impact on the provision of health services. The provinces operate out-of-province health insurance programs that provide temporary coverage to their residents at either preestablished or pre-negotiated rates. These interprovincial agreements are made to comply with the portability principle of the Canada Health Act. This portability principle ensures public health insurance must be provided to all Canadians even when they travel within Canada or move from one province to another. For example, there is currently a three-month coverage for interprovincial moves as set out in the agreement between provinces. The three-month waiting period for OHIP aligns with the agreement period. Virtual care dovetails nicely with the Canada Health Act principles and the interprovincial agreements because Canadians who are traveling within Canada or moving between provinces can have virtual access to their existing GP or specialist. The CPSO policy should be worded to recognize these realities. Otherwise, the words become an inadvertent barrier to the portability and accessibility principles under the Canada Health Act. Indeed, the CPSO should be the leader amongst medical regulators with permissive wording that clearly supports i) the intent of the interprovincial agreements and ii) supports the vital role of virtual care for Canadians during these periods. If all provincial medical regulators follow the lead of the CPSO, this issue could be put to rest in a clear and simple fashion. Suggested wording for the policy: The CPSO recognizes: i) the principles of portability and timely accessibility of health care services under the Canada Health Act; ii) the periods identified in the interprovincial agreement on health care coverage (“Agreement Periods”); iii) the vital role that virtual care can play during the Agreement Periods. A physician registered in another province may provide virtual care for patients in Ontario during Agreement Periods without the need to register with CPSO. Any complaint regarding the quality of care will be referred to the physician’s regulator. A physician in Ontario may provide virtual care for traveling Ontarians or former Ontarians during Agreement Periods. Any complaint regarding the quality of care will be addressed by the CPSO.
Organization
[November 22, 2021 11:42 AM]
Ontario Medical Association (OMA)
Response in PDF format.
Organization
[November 22, 2021 10:44 AM]
OMA Section on General & Family Practice (SGFP)
Response in PDF format.
Organization
[November 22, 2021 10:00 AM]
Office of the Information and Privacy Commissioner of Ontario (IPC)
Response in PDF format.
Physician (including retired)
[November 22, 2021 9:57 AM]
The requirement for physicians to arrange follow up in person care when required needs to be removed. This is discriminatory against those in rural areas where no in person care may be available. For many of these patients, virtual care is their only access to care, and many physicians will refuse to provide care to these patients if this impossible to meet requirement is implemented. Also, the prohibition on virtual care across provincial borders into Ontario is regressive. Both the CMA and FMRAC have appropriately called for national licensure for telemedicine, due to virtual care's ability to remedy inequity of physician access between provinces. This draft policy represents an unfortunate step in the opposite direction of the profession's recommendations.
Physician (including retired)
[November 22, 2021 9:18 AM]
I applaud the college on developing a policy. However, a few things need to be taken into consideration: a) if virtual only clinics are not permitted to operate, then can primary care and the ER accommodate the resulting up tick in visits b) if virtual only clinics cannot operate, what happens to patients that were completely reliant on these clinics for care? c) if virtual only clinics are not able to operate, will physicians who work in these models be given a 3 months buffer to notify patients of the resulting closure? Virtual only clinics can provide an important safety net and safety valve in our system. If primary care is not forced to operate 24/7 then there will always be a need for virtual only clinics. While I agree that not all care can be provided in a virtual only setting, a significant number of patient concerns can be i.e. rashes, uncomplicated UTI, mental health, medication refills, surveillance for chronic disease using remote monitoring
Physician (including retired)
[November 21, 2021 3:20 PM]
I am surprised pandemic safety issues are not discussed. With the government, OHIP and CPSO admonishing Doctors to get back to live work discussion of this issue is necessary. Here is a letter I wrote in response to the Dr. Moore, Ohip, and Cpso about Doctors doing in person. Hello I in general agree. I also believe individual circumstance mitigate your position. I am a psychiatrist in the community And I am 76. My wife is 75 with a debilitating condition. Her getting COVID puts her life at risk The vaccine is not a firewall. Seeing people in person in an office with two other clinicians puts myself and my wife more at risk than most others. With a booster and fewer numbers the risk would be less. I do 20-22 hours per week mostly longer term psychotherapy. My patients are doing well and over half prefer virtual. None have gone to emergency. I hope you policy position has flexibility for those of us more at risk. Today November 21, 2021 half of Ontario covid case are in vaccinated people. The R value is above one. Dr Juni says be cautious and safe--no indoor gatherings. Doing psychotherapy which rarely needs in person and seeing people an hour at a time puts those in the office at risk. Aged patients and doctors who are at risk of dying from covid should do virtual psychotherapy for safety purposes.
