Table of Contents
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Purpose of the Document
This document summarizes a scan of Canadian jurisdictions' virtual health guidelines, tool kits, policies and related resources. The document is a living document and will be updated and revised as new information is discovered.
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Other guidelines relevant to digital accessibility and inclusion have also been collected and are located at https://wiki.fluidproject.org/download/attachments/202506392/Jurisdictional_Review%23FB93A.xls?api=v2 and in the Legislation and articles of interest pages of the wiki .
Summary of Relevant Guidelines
The following section provides links to resources published by the governing bodies in each province or territory that we were able to access. All information is gathered from official, publicly available documentation from governing bodies in each of the provinces and territories.
In the sections "Telepractice in other fields" and "Examples of Accessibility Guidelines Not Related to Virtual Healthcare" below, information is gathered from sources in other practices / industries, or outside of governing bodies in Canada.
Regional Resources
Most regions in Canada have guidelines published by their governing body that are publicly accessible on the Internet.
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- New Brunswick
- Northwest Territories
- Nunavut
Common elements in virtual care guidelines
We examined virtual care guidelines for a variety of elements including ones related to accessibility. The most common elements in the guidelines were:
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Unknown = Inconclusive. Information may require special access
Consent
In all jurisdictions, consent is required to proceed with virtual visits. There are two main forms of consent: written and verbal. Many governing bodies reference the communication templates published by CMPA.
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- Telemedicine guide has a short outline of a workflow which includes informed consent. No other explanation or examples are provided.
Consent Analysis
The process for consent is fairly uniform across all jurisdictions likely due to established in-person protocols for consent, and the CMPA guidance and templates published. In all cases verbal or written consent is required to be recorded into the patient's medical record.
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- patient to provide consent in other forms:
- non-verbal, non-written consent. This can include gestures, movement, symbols, and utterances.
- languages other than English or French
- patient risk and limitation information provided in multiple formats and modalities for informed consent
- provide patient rights as part of informed consent
Privacy
Patient health information privacy and security are often dealt with together, with a general consensus around privacy safeguards.
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- Telemedicine guide page 2 outlines the requirements for physicians to ensure setting and patient information is private.
Privacy Analysis
While all jurisdictions understand the importance of privacy, the guidance presented varies drastically from jurisdiction to jurisdiction. For example, in one province privacy in virtual healthcare may refer to privacy settings in a web conferencing platform, while in another province, privacy refers to data storage and retention. In some regions, legislation already exists regarding (electronic) privacy and it may be up to the healthcare practitioner to understand aspects of that legislation as it applies to their virtual healthcare practice and their patients.
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Since privacy can encompass such a large domain, a challenge will be to distill privacy concerns to be practical and meaningful.
Security
The term "security" has different meanings depending on the context it is used in virtual care. Security can refer to end-to-end encryption of a video conferencing system, or it could mean the safeguarding of data. For example in Manitoba and PEI, security is referred to only in context of selecting a video conferencing app. Conversely, the Doctor's Technology Office in BC provides distinctions between session and technology safeguards, and provides guidance.
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- Telemedicine guide page 2 outlines the requirements for physicians to ensure setting and patient information is secure.
Analysis on Security
The topics covered by security is wide-ranging and differs greatly from region to region. Information security is a large domain, with some aspects not immediately relevant to practitioners, caregivers, or patients.
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- define clearly the difference between security and privacy as it relates to virtual healthcare
- break down security into 4 topics for patients: physical space, device, network, and storage (including personal information and passwords).
- break down security into 7 topics for practitioners: physical space, device, network, communication tools, virtual visit software / platform, storage (including patient records, and passwords), and legislation / regulations.
- inclusive and accessible forms of security - the challenges posed by accounts (logins and passwords), and captchas
- strategies for accommodating less-than-ideal security situations such as patients in communal environments, insecure networks, etc.
- shift the burden of security from the patient to the infrastructure and design of the platform (i.e. make it easier for the patient to engage)
- See notes about registration challenges in notes from Maritime doctor
Virtual Visit Software Tools and Platforms
Each region in Canada has different criteria and recommendations when it comes to virtual visit software and platforms.
