Review of Existing Relevant Virtual Health Guidelines and Practices
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.
- Alberta
- British Columbia
- Manitoba
- Newfoundland & Labrador
- Nova Scotia
- Ontario
- Prince Edward Island
- Quebec
- Saskatchewan
- Yukon
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.
Region | Consent | Privacy | Security | Software Tools | Regulations / Standards | Billing | Accessibility | Patient Guide |
---|---|---|---|---|---|---|---|---|
Alberta | ||||||||
British Columbia | ||||||||
Manitoba | ||||||||
New Brunswick | Unknown | Unknown | Unknown | Unknown | ||||
Newfoundland & Labrador | ||||||||
Nova Scotia | ||||||||
Northwest Territories | ||||||||
Nunavut | ||||||||
Ontario | ||||||||
Prince Edward Island | ||||||||
Quebec | ||||||||
Saskatchewan | ||||||||
Yukon |
Legend:
= Information present and publicly available from governing body
= Information not found in context of virtual healthcare
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.
Alberta:
- https://www.albertadoctors.org/leaders-partners/ehealth/virtual-care#toolkit
- References CMPA template
BC:
Manitoba:
New Brunswick:
- Inconclusive. Most information for practitioners requires login credentials.
- Privacy in Zoom Visit Guidelines
Newfoundland and Labrador:
- http://nlma.nl.ca/FileManager/VirtualCare/docs/2020.04.30_NLMA_Virtual_Care_Toolkit.pdf
- References CMPA template
Northwest Territories:
- No information found.
Nova Scotia:
- https://doctorsns.com/sites/default/files/2020-06/toolkit-virtual-care-v2.pdf
- References CMPA template
Ontario:
Prince Edward Island:
- Verbal consent is required. Written consent is waived for virtual visits (See page 2 of guide)
Quebec:
- Informed consent and disclosure of risk must be given (Page 14). References Patient Consent form from McGill.
Saskatchewan
- Verbal and Written consent is required, and references CMPA template as examples.
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:
- Virtual care tools require a Privacy Impact Assessment (or PIA)
- In response to COVID, a number of tools are pending assessment, but can be used.
- References:
British Columbia:
- Guidance from the Doctor's Technology Office outlines privacy practices and safe guards.
- References:
Manitoba:
- Quick start guide mentions legal and professional obligations to privacy and security, and acknowledges that streamlining the process may be necessary to respond to crisis.
- References:
New Brunswick:
- Inconclusive. Information for practitioners requires login credentials.
Northwest Territories:
- Outline of rights of patients under the Health Information Act, and a basic privacy guide.
- References:
Nova Scotia:
- Getting Started guide page 9 outlines privacy and security safeguards. References the Doctors of BC DTO security guide
- Privacy legislation in 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
- Privacy mentioned in context of the Pexip software.
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:
- Doctors are reminded of their professional and legal obligations to security in the quick start guide.
- Security features of applications are documented in Video Visit Apps guide.
New Brunswick:
- Inconclusive. Information for practitioners requires login credentials.
Newfoundland and Labrador
- Guidance provided to Newfoundland is a copy of the same safeguards from the DTO office in BC, which includes guidance for session and technology safeguards.
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
- OTN outlines the security requirements for selecting a virtual care platform including virtual visits, messaging, and data storage.
Prince Edward Island
- Security is discussed in terms of Zoom settings. (Guide page 4)
Quebec
- Guidance has been published for email and text (SMS) messaging security best practices
Saskatchewan
- Security mentioned in context of the Pexip software.
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)
- 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.
Alberta:
- Alberta's Virtual Care toolkit has a list of possible software tools including tools that have PIA submissions.
- Zoom is used at Alberta Health Services.
British Columbia:
- BC Provincial Health Services Authority is subsidizing Zoom licenses for physicians, nurse practitioners, and specialists.
- DTO quick start guide also mentions Doxy.me, Livecare, Memora Health as other possible platforms.
Manitoba:
- Adapted technology list based on the list from BC and suggests flexibility in choosing video conferencing application.
- Manitoba College of Physicians suggest a variety of free tools, including Facebook Messenger.
New Brunswick
- Inconclusive. Information for practitioners requires login credentials.
Newfoundland and Labrador
- Newfoundland recommends Cisco Jabber, and Telus Virtual Visits and Telus Health Myself
Northwest Territories
- No information found
Nova Scotia
- Nova Scotia has subsidized Zoom, QHR Medeo, Telus Virtual Visit / Health Myself. Other apps are not recommended.
Nunavut
- No information found
Ontario
- Ontario has two vendors of record: Novari Health and ThinkResearch.
- Other applications may be used as long as they meet the requirements outlined by OHIP bulletin #4746
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
- Pexip is used in Saskatchewan for patient-provider virtual visits, and Webex for group or public sessions
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.
The following regions in Canada have published patient guides:
- 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.
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:
- 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.
- 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.