Technology inevitably advances
faster than the regulations designed to govern it, and
the growing field of telemedicine is no exception.
In the case of interprovincial
telemedicine, however, that phenomenon hasn't spurred
growth as it has in other areas, like online video sharing
or email spam.
In September, the College of Physicians
and Surgeons of Saskatchewan began a new effort to fix
that, with a proposal to create special licensing that
would encourage doctors to practise telemedicine.
DEMAND
IS GROWING
Instead, the potential of interprovincial telemedicine
in Canada has largely been squandered so far because
of a lack of regulatory guidelines that would reassure
physicians about liability and licensure issues.
"The regulations in place are mainly
to do with intraprovincial activity," says Dr John Carlisle,
a health law expert and former deputy registrar of the
College of Physicians and Surgeons of Ontario. "The
amount of [telemedicine] activity between provinces
is not high enough to make it a priority." But the demand
is growing, and regulatory bodies are therefore taking
another look.
Despite recommendations made nine
years ago by the Federation of Medical Regulatory Authorities
of Canada (FMRAC) that provincial Colleges of Physicians
and Surgeons should set clear regulations, precious
few rules on interprovincial practice are currently
in place.
LOCATION
OF CARE
Liability remains the biggest concern for doctors doing
interprovincial telemedicine because there's no consensus
among provinces over how to define where telemedicine
treatment is considered to be taking place. "In Quebec
and BC, the locus of practice is where the physician
is located," says Dr Trevor Cradduck, vice-president
of the Canadian Society for Telehealth. In all of the
other provinces, the locus is where the patient resides."
Without agreement on that, interprovincial "visits"
raise prohibitive concerns about jurisdiction and liability.
Other health professionals don't
have that problem. "For nurses who practise telemedicine,
the colleges regard the locus of practice to be where
the nurse is located," says Dr Cradduck.
Even in provinces that have tried
to regulate this issue, confusion persists. Ontario's
new policy, established this July, allows some interprovincial
telemedicine to take place. It requires its doctors
to comply with the licensing requirements of the other
province or territory they practice in, but Ontario
claims to retain jurisdiction over their services and
any complaints. "I think the issue is one that FMRAC
needs to get into again," says Dr Carlisle. "It's the
responsibility of regulators to give as much guidance
to the profession as they can, in the public interest."
BILLING
DISPUTES
Many doctors are also cautious because it's not clear
in cases who will pay them for interprovincial telemedicine.
"There's a general lack of policy regarding physician
reimbursement," says Raymond Pong, PhD, the research
director at the Centre for Rural and Northern Health
Research at Laurentian University.
Almost all provinces have established
remuneration policies for intraprovincial telemedicine
but interprovincial remuneration hasn't received the
same level of attention. Dr Pong outlined this problem
in a Health Law Review article in 2000; since
then, there hasn't been much progress, he says.
SOLVING
LICENSURE
With Saskatchewan's efforts, regulations on licensure
fees, stalled by disagreement for years, now appear
to be moving forward. Instead of forcing doctors who
practise telemedicine on Saskatchewan patients to apply
and pay for a full licence to practise, the College
of Physicians and Surgeons is considering a plan to
introduce easily acquired, reduced-rate telemedicine
licences, much like locum licences. That's the solution
FMRAC's 1998 recommendations suggested all provinces
adopt. But in most provinces, a full licence to practise
is still required, though some exceptions exist.
"There have been situations where
some provinces made special arrangements," says Dr Pong.
"But that's governed in a case by case manner, which
is not the best in the world. It would be better to
have a policy across the country."
"It is an evolving thing," says
Dr Carlisle of interprovincial telemedicine practice.
"There are a lot of issues that have to be resolved.
Unfortunately, it may take a couple of very large lawsuits
for people to realize that this needs to be regulated
appropriately."
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