Review of Existing Relevant Virtual Health Guidelines and Practices

Owned by Vera Roberts
Last updated: May 28, 2021 by Jonathan Hung
16 min read

Table of Contents


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.

The source table for this summary is located at https://wiki.fluidproject.org/download/attachments/202506392/IUI%20Accessibility%20Review.xlsx?api=v2

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.

Regions in Canada where published guidelines were not found for governing body:

  • 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:

  • Consent
  • Privacy
  • Security
  • Software Tools and Platforms
  • Regulations / Ethics
  • Billing


The following table summarizes areas of guidance specific to virtual healthcare from each province in Canada. It is important to note that this table indicates the topic being mentioned, and does not indicate the breadth or depth of that discourse.

RegionConsentPrivacySecuritySoftware ToolsRegulations / StandardsBillingAccessibilityPatient Guide
Alberta

Yes

Yes

Yes

Yes

Yes

Yes

No

No

British Columbia

Yes

Yes

Yes

Yes

Yes

Yes

No

No

Manitoba

Yes

Yes

Yes

Yes

Yes

Yes

No

No

New BrunswickUnknown

Yes

UnknownUnknownUnknown

Yes

No

No

Newfoundland & Labrador

Yes

Yes

Yes

Yes

Yes

No

No

Yes

Nova Scotia

Yes

Yes

Yes

Yes

Yes

Yes

No

No

Northwest Territories

No

Yes

No

Yes

No

No

No

Yes

Nunavut

No

No

No

No

No

No

No

Yes

Ontario

Yes

Yes

Yes

Yes

Yes

Yes

No

Yes

Prince Edward Island

Yes

Yes

Yes

Yes

Yes

Yes

No

Yes

Quebec

Yes

Yes

Yes

Yes

Yes

No

No

Yes

Saskatchewan

Yes

Yes

Yes

Yes

No

Yes

No

Yes

Yukon

Yes

Yes

Yes

No

No

No

No

Yes

Legend:

Yes= Information present and publicly available from governing body

No = Information not found in context of virtual healthcare

Unknown = Inconclusive. Information may require special access

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.

Alberta:

BC:

Manitoba:

New Brunswick:

Newfoundland and Labrador:

Northwest Territories:

  • No information found.

Nova Scotia:

Ontario:

Prince Edward Island:

Quebec:

Saskatchewan

Yukon

  • 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.

Opportunities for inclusion:

  • 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.

Alberta:

British Columbia:

Manitoba:

New Brunswick:

  • Inconclusive. Information for practitioners requires login credentials.

Northwest Territories:

Nova Scotia:

Nunavut:

  • No information found

Ontario:

Prince Edward Island:

  • Guide has some information about privacy as it relates to sharing patient information, verbal consent, and compliance with the Health Information Act.

Quebec

  • Section 2.4 of the Guide discusses the doctor's responsibility to protect the privacy of the patient. Asks questions about security of data storage and retention.

Saskatchewan

Yukon

  • 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.

Security is often mentioned alongside guidance for privacy. While there are aspects of privacy that overlap with security, the two issues are actually distinct. This can lead to an incorrect assumption that addressing privacy issues is equivalent to addressing security issues.

The following are suggestions to improve the implementation of privacy practices in virtual healthcare:

  • Define the distinction between privacy and security
  • provide guidance to both healthcare providers and patients to be active participants in privacy
  • articulate the different aspects of privacy:
    • considerations for physical spaces
    • communication privacy (what should, or shouldn't go into patient-practitioner communication)
    • ensuring privacy of devices used before, during, and after visits
    • considerations with 3rd parties involved in care such as MOAs, and patient caregivers
    • network privacy
    • existing legislation and policies

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.