Physician (including retired)
[November 18, 2021 5:41 AM]
As a specialist I have seen the deterioration of primary care to an immense degree during pandemic. 90% of my patients consistently complained they were unable to see in person their FP and even by phone appointments would be given weeks away with net result patients going to ERs. On the other hand I have never seen so many inadequate and bad referrals with no background documentation, simply because FPs by phone have been acting as "traffic cops" rerouting traffic to ERs or specialist like me with no work on their part. I have complained numerous times, reject 4-6/7 referrals as inadequate and even written a paper in Medical Post. I also have never diagnosed malignancies in a short time, simply because FPs never saw the patient in person. I see nothing in this draft that OBLIGES the FP to provide in-person care in a timely fashion if the patient asks for it (except of course unsafe situations).
Member of the public
[November 17, 2021 7:23 PM]
I think it is great to have virtual health care option. But the all video and writing telecommunication should be secured. And I oppose possibility of unlicensed health care providers since it will bring lack of trust to the health care, miscommunication and chaos in patient/provider communication. For example if provider would not have a licence (and not registered at CPSO) where patient may complain if needed? Unlicensed provider won't know all standard and could make too many costly mistakes.
Physician (including retired)
[November 17, 2021 9:54 AM]
The policy needs more clarity on the guidance regarding "licensing requirements" and "jurisdictions" instead of deferring to the MOH and CPMA. There is much confusion about this. It would be helpful to include a table of at least all of the Canadian provinces and scenarios when either patient or physician is in one of these jurisdictions. If such a resource already exists, help physicians by linking them to this resource. Physicians are expected to provide continuity as per CPSO policy, but such vague wording regarding licensure and jurisdictions in this virtual care document creates confusion. Although the CPSO is not tasked with clarifying billing issues, there are significant billing implications to providing care to patients if both parties are not in Ontario. Again, if not included in this policy, linking to MOH resources where this information could be found to clarify this would be helpful.
Physician (including retired)
[November 14, 2021 10:24 PM]
Sometimes a patient moves out of province while being actively treated and cannot find a physician or appropriate specialist in the new province of residence for some time. If the patient contacts their physician during that time period, is the physician morally obligated to continue to care for the patient?
Physician (including retired)
[November 14, 2021 3:32 PM]
I absolutely agree. I would take this a step further and insist that they mast have a defined number of appointments set aside per day in case a patient must be called in for an in-person physical exam. In this way they are not offloading their patients on walk in clinics or into the emergency departments, or even ordering MRI/CT instead of a physical exam. After all, we already have TeleHealth Ontario for Triage.
Physician (including retired)
[November 14, 2021 3:26 PM]
The draft policy now clarifies that physicians must have an active CPSO license when providing virtual care to Ontario patients who are located in Ontario, while it allows some exceptions where it is in the patient’s best interest. For example, not readily available in Ontario such as specialty care. I worry that if this point is not defined more specifically, this may open an avenue for non- CPSO licensed clinicians or non-Ontario residing clinicians to offer services in Ontario. As a Radiologist, I worry that this could be easily manipulated by out-of-Province Radiologists to remotely practice in Ontario without a Ontario license, arguing an unmet need for their services and expertise. This is especially worrying given the bourgeoning for profit teleradiology megacompanies abroad.
Physician (including retired)
[November 14, 2021 3:24 PM]
From a radiology perspective, the proliferation of telemedicine during the COVID pandemic has caused a spike of inappropriate ordering of imaging. (Often seemingly ordered in-lieu of a physical exam.) I would argue that advanced imaging such MR, CT or PET should only be ordered after an in-person physical exam (barring some special extenuating circumstances). Inappropriately ordered studies often delay appropriate medical care, unnecessarily expose the patient to radiation and the risk of a serious contrast reaction such as anaphylaxis, while inappropriate allocating resources and contributing to the rising cost of medicine in general. Furthermore, the physical exam findings and clinical history provided by the ordering clinician, are invaluable to the radiologist who combines them with the ‘imaging findings’ to provide a more sensitive and accurate report and diagnostic differential.
Organization
[November 10, 2021 11:12 AM]
OntarioMD
Response in PDF format.
Physician (including retired)
[November 09, 2021 11:43 AM]
I totally agree with your comment. I don't think stand alone "virtual walk in clinics" should be permitted. All patients should have access to physical exams if needed, and not be told to go to the ER. It's like Telehealth Ontario 2.0 has been created.
Organization
[November 09, 2021 11:02 AM]
Canadian Medical Protective Association (CMPA)
Response in PDF format.
Physician (including retired)
[November 08, 2021 11:05 PM]
For virtual care - It is not acceptable that a physician is expected to discuss with every patient ,every time - the risk and benefit of virtual care. Once the patient has signed the consent form OR accepted the virtual appointment that states the limitations of the virtual appointment - it should be deemed adequate.
Member of the public
[November 08, 2021 1:48 PM]
Note: Some content has been edited in accordance with our posting guidelines. I think Virtual care is good to some extent but some patients need physical examination and this is matter of Big Concern.