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Yukon
- No information found
Analysis on Virtual Visit Software and Platforms
Since there is a wide range of virtual visit platforms recommended in each region, the following are general suggestions to consider:
- Have a fall-back method of communication including phone, and combination of online video with phone voice.
- See notes about technology challenges in notes with Speech Language Pathologist
- Be aware of strategies to improve performance when connectivity is not ideal
- Availability of the software in preferred language
- Ability for patients or caregivers to login, test hardware and meeting features in advance
- WCAG compliance is not an indicator that the software is usable by people with varied needs and preferences
- Provide patients and caregivers the tools they need to adequately prepare and voice their needs
- Instructions provided in advance, even in English thanks to translation apps or helpers.
Billing
Many published guides for virtual care contain information for billing codes for virtual care. Analysis of billing is beyond the scope of this exercise.
Regulations
The following are regulations specific to virtual healthcare:
- Northwest Territories - No information found
- Nova Scotia
- Nunavut - No information found
- Ontario - Telemedicine, Telephone
- Prince Edward Island
- Quebec (use of technology and information, and not just specific to virtual health)
Analysis on Regulations
Not every region has regulations specific to virtual care, and many regions have other regulations that are relevant such as regulation governing privacy or storage of patient health information, or use of electronic communication.
Patient Guidelines
"Patient Guidelines" generally refers to information published to prepare patients and their caregivers for virtual visits with their healthcare provider. CMA has a comprehensive guide for patients. Some guides cover basics of using a particular software (like in Quebec), while other guides are more general like Ontario and Newfoundland.
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- Newfoundland and Labrador
- Northwest Territories
- Ontario
- Prince Edward Island
- Quebec - a guide on how to use Zoom
- Saskatchewan - copy of the CMA guide
- Yukon Territory
Analysis on Patient Guidelines
Many of the guidance for patients are either too general to be practical, or too specific and does not address broader concerns related to virtual healthcare. The guidance provided by Prince Edward Island is fairly comprehensive as it covers high-level concerns about virtual care (like "What are the risks of virtual care?"), and delves deep into specific software application used for virtual care in the province.
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Todo: telephone option, troubleshooting technical issues, how to effectively communicate
Virtual Visit Guidelines with Specific Accessibility Considerations
In all cases, published guidelines for virtual healthcare by governing bodies do not specifically include information on accessibility. This includes:
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In some regions, such accessibility information may already exist separately in the form of a guideline or regulation (for example, the AODA in Ontario). This places the need on the practitioner and patient to understand existing regulations and rights, and apply it with discretion in the context of virtual healthcare.
Telepractice in other fields
Other fields investigated for virtual / telepractice:
- Audiology and speech language pathology
- "ASHA Telepractice Guide", American Speech-Language-Hearing Association
- Evidence Map for Telepractice, American Speech-Language-Hearing Association
- "Dysphagia Assessment and Treatment During the COVID-19 Pandemic: Lessons Learned from the Transition to Telepractice", Speech-Language Audiology Canada
- "Assessing the Speech and Language of First Nation Children: A helpful checklist", Speech-Language Audiology Canada
- Standard and Quality of Services when providing virtual care - Alberta College of Speech-Language Pathologists and Audiologists
- Legal / Judicial system
- "COVID-19 Procedures and Scheduling", Ontario Court of Justice
Examples of Accessibility Guidelines Not Related to Virtual Healthcare
- "COVID-19 and people with disabilities in Canada", Government of Canada
- "COVID-19 Communication Rights Toolkit", Communication Disabilities Access Canada
- "Communication supports for children and adults with complex communication needs during the COVID-19 pandemic", Kelsey Mandak, Rehabilitation Engineering Research Center.
Summary of Existing Practices
Digital inclusion and remote interaction
Digital inclusion and virtual care applications
Areas of focus
-Note: we will look at structuring this section around the dimensions of inclusive design
Gaps
In reviewing the guidelines available to practitioners, there some general patterns that begin to expose gaps.
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Recommended Models and Best Practices
Up to this point, we have not discovered any model or practice that has an inclusive design perspective. We are delaying recommendations until after we can carry out co-design sessions with stakeholders to develop recommendations that are grounded in stakeholder needs.
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