Security can cover the following topics relevant to virtual healthcare (not an exhaustive list):

  • encryption on electronic communication
  • viruses and malware
  • secure and private physical environment for both patient and practitioner
  • secure and private communication network, portals, and firewalls
  • secure and insecure methods of communication
  • identity validation including login passwords, unique URLs, and patient
  • data storage
  • data retention
  • digital information security regulation and legislation

Alberta:

  • The Office of the Information and Privacy Commissioner of Alberta has published an advisory covering: interception, misdirection, alteration, loss, and inference of information. The advisory has guidance to safeguard against these risks.

British Columbia:

  • The DTO has provided guidance on three dimensions of security: informed risk, session safeguards, and technology safeguards.
  • 10 hospitals in BC have a joint policy for digital communication. The policy covers permitted communications, consent, identity validation, device and application requirements, encryption, record keeping, and breach notification.

Manitoba:

New Brunswick:

  • Inconclusive. Information for practitioners requires login credentials.

Newfoundland and Labrador

Northwest Territories

  • No information found

Nova Scotia

  • Page 9 of Getting Started guide outlines device safeguards. References the Doctors of BC DTO security guide

Nunavut

  • No information found

Ontario

Prince Edward Island

  • Security is discussed in terms of Zoom settings. (Guide page 4)

Quebec

Saskatchewan

Yukon

  • 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.

Suggestions on improving communication on matters related to security:

  • 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)

Virtual Visit Software Tools and Platforms

Each region in Canada has different criteria and recommendations when it comes to virtual visit software and platforms.

Alberta:

British Columbia:

Manitoba:

New Brunswick

  • Inconclusive. Information for practitioners requires login credentials.

Newfoundland and Labrador

Northwest Territories

  • No information found

Nova Scotia

Nunavut

  • No information found

Ontario

Prince Edward Island

  • Zoom has been approved by PEI during COVID-19 response (page 2 of the Guide).
  • Other applications under pilot are Maple and Telemerge).

Quebec

  • In response to the pandemic, Quebec has authorized use of Zoom Health, Microsoft Teams, and Philips Reacts

Saskatchewan

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.
  • 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:

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.

The following regions in Canada have published patient guides:

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.

Patient guidelines should include:

  • general questions about virtual care: What is it? Is it effective? What are the risks?
  • privacy and security for both online and physical space
  • network connectivity
  • device considerations (hardware specifications, software versions, device features like cameras, etc)
  • stating any needs or preferences - such as language, personalization / accessibility support
  • on-ramp instructions on how to register and install virtual care software tool
  • how to prepare for a virtual visit
    • physical space needs
    • mobility and ergonomics
    • lighting

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:

  • language (other than English or French)
  • geography
  • physical and cognitive ability

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:

Examples of Accessibility Guidelines Not Related to Virtual Healthcare

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.

  • Geography disparity: At this moment, the Northern territories lack guidance coverage as seen in the Provinces.
  • Maturity and completeness of guidance: Generally, the published guidance lacks the maturity and completeness. This is evident by the uneven documentation of topics of interest (such as privacy and security), and the lack of consensus on practices and tools (such as generally accepted protocols for software platforms).
  • Patient needs and contexts: Currently much of the guidance assumes that the benefits of virtual healthcare is sufficient motivation for patients to want to engage in virtual healthcare. The guidance also generally assumes or that patients are capable of engaging in virtual healthcare with ideal contexts and access to ideal configurations. The publications do not address fundamental patient needs such as communication or accessibility requirements, and appropriate accommodation for digital literacy or technology proficiency.
  • Practitioner needs and contexts: The published guidance assumes that the practitioner has sufficient ability, technology, space, and knowledge to carry out the functions described in the documentation. The guidelines provide little guidance on situations that are less than ideal
  • Adaptibility, customization, and personalization: guidelines do not account for changes and unpredictability with individuals involved in the circle of care. Guidelines also lack any suggestions for practices for providing adjustments, customizations, and personalizations to accessing and engaging in healthcare such as language preferences, changes to vision, mobility, or technology.

Gaps in specific topics:

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.