Physician (including retired)
[November 08, 2021 9:15 AM]
Hello I am glad to see the CPSO setting a policy on virtual care. I’m sure you are reviewing policies from other jurisdictions. The College of Physicians and Surgeons of Manitoba has an excellent policy. Virtual care ON ITS OWN provides inadequate patient care. I believe patients should continue to have a choice of how to receive care, however, physicians should be seeing patients in person again as the pandemic is settling, unless the clinical complaint is better addressed by virtual care and ideally the patient is already known to the physician. Thank you
Physician (including retired)
[November 08, 2021 1:00 AM]
Virtual care should be made permanent especially for mental health. It saves time and cost and nobody wants to sit in a waiting room with potentially sick people. It's especially useful for the mobility challenged or the time challenged.
Physician (including retired)
[November 08, 2021 12:54 AM]
It is especially important to allow temporary care to patients when the MD or patient is out of province/country. It is also important that virtual care include phone and also video platforms beyond OTN such as Microsoft Teams or Zoom. Thank you
Physician (including retired)
[November 07, 2021 5:55 PM]
The first comment made by this physician is one of the key points in this discussion group. If a physician is going to be offering virtual care, they must have the capability of providing access to an in person assessment.
Physician (including retired)
[November 07, 2021 12:25 PM]
I support the proposed policy, which is balanced and reflects the current realities of health care delivery. It's important that physicians see patients in-person when this is needed to address patients' medical issues. It's also important for collegiality, so specialists aren't sending patients back to their community physician to perform a physical exam, and community physicians aren't referring patients to specialists or ordering tests to avoid doing an in-person visit and physical exam.
Physician (including retired)
[November 07, 2021 9:45 AM]
Virtual Care is here to Stay..... Virtual care is a time and money saver as long as quality, continuity and TRUST of care been provided by the care provider....and the patient.
Physician (including retired)
[November 06, 2021 9:34 AM]
I have been using OTN and now video platforms from 2007. As a family doctor initially used to provide care in remote communities and jails however most people who asked for the services were not able to have since the technology was not available. The technology is here and variety of portable devices to monitor patients as well. I think the virtual care specifically video has been well received by patients. my patients span from families to elderly. They all have appreciate virtual access the reasons they tell me are: 1. No need to take a time off work or school. 2. Clients do not want to sit in waiting rooms when patients come with different set of complains one may be with toe fungus and another with respiratory infection. 3. Patient often need to come to doctors office after work driving polluting the air, stay in traffic increase road congestion, stress to be late and then being late and wait more adding unnecessary stress. Review of literature demonstrates that virtual care is safe and effective. The history and patient's assisted examination through video provide majority of the information needed to make a proper diagnosis in many cases. Of course there are situation when it is not possible. review of the policy draft: 1. Due to the distinct skillset required to provide safe and effective virtual care, physicians must ensure they have the competence to provide care virtually, including effectively using the technology. (it is poorly defined) it should say that physician should be confident in providing virtual care using modern technology. 2. The policy draft about the care when appropriate should not be having restrictions as the patient should not justify to a physician why they need to have a virtual appointments. The physician should not be required to confirm patient's reasons for this service to be provided virtually.
Member of the public
[November 05, 2021 7:25 PM]
A few years ago, I had a biopsy for what turned out to be basal cells, but obviously wouldn’t know that until the pathology report. The doctor told me that I would need to make an appointment with him to find out the biopsy results. When I asked if he could just call me with the results, he told me that he wouldn’t get paid for that. While I understand his position, I resent having to drive across the city, pay for parking and then wait to be seen. What a waste of time and healthcare dollars. Surely there is a better way to provide this level of care. Perhaps a silver lining of the pandemic is that we have, out of necessity, found a different way of offering service. Obviously there are situations in which virtual care is not appropriate, but conversely, there are situations in which it is a better method of service than in person. Interestingly, McMaster University found the same thing in a study recently published in the British Medical Journal.
