GUIDE FOR THE PROVISION OF SECOND OPINIONS 5060-3080 Ynge Street, Bx 71 Trnt, Ontari M4N 3N1 416-975-5347 1-800-993-9459 www.caslp.cm September 2018 1
GUIDE FOR THE PROVISION OF SECOND OPINIONS PURPOSE The purpse f this Guide is t supprt audilgists and speech language pathlgists (SLPs) when applying practice standards, regulatins and legislatin t the prvisin f secnd pinins. THIS GUIDE APPLIES WHEN: A secnd pinin is requested by the patient, substitute decisin maker (SDM) r a third party such as the Cllege, a lawyer, insurance cmpany, legal prceeding r by curt rder. The secnd pinin is, a) a patient recrd review r, b) a recrd review and a patient assessment with recmmendatins. The riginal clinical infrmatin is available. DEFINITION OF SECOND OPINION An audilgist s r SLP s independent clinical findings relating t the validity and apprpriateness f sme, r all, f a patient s interventin, prvided by anther prfessinal with the same r similar scpe and area f practice. PRINCIPLES 1. Yu shall practice within the limits f yur cmpetence as determined by yur educatin, training and prfessinal experience (Cde f Ethics 4.2.2). 2. When cnducting a secnd pinin, yu must be hnurable, bjective and impartial (Cde f Ethics 4.1.3 and 4.1.7). 3. Yu must ensure that the secnd pinin is reasnable, fair, balanced, and substantiated by bjective data and clinical judgment (Cde f Ethics 4.2.7). 4. Yu must identify and mitigate bias r cnflict f interest that culd reasnably affect yur secnd pinin. This may include declining yur invlvement. 5. Yu are nt required t prvide a secnd pinin and may chse t decline t d s. CONSENT REQUIREMENTS When reviewing a patient s persnal health infrmatin, knwledgeable cnsent frm the patient must be btained and dcumented. Only then can yu cllect, use and disclse persnal health infrmatin in yur reprt and/r testimny. When cnducting a patient assessment, infrmed cnsent fr the assessment must be btained frm the patient and dcumented. If the patient des nt have capacity t cnsent, the patient s SDM must prvide bth cnsent t cllect use and disclse health infrmatin and/r cnsent t assess. 2
Cnsent may have been btained by anther health care prfessinal r a third party, such as a lawyer r insurance cmpany. Yu must ensure that the patient being assessed understands the purpse f the assessment, hw the assessment will prceed, and where the reprt will be sent. There are legal prceedings (summns r rders) that may require the disclsure f persnal health infrmatin withut cnsent. The Persnal Health Infrmatin Prtectin Act permits disclsure fr a prceeding in which yu are a party r witness. (PHIPA 2004, c. 3, Schedule A, s. 41 (1).) Patients can withdraw cnsent at any time; hwever, this may prevent yu frm cmpleting the assessment and submitting a secnd pinin. Patients are entitled t place limits n the infrmatin that audilgists and SLPs can disclse in a reprt. Yu shuld cmmunicate t the patient that such limitatins may affect yur secnd pinin. COMPETENCIES In rder t develp an bjective and reasnable secnd pinin, yu must pssess the requisite knwledge, skill and judgement t: Cmmunicate apprpriate infrmatin t the patient including, but nt limited t: the purpse f the secnd pinin and hw it may affect the assessment prcedure wh is requesting the secnd pinin the relatinship between yu and the third party Cmply with current relevant legislatin, regulatins, prcesses and criteria that gvern the requested secnd pinin. Fr example, legal and insurance cmpany requirements such as independent medical examinatins (IMEs) als knwn as independent evaluatins (IEs). Determine the relevance f any infrmatin cllected fr the recrd review r assessment. Identify gaps in infrmatin and make reasnable effrts t seek ut further infrmatin that may impact the secnd pinin. Identify and declare any cnflict f interest. Cnsider, declare (if applicable) and mitigate any biases, including persnal pinins and different therapeutic appraches. Use and dcument current, evidenced-based research t supprt yur pinin. Prvide a clear ratinale fr hw and why yu arrived at the secnd pinin. When assessing a patient, the fllwing additinal cmpetencies are required: 3
