Like my colleague Dr. Julien Martel, Dialogue’s Chief Medical Officer, I’m passionate about telemedicine and the opportunities it offers. In a healthcare system plagued by lack of access and inefficiency, telemedicine is disrupting outdated care processes and paving the way for virtual care to progressively replace most in-person encounters.


Still, there are good and bad ways to practice virtual care and physicians need to be aware of several additional issues beyond those outlined by Julien in the first segment of this post.

 

Serving patients located outside your license jurisdiction

If a telemedicine company tells you that you can serve patients that are not in a geographical location where you have a medical license, beware!

There are two key issues.

First, you don’t want to be vulnerable to a charge of practicing medicine without a license. However, you will generally be committing an act of professional misconduct if you do not hold a license in the jurisdiction where the patient is located at the time of your encounter with them. That rule applies both within Canada (with some select exceptions) and in the rest of the industrialized world. Do you really want to be answering to a regulatory authority in the US or overseas because you provided a telemedicine service to someone located in that nation?

The second issue, which applies to serving any patients outside Canada, is that the CMPA will not provide assistance with a malpractice claim that arises from an episode of care that begins when the patient is travelling internationally. That means that unless the telemedicine company you are working for has arranged liability insurance for its physicians in such instances, you will not be covered for legal costs or court awards arising from care provided to patients outside Canada.

The regulatory and malpractice environments will eventually evolve to better serve patients when they travel. But the present reality is that a single bad outcome can create substantial professional liability and potentially enormous financial cost for the individual doctor.

 

Patient authentication

An easily overlooked challenge in telemedicine service is patient authentication, meaning verifying that patients are who they say they are. Although this might seem trivial, it isn’t. How can you be sure the patient you are chatting with isn’t actually someone borrowing an eligible user’s phone? Is there a mechanism in place to visually confirm the patient’s identity with photo ID, even for chat communication? And Is the patient app secure? For patient safety and privacy reasons, our regulators and the law require that we make best effort to confirm we are serving and sharing information with the correct person - make sure that any telemedicine opportunity you consider has robust patient authentication technology and processes.


Continuity of care

We have abundant research evidence demonstrating that continuity of primary care enhances quality and safety. That evidence argues that virtual care should take place within the context of a long-term doctor-patient relationship. 

Unfortunately, there are several realities that prevent us from meeting that ideal:

  • 15% of Canadians don’t have a regular doctor (Statistics Canada 2017 data)
  • Only 43% of Canadians with a regular doctor can get an appointment with their doctor the same day or the next day (CIHI 2017 data)
  • Even when patients can get a same or next-day appointment, the travel demands to get to the doctor’s office makes it very difficult to attend

Together, these access problems prevent continuity of office-based care for large numbers of Canadians.

Telemedicine can improve access, particularly for patients who most need it. But many telemedicine companies don’t take advantage of the opportunities for continuity that virtual care provides. By only offering the first-available physician, their services prevent patients from seeing the same doctor for an initial encounter and its related follow-up visits. That’s needlessly substandard for mental health or for any problem that requires continuing care.

At Dialogue, we assure that patients who require a follow-up visit can see the same doctor, whenever schedules permit. That improves continuity, protecting the patient and the doctor from the negative consequences of substandard care.


Patient testing and referrals

Speaking of continuity, many problems that can be safely managed via virtual care will require investigations and specialist referrals. But without the continuity noted above, the follow-up patient encounters to review the investigation and referral reports will be fragmented, reducing the quality of care.

Equally important are careful processes and a diligent team to manage the incoming reports from tests and consultations. Many avoidable patient harms arise from information “falling through the cracks”, which is more likely to occur when a telemedicine company tries to limit its work to simply connecting a patient with a doctor. But Dialogue makes sure that a health professional carefully reviews each incoming report on the day we receive it. And our support team tracks significant tests from the time the doctor creates the requisition until we receive the report, just as our regulating/licensing bodies require.

 

Does the telemedicine company look after both you and your patients?

The current version of telemedicine is wonderful: a patient can connect to a doctor from anywhere, at anytime using just a mobile device. And the basic technology is simple and cheap enough that the barriers to launching a telemedicine platform are deceptively low.

But telemedicine is still the practice of medicine, with accountabilities that are no different than in a conventional in-person encounter.  Thus, a telemedicine platform has to be much more than “facetime for doctors”; without people and processes to guide the assessments, management, treatment and information flows, telemedicine will not conform to evidence, regulations and laws, putting the patient and the doctor at risk.

Sadly, some telemedicine companies have cut corners in these areas, . Worse, they then make claims about these “innovation efficiencies” that are not supported by evidence. The result is that they mislead their doctors into engaging in substandard practice.

Our advice? Scrutinize the care and motivations of the owners and management of any telemedicine company that you consider working with. And look particularly closely at your physician colleagues who are the company’s medical leaders. At Dialogue, we invite that scrutiny and would be happy to discuss our platform with you - just contact us at info@dialogue.co.

 

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Dr. Mark Dermer

Dr. Mark Dermer is a telemedicine physician. He has extensive clinical, leadership, consulting and innovation experience in a broad range of healthcare environments. Dr. Dermer is a graduate of McGill University.