Physician (including retired)
[November 05, 2021 3:37 PM]
The physician is to be competent in the use of the technology used in virtual care. Is the physician responsible for the failure of the technology used in the virtual interaction. How is the virtual care ‘no show’ to be defined and managed by the physician
Physician (including retired)
[November 05, 2021 2:42 PM]
As a physician working in general practice and urgent care, I really applaud the CPSO on their ability to recognize that virtual care can play a valuable role in medical care when it is done safely. My urgent care clinic provides a mix of virtual care and in-person care, as well as blended care where some virtual care visits transition to in-person visits when it is deemed necessary to perform a physical exam to provide adequate medical care. I find that our patients are extremely pleased with the flexibility and convenience of virtual care overall and the blended care model we provide and as a result of the success of this model I would like to see virtual care remain as PART of medical care in the post-COVID era. That said, this advantage is clearly best seen in the context of physicians providing a BLEND of virtual and in-person care as we do at our clinic, since we have all heard about how patient care clearly suffers in instances when individual physicians insist on ONLY providing virtual care and refuse to see patients in person even when indicated. In contrast to some of my colleagues postings below, I find that there ARE multiple instances where virtual care can be safe and appropriate - for example prescription refills, most basic mental health visits, and a variety of skin or superficial complaints (we allow patients to send us pictures to accompany the virtual encounter), certain benign GI complaints. Additionally, in primary care, virtual care is especially applicable to patients with questions about general health status (very common in primary care), most follow-up visits where a physical exam has already been performed at an initial visit, or review of test results (i.e. what was your bloodwork or US or MRI result and discuss what are the next steps). Additionally, most patients themselves accurately determine whether or not their complaint requires an in-person component or whether it can be handled virtually and between the patient and the physician, both make an informed decision together on whether or not virtual care is sufficient vs when an in-person component is required. I agree there may need to be stipulations for providing care when either the ontario-residing patient or the ontario-lisenced physician are physically located outside ontario - i.e. other parts of canada or internationall. Could these situations absolve the need to comply with other lisencing jurisdictions?
Physician (including retired)
[November 05, 2021 2:17 PM]
We have been providing full face to face service for over one year I feel all these virtual consultations are the result of expediency, if not laziness. Get back to work girls and boys!!!
Physician (including retired)
[November 05, 2021 2:07 PM]
When utilised appropriately by a physician, virtual care is an invaluable component of comprehensive medical care. Appropriateness includes an established patient doctor relationship (ie with your family physician) as well as the provision of follow up in person visits when deemed clinically necessary. It should continue to remain a component of general practice in the future. Time saved is just one invaluable aspect from both my professional and patient experience of it.
Physician (including retired)
[November 05, 2021 1:36 PM]
In terms of the physician’s location, can a physician fully registered with the CPSO provide care from a location outside the country? Can they do this on an exceptional basis only or can they do that consistently, on a regular basis?
Physician (including retired)
[November 05, 2021 1:31 PM]
I think virtual care by a medical professional is dangerous and has no sense now when Covid is much contained.I would rather cross the border pay cash and see a proper doc for my ailments.Shame on health Canada and CPSO for allowing this way of medical...
Physician (including retired)
[November 05, 2021 1:30 PM]
Please make sure that your expectations regarding documentation of encounters including telephone calls are clearly spelled out.
Physician (including retired)
[November 05, 2021 1:08 PM]
Re telemedicine, my feedback is that it should not be seen as a temporary measure, rather, a long-term solution and adjunct to primary (and secondary/tertiary) care that is held in person. It is a valuable tool for patients who do not wish to attend in person for various reasons, and it needs to be made a permanent part of the ohip codes. furthermore, it should be expanded to include some of the in person codes we do for patients as well such as: Smoking Cessation Premium e079 and follow up k039 Well Adult checks (k130) amended to include parts we do virtually and parts we need to see patients in for diabetic management - k030 fibromyalgia/chronic fatigue k037 + anything from the ohip billing code that is realistically amenable to being done virtually as well. There should be a caveat that a certain percentage of visits should be done in person (to favor), and perhaps that can be studied and incorporated in the payment model, but for now, making it permanent, and including some of the more easy codes into virtual care (Which are not currently) would be the next logical step.
Physician (including retired)
[November 05, 2021 1:02 PM]
Important that emails be included in the definition of acceptable modes of virtual care. Most patients are comfortable with this having been offered informed consent. It provides a direct written account of all that was discussed.
Physician (including retired)
[November 05, 2021 12:37 PM]
Too many vague statements to make a meaningful impact. Clarify the status of telephone visits and the expectations around encryption. Many patients are eager to use the phone, but not familiar on how to use more secure platforms. In-person exams are almost always essential. Consider restricting virtual care to follow-ups after recent in-person visits, with very few exceptions.
Physician (including retired)
[November 05, 2021 12:12 PM]
A few comments (as an internal medicine subspecialist): 1. Physicians should consider using virtual care more for follow-ups rather than first consultation visits, especially where a physical examination may contribute greatly to the initial diagnosis / synthesis. 2. Elder patients who are hearing or slightly cognitively impaired are not ideal candidates for virtual care unless a patient caregiver of family member is also present (my experience). While they may be less mobile and may benefit from virtual care, the quality of the information gathering may be compromised by virtual care. 3. Video visits are preferable to telephone visits. Don’t want to be overly prescriptive, but most physicians would agree with this. 4. Lower income and more marginalized patients often do not have video capabilities, and should not be relegated to phone visits when in person visits might provide better care. 5. It may be worth commenting on the suitability of communicating with a patient through a family member vs. directly with the patient. 6. I frequently follow a first video consultation with an in person follow-up, unless the case is very straightforward and resolving.