Cnsider any restrictins t timelines fr re-administering standardized assessment prtcls. Identify significant clinical differences between the riginal interventin and the secnd pinin. This wuld include technlgical and clinical advances and whether assessment tls r equipment were available. Select an apprpriate assessment prtcl, especially if yu cannt repeat the riginal assessment prtcl, t generate a clinical finding. Review the scpe f the secnd pinin, and nt prvide an pinin r interventin utside that requirement. Prtect the patient s well-being by reducing ptential stress r cnfusin stemming frm what may be an impersnal prcess. If yu determine yu d nt have the required cmpetencies r yu are in a cnflict f interest t prvide a secnd pinin at any pint in the prcess, yu shuld withdraw yur services. Yu shuld infrm the patient and whever made the request fr a secnd pinin. DOCUMENTATION Yu must keep a patient recrd fr bth a recrd review and assessment. When cnducting a recrd review and writing a reprt where yu are nt assessing the patient, the fllwing dcumentatin needs t be retained: The patient s cnsent t cllect, use and disclse persnal health infrmatin Infrmatin n wh requested the secnd pinin and why The dates yu cnducted yur recrd review A cpy f yur reprt, if written Ntatin f wh received yur reprt When assessing a patient, a patient recrd must be develped and retained, as per the Recrds Regulatin (2015). Include infrmatin regarding the evidence used t substantiate the secnd pinin. GLOSSARY ASSESSMENT: the use f bth standardized and nn-standardized measures t bserve and recrd a persn s functining in a variety f areas. This is dne in rder t gain an understanding f a patient s strengths and weaknesses s as t allw the member t make an evaluatin statement and plan a treatment prgram. KNOWLEDGEABLE CONSENT: the patient understands why their persnal health infrmatin is being cllected and used and the purpse fr disclsing their infrmatin t anther health infrmatin custdian, agent r third party and agrees t the cllectin, use and/r disclsure. The patient als is infrmed that they may give, withhld r withdraw cnsent. 4
INFORMED CONSENT: Befre receiving service, the patient r SDM has received infrmatin that a reasnable persn in the same circumstances wuld require. In additin, the persn must have received respnses t his r her requests fr further infrmatin. Necessary infrmatin includes: The nature f the service. The expected benefits f the service. The material risks f the service. The material side effects f the service. Alternative curses f actin. The likely cnsequences f nt having the service. INTERVENTION: includes screening, assessment, treatment, management, cnsultatin, educatin and cunselling. RECORD REVIEW: when a member prvides a prfessinal pinin based slely n a patient recrd with n direct patient interventin. PATIENT RECORD: an electrnic r paper patient health recrd that is made, used, maintained, retained and disclsed by audilgists and SLPs in English r French in accrdance with the Recrds regulatin. REFERENCES The Cllege f Physicians and Surgens f Ontari (2012) Medical Expert: Reprts and Testimny The Cllege f Physicians and Surgens f Ontari (2012) Third Party Reprts The Canadian Medical Assciatin (2004) Cde f Ethics The Cllege f Chirpractrs f Ontari (2013) Third-Party Independent Chirpractic Evaluatins FREQUENTLY ASKED QUESTIONS Q1 A1 I prvided a secnd pinin regarding an SLP s treatment plan, this invlved a recrd review. I have since been asked t prvide verbal testimny in a curt prceeding regarding my secnd pinin. Are there any cnsideratins I shuld be aware f? It shuld be n different than if yu were required t prvide testimny as the patient s primary SLP r audilgist. The typical guidance given by the Cllege is t answer questins within yur scpe and area f practice and regarding the service yu prvided, in this circumstance a recrd review and reprt. 5