Physician (including retired)
[November 05, 2021 12:05 PM]
I am a family physician who does only CBT for appropriate mental health issues. Since COVID 19 I have found virtual care to be very effective and preferred by the great majority of my patients. The majority also find the convenience of a straight up phone call without a visual component to be completely adequate. The time saved, and personal comfort psychologically of being in one's own home or car seems to be an advantage. Going forward, obtaining mental health resources should remain as flexible as possible, serving what is preferred by the patient.
Member of the public
[November 05, 2021 8:08 AM]
The closure of doctor offices has been an absolute cluster. I've now had to go to ER twice for simple things with which my doctor could have have helped. Also, my kids' pediatrician was pushing off their childhood vaccines and we had to insist on coming in just so our children could be properly immunized. The only reason I could see for virtual care would be for things like refilling prescriptions or maybe providing test results. Everything else results in experiences that are not useful to the patient.
Prefer not to say
[October 26, 2021 2:54 PM]
Ultimately the standard for virtual care assessments should be: Is there anything I or my team would have done significantly different to assess the patient if the patient was sitting in front of me? If the answer if yes, then the standard cannot be met virtual care.
Physician (including retired)
[October 24, 2021 1:00 PM]
Ultimately, the decision should remain with the physician and patient with regards to how to interact. The decision is no different from if a clinician needs to decide if a patient should come into clinic or go to the ER. I do not think it's appropriate to get too granular with the details of this policy other than specific things that should not be done via virtual care i.e. chest pain, opioids or controlled substances for patients with one does not have a relationship with, etc. To the point of virtual only clinics, this is more a testament to a lack of accessible primary care. Similar to walk-in clinics, there is a necessary equilibrium thats been established between primary care and episodic care doctors. If one was to shut down virtual walk-in clinics, the ERs will be even more overwhelmed. Patients who are orphaned and have no access other than virtual walk-in will once again fall between the cracks.
Organization
[October 19, 2021 2:08 PM]
Professional Association of Residents of Ontario (PARO)
Thank you for the invitation to provide feedback on the CPSO Virtual Care Policy and the Advice Document. We recognize and support the CPSO’s role to serve and protect the public and appreciate the privilege that we are afforded as physicians and surgeons to be a self-regulated profession. We appreciate that the CPSO has a very important role in protecting the best interests of patients and educating physicians on their ethical obligations towards their patients. We found this Policy and the accompanying Advice document to be comprehensive, provide clear guidance to physicians on the matters contained and to cover many of the nuances that arise with virtual care. We did have a couple of specific suggestions: • One point that we believe should be expanded on in the Policy or the Advice document is how to involve substitute decision-makers in a virtual care setting, as there can be some unique issues regarding privacy and confidentiality in this scenario. • We believe whether the exact physical location of the patient needs to be confirmed should be clearly identified in the Advice document and/or clarified in the policy itself. We thought it may be helpful to even include a line to the effect of 'physicians should consider the possibility of a patient requiring emergency assistance during a virtual visit, and are encouraged to confirm a patient's physical location for this reason.' We did also wonder about any liability concerns with regards to this, though that issue may be better suited for the CMPA. We do, as always, appreciate being included in the CPSO's consultative process.
Physician (including retired)
[October 15, 2021 7:52 PM]
Virtual care is the worst thing to happen to the medical profession in the recent past. The fact that it is still being supported and remunerated is reprehensible. Medicine cannot be practised without a direct patient interaction and a physical examination. Anyone who believes otherwise is lazy and using the pandemic to support this behaviour. The only services that can be provided by phone or virtual are to follow up tests or counselling (but not in all circumstances). I would strongly advocate that the fee codes for virtual/telephone care be removed.
Physician (including retired)
[October 15, 2021 2:38 PM]
My experience with virtual care has been positive for the most part. Many patients who needed care during the early pandemic were able to book virtual visits with me either by phone or video and appreciated that I could offer some triaging in this manner before seeing them in person if needed. Many of my patients still prefer to book virtual visits for things like prescription renewals or mental health concerns. I wholeheartedly agree there are some conditions that MUST be seen in person such as abdominal pain, but I also have gained skills over the last 2 years to complete quite effective virtual exams for many conditions. I also provide care through a virtual medicine platform where we see over 50% of patients who do not have family physicians. For these patients, we are often (80-90% of the time) able to address their needs that they are calling for and often keeping them out of the emergency. Again, virtual care is not appropriate for all conditions, and a clinician should not try to provide virtual care when an in person visit is warranted. But, I have personally seen 100s of patients that would have avoided care or gone to the ER had a virtual medicine platform not been available. Happy to have this policy which highlights the need to treat only the appropriate patients with virtual care.
Physician (including retired)
[October 13, 2021 6:57 PM]
I don't think physicians should be ultimately responsible for deciding what is considered appropriate for telephone or virtual care, and what is appropriate for in-person care. Many situations can arise where the physician does something virtually, and then the patient complains that they don't think it should be done virtually. At this point, a complaint committee could rule that they wouldn't have done the visit virtually, based on what they consider is appropriate. What should happen, is the CPSO should come up with clear guidelines for exactly what is allowed to be handled over telephone and/or virtual visit, and then the rest can be considered not appropriate for handling over virtual/phone visit.
Physician (including retired)
[October 09, 2021 9:57 AM]
I agree with my colleagues below - as an Emergency Physician, I'm seeing a flood of patients who were "seen" in virtual only to get referred in for a complete assessment by a 'real', analogue, physical doctor. "Virtual" care is just a rebranded form of Telehealth, which we've been doing for a while. It excludes the elderly, the technologically limited population, the ones who have no access internet. I think the utility of virtual care should be limited to "Advice Only" - in very limited settings such as renewals of script, management of chronic stable conditions, and potentially counselling of non-acute mental health conditions. I think the CPSO and OMA should make a priority of making Virtual Care/Consultation available to Northern communities, the elderly, and in settings where patients have no readily accessible primary care - rather than what it has become... a revenue generating scheme for the established physicians; serving an already well-informed, well-connected populations. If anything this pandemic had taught us is that our disparities and inequities grown larger, and virtual care just has highlighted that. Here's a short list of harm caused to real patients by virtual care (no PHI): - child misdiagnosed as constipation x 2 weeks only to have an obvious liver mass (neopplastic) found on exam - an elderly treated for UTI x 3 months, only to be diagnosed with advanced bladder cancer - a young woman treated by multiple virtual providers only to have PID diagnosed on exam - a middle aged woman treated for bronchitis x 2 months - advanced lung cancer diagnosed - UTI diagnosed in elderly who was found to have an AAA - a child told to have an URI only to have an obvious foreign body in the nose - middle age woman treated for 'gingivitis' presenting with a Ludwig's Angina Virtual care was supposed to be a stop-gap measure to patch-over care, and it seems that it replaced primary completely and with it all standards history/exam have become completely bastardized. I would recommend that CPSO has a firm stance that primary should return to real care; if my massage therapist, acupuncturist, hair dressers, and Dentists can make the return, there's no reason why our GP's can't. ​
Physician (including retired)
[October 07, 2021 1:24 PM]
I am a surgical specialist. At this time, approx HALF of my new referrals from family physicians have not been seen in person by the family physician and have not had a basic physical exam completed prior to the referral being sent. We are being asked to see very basic complaints simply because the family physician is not making themselves available to examine the patient in person. Our office has become a "physical exam station" for family physicians. It is ludicrous and makes a mockery of what virtual care was intended to be. The College and/or the OMA need to address this firmly
Physician (including retired)
[October 07, 2021 12:01 PM]
One area there is tremendous potential is in addiction medicine and mental health. As an emergency physician, arranging reliable follow-up for this population is quite challenging and some communities do not have access to these services at all. The COVID-19 experience tells us that withdrawal management and anti-craving therapy can safely be started and titrated in the virtual setting and allows patients to have increased privacy over what continues to be a stigmatizing issue that not all physicians have a sound approach to. We are seeing record opioid toxicity deaths in Ontario and the status quo is not working. Organizations like META:PHI have thankfully come to the realization that we totally have gotten things like opioid use disorder wrong historically. Existing protocols requiring signed treatment agreements, forcing patients to stand in a line and pee in a cup, have observed doses of medication, limited carries and painfully slow titration are inhumane and don't work.
Physician (including retired)
[October 03, 2021 12:52 PM]
The physician has the right to protect his health and other patients in case of vulnerable medical conditions for MD or other patients
Physician (including retired)
[September 27, 2021 11:08 AM]
CPSO virtual care policy input 9 27 2021 Virtual care is not an equal substitute of face to face care because physical exam is impossible and physician has to only rely on history and lab results etc to make medical decisions. Therefore, virtual care cannot meet the standards of care originally developed for in-person care. Virtual care "standards" have to be separate and lenient from the standards for in-person care because as much as 50% of data might be missing in supporting medical decision making. However, it is also a necessity as current environment has made clear. Holding physicians providing virtual care to same standards as in-person care is imposing onerous burden on physicians beyond humanely possible to comply without undue hardship, and will /does contribute to physician burnout. Physicians locked down at homes last year did not have the access to medical staff to assist in lab result access, faxing, appointment booking/confirmation, lab requisitions, referrals, and all other work that was done at least 2 other staff -all to be done by the physician him/herself, not to mention even having access to fax machines and printers at home. It is an onerous ask of physicians to meet same standards of care meant for in person care when providing virtual care. Virtual care calls for the "best of sincere effort, with the information and infrastructure available" policy. There are some idealistic goals but they are useless when not practical. 2.patient best interest "Quality of care" will be compromised in ALL virtual care scenarios because physical exam data is not available. To think or expect otherwise is mis-informed. Therefore, virtual care policy needs its own, and lenient, expectation of care guideline which is realistic and within reasonable means of the physician, without any onerous requirements. Timely patient care must always remain centered, and quality must depend on the reasonably available resources at the time of delivery of care. "Best interest of the patient" is also very lucrative term to use on paper. However, it was not in the best interest of patients to not be seen in person when HC/ MOH shut down all clinics last year as many patients died from delayed diagnosis of CHF, cancer, and other diseases or there complications as a result of these shutdowns. Number of deaths from heart diseases and cancers were higher in 2020 than previous years because of lack of timely care, rendered impossible by HC/MOH with imposed restrictions shutting down medical clinics in a "medical emergency". 