Q2 A2 I have been asked t carry ut an assessment f a child and prvide a secnd pinin, hwever the parents refuse t prvide the SLP s r audilgist s riginal assessment and clinical infrmatin. What shuld I d? If yu d nt have access t the riginal recrd r the assessment and clinical infrmatin, yu cannt prvide a secnd pinin. Parents, as substitute decisin makers have the right nt t disclse persnal health infrmatin. Infrm the parent that withut the previus recrd, yur assessment can nly be cnsidered a valid reflectin f the child s current abilities and is nt an pinin n the previus assessment. Yu can, hwever, agree t carrying ut an assessment and share yur clinical findings and recmmendatins. Ensure the parents understand that yur assessment is nt a secnd pinin. Q3 A3 A clleague has asked me t review an audigram and his reprt regarding ne f his patients wh presents with a cmplex hearing histry. Is this cnsidered t be a secnd pinin? Reviewing a clleague s assessment results, reprts r bserving a clleague prvide service is nt a secnd pinin. This is a cnsultatin which happens frequently with bth audilgists and SLPs. Members must cnsider if the clleague is in the Circle f Care, and if nt, btain knwledgeable cnsent t disclse the patient s persnal health infrmatin. Q4 A4 A patient wh isn t happy with his hearing aids prescribed by anther audilgist has asked me fr a secnd pinin. The patient wants t knw if the hearing aids prescribed were apprpriate. The aids were prescribed ver five years ag and technlgy has changed significantly s they wuldn t be apprpriate nw. What shuld I say? Yu shuld infrm the patient that hearing aid technlgy has changed ver recent years, and if they want t pursue a secnd pinin, yu will need the riginal audigram and prescriptin infrmatin. The secnd pinin yu prvide shuld reflect the technlgy that was available five years ag. Yu can als ffer the patient an assessment t prvide a recmmendatin fr new hearing aids that fit his current hearing needs. Q5 A5 I am an SLP and I was asked by a family t prvide a secnd pinin regarding an aphasia assessment and treatment plan prvided fr their father. The family nw want me t prvide services t their father. Is this OK and is the service I prvide still cnsidered t be a secnd pinin? Fllwing the prvisin f a secnd pinin yu may prvide aphasia treatment t the patient. The subsequent service des nt fall under what the Cllege cnsiders the prvisin f a secnd pinin. 6
Q6 A6 I wrk as an SLP in the aut insurance sectr prviding assessment and treatment t patients with acquired brain injury. What happens if there is disagreement regarding the assessment/recmmendatins by the clinician prviding the secnd pinin? Mst insurance cmpanies address this circumstance with specific prcesses. Yu shuld fllw the prcesses prvided by the insurance cmpany r their gverning bdy. The prcesses may change s yu must keep up t date with what they are. Q7 A7 I am an audilgist and I have been asked by the spuse f a patient t prvide a secnd pinin regarding an audilgical assessment carried ut by a Hearing Instrument Practitiner (HIP). HIPs are nt regulated, s are there any differences in the cnsent r secnd pinin requirements? Yu will still have t btain and dcument cnsent frm the patient, if they are capable, fr the cllectin, use and disclsure f persnal health infrmatin. Because HIPs are nt required t fllw CASLPO standards regarding audilgical evaluatins, yu shuld keep this in mind when develping yur secnd pinin. Q8 A8 I have agreed t prvide a secnd pinin regarding the interventin with a child wh has a severe stutter. I am cnfident in my knwledge, skills and judgement in the area f stuttering. Hwever, the member wh cnducted the patient assessment has a cmpletely different apprach than I d (she prvides direct therapy t yung children and I fcus my interventin n parent training). Shuld I still prvide a secnd pinin? Use yur prfessinal judgement. Yu have recgnized yur therapy bias, s ask yurself if yu can prvide an bjective and impartial pinin that is reasnable, fair, balanced, and substantiated by bjective data and clinical judgment. If yu feel that yu cannt, then yu shuld infrm the party that requested the secnd pinin and withdraw yur services. Q9 A9 What is the difference between a secnd pinin and an expert pinin? An expert pinin is a legal term fr the pinin rendered by an expert witness r subject matter expert in a legal prceeding. This may r may nt be a secnd pinin, depending n the circumstance. Fr example, it is a secnd pinin if it pertains t a patient, the riginal clinical infrmatin is available and the member is prviding an pinin regarding the clinical infrmatin. 7