3. There are many more important factors that must be included but the list may be too long to be all inclusive. Therefore goal should be to provide timely care, at reasonable standards, with the means available. Restricting a physician who has recently travelled from seeing patients above the age of 64 is not only arbitrary but also onerous disservice to this patient age population which makes the majority of medical encounters given the multiple and severe medical conditions they suffer from. For a physician denied to care a patient with CHF or new onset A fib because he/she travelled is denying timely and quality care to patients who otherwise may not want to go to hospitals either because Privacy and security "confirming the patient is in a reasonably private setting and is comfortable discussing or sharing their PHI during the appointment" is up to patient. If patient wants to talk to his/her doctor in company of others then that is their prerogative. Wasting limited encounter time in going out of the way to add this requirement will delay timely care and will compromise the time doctor can spend delivering quality care. CPSO must stop burdening physicians with administrative work and let them concentrate on quality of care they deliver. Purpose of virtual care is to provide timely care. Policy should be re-written to enable that.
Physician (including retired)
[September 24, 2021 12:18 PM]
Note: Some content has been edited in accordance with our posting guidelines. re #7 "Where the virtual encounter is synchronous (i.e., involves real-time interaction with the patient), physicians MUST confirm the physical setting where the patient is receiving virtual care is appropriate and safe." and 9C Confirm the patient is in a reasonably private setting Exactly how can the physician "confirm" this information? By asking the patient? By doing a 360 degree sweep of the camera? This begs explanation. I am a psychiatrist in [redacted] serving smaller communities via OTN. It is impossible to confirm the physical setting of the patient is "safe and appropriate." I can only see what is within the view of the camera. I always ask if the patient has privacy, for example. Some patients have said "yes" even though there are other people in the room, whether overhearing or monitoring the conversation. Much of the policy is a collection of "motherhood" statements that are true but not helpful insofar as it is not always clear HOW to do this.
Physician (including retired)
[September 24, 2021 8:02 AM]
The requirement that virtual care platforms be encrypted is not consistent with the use of regular telephone calls, which are permitted, yet are not encrypted. This wording should be corrected.
Physician (including retired)
[September 23, 2021 2:19 PM]
I agree with the need for a policy regarding the virtual care As a matter of fact, physical examination is possible and desirable. Vanderbilt University started education in this regard a long time ago. Musculoskeletal examinations were validated in numerous studies (e.g., Cottrell MA, O'Leary SP, Raymer M, Hill AJ, Comans T, Russell TG. Does telerehabilitation result in inferior clinical outcomes compared with in-person care for the management of chronic musculoskeletal spinal conditions in the tertiary hospital setting? A non-randomised pilot clinical trial. J Telemed Telecare. 2019 27(7):444-452.) Our group recently submitted a study Chronic pain management during COVID-19 pandemic: can telemedicine replace in-person consultation? (under review) I would argue and it is supported by an experimental research that a telephone consultaion is ineffective and possibly misleading (Delichatsios H, Callahan M, Charlson M. Outcomes of telephone medical care. J Gen Intern Med. 1998;13:579–585 Rutledge T, Atkinson JH, Chircop-Rollick T, D'Andrea J, Garfin S, Patel S, Penzien DB, Wallace M, Weickgenant AL, Slater M. Randomized Controlled Trial of Telephone-delivered Cognitive Behavioral Therapy Versus Supportive Care for Chronic Back Pain. Clin J Pain. 2018;34(4):322-327) Last thing: I disagree with the need in obtaining consent. Physicians do not obtain consent for in-person visits and this rule should hold for virtual encounters. Physicians must warn patients if the connection is not secured and abort the visit if they express concernrs
Physician (including retired)
[September 23, 2021 1:32 PM]
We are being put in an impossible situation as family physicians. up to 2 hours per day of our own time reviewing labwork, adding to EMR, contacting patients re abnormal labwork, doing virtual calls for 6 hours per day, THEN remotely completing progress notes, forms, labreqs, referrals after the 10minutes on the phone (all unpaid), THEN being expected to also see patients in person (including those not vaccinated) at THEIR whim now whether deemed to be an appropriate request or now..all the while wiping down all surfaces between patients, paying for the PPE our of our pockets for us (and for them when they arrive with a cloth mask), only one patient in office at any one time (so as not to put others in a waiting room at risk for COVID and trying to keep kids from contaminating all surfaces in waiting area) which means--in a small shared office only one of us can work on any given day. When we do see patients in person, given we are limiting this to one patient in office at any one time--those of us on FFS/FHG can't pay the bills. THen when we arrive back at our homes we are expected to do all the paperwork/phone calls etc...so it's 11-12 hour days (of which at least 4 hours is unpaid), and at least 6 hours on weekends (unpaid forms, etc). We preach work/life balance to our patients...but currently if I add in all the unpaid paperwork...after 40 years in practice I am earning $17 per hour before taxes. impossible.
Physician (including retired)
[September 23, 2021 12:51 PM]
I think providers of virtual care should be obligated to give patients access to a physical exam or in person assessment where this is indicated - they should not be providing virtual care if they do not have a site where a physical exam can be done (even if it is only needed rarely). An example where this is not the case is "virtual walk in clinics" where if there is a complaint that should be examined in person, these companies don't even have a physical facility or site for an in-person assessment available as an option to complete their assessment that they are billing OHIP for, and often will refer the patient to subsequently be seen at the emergency department or to go see another completely unrelated family physician who has a real office instead (and the patient ends up billing the system twice for the exact same problem). The other area that I see that might need to be addressed is if the patient requests an in-person visit, this should be an option available to the patient - even if the in person appointment may be booked at a much later date. I have had many patients tell me that they request in person appointments with their specialists or family physicians now, only to be told that their physician is only providing virtual care entirely, and refuses to see them in person for an in person assessment for legitimate concerns. There might also be a reminder that in providing virtual care, establishing a therapeutic relationship with you patient is still important, and that it is highly recommended that physicians meet their patients (at least for the first time, for new patients) within the first year of initial virtual visit/telephone call. I also have many older patients who tell me that they were referred to a specialist during this pandemic, but have only spoken over the phone, never having never met their physician, not been assessed physically or seen in person, so they don't even know what their own doctors look like, and it affects how they feel cared for, and adds to poor communication between them.
Physician (including retired)
[September 23, 2021 12:20 PM]
The promotion of virtual care has put an unfair pressure on the ED departments Ontario wide. Patients are complaining of not being able to see their clinician in person for over a year. As an ER physician - I am fed up with having to see minor complaints that could have been dealt with in person. With increased volumes, burnout, and nurses leaving - the EDs are suffering. There is no excuse not to see patients in person. Physicians and and staff are vaccinated. Most of the patient population is vaccinated and PPE supply levels are stable. WIC and UCC are refusing to see patients and are talking to patients in the parking lot. Only to refer them to the ER. These clinics are no different than a drive though McDonalds. The OMA and Colleges are promoting virtual care as they continue to quote physician satisfaction. Yes, that is true. If I didn't have to go to office and not examine any patients my life would be easier. If I could just defer patients to and UCC or local ER I would not have to accept any responsibility. Why doesn't the OMA of the College see what patient satisfaction is? It has been very low since the start of the virtual care codes. Overall Virtual Care has not been good for patients and those who work in the acute care setting. Patients should have the choice to see their practitioner without fall. It should be their choice not the choice the their family doctor/WIC/UCC. If they cannot, they should be educated on the right to complain to the CPSO with the physician having to defend why they could not see their physician in person.
Physician (including retired)
[September 23, 2021 12:11 PM]
Note: Some content has been edited in accordance with our posting guidelines. We have a situation in [redacted] where a particular specialist will not see any patient who is not fully vaccinated, no exceptions, even if he patient needs and wants an in-person appointment and is asymptomatic with respect to covid-19. Perhaps a statement about this particular situation should be in the policy, in plainer language than just the risk/benefit argument.
Physician (including retired)
[September 23, 2021 11:55 AM]
Have you considered addressing the situation where a patient from Ontario is vacationing in another part of the country but a virtual care consultation is performed? For instance, a regular patient from Ontario is started on a new medication and a telephone follow-up is needed in 4 weeks to see how things are going and at the time of the follow-up the patient is travelling--either out of the country or in another province. Does that need to be referenced specifically? Thanks.
Physician (including retired)
[September 23, 2021 11:21 AM]
Note: Some content has been edited in accordance with our posting guidelines. I would like to additionally suggest that the word 'or' in section 3bi be changed to 'and'. I think both requirements should be in place to safely and properly provide virtual care. Thanks
Physician (including retired)
[September 23, 2021 11:13 AM]
As an Internist trained in the 1980s, and as a perfectionist, I am totally opposed to virtual care for any significant medical problem. Without examining the patient, it is IMPOSSIBLE to diagnose and treat properly... The only place I see for this is for renewal of prescriptions, MAYBE
Physician (including retired)
[September 22, 2021 11:38 AM]
For the most part, the statements appear to be collection of motherhood statements around virtual care. No suggested modifications.