When an RP enters into a private practice business arrangement with another person, it is essential that they address key details of their business relationship at the outset in order to prevent the possibility of confusion and disruption in client care. Along with the commercial aspects of business (remuneration, marketing, etc.), these details should include the informed consent process, information and documentation practices, and what will happen when the business relationship ends.
Registrants considering entering into a business arrangement need to take into consideration the requirements and standards of practice that apply to CRPO registrants and any other regulated health professionals who may be involved. Below is guidance for CRPO registrants to assist them in this regard.
Principle-based decision-making
CRPO registrants can look to the Professional Practice Standards for useful guiding principles that can help assess if the particulars of a business arrangement are ethical and/or aligned with the standards. We’ve put together a case study, which appears at the end of this article, to illustrate how the standards can be used.
Identifying the health information custodian
Identifying how the role of the “health information custodian” (HIC) will be addressed within the practice is essential. Under the Personal Health Information Protection Act, 2004 (PHIPA) HICs have specific obligations with respect to security of and access to client personal health information. A first step here is to understand the array of possibilities with respect to who or which entities can occupy the role of HIC. PHIPA lists the individuals and entities that are eligible to act as a HIC.
There are a number of possible arrangements with respect to the role of HIC in a private practice setting. Examples include:
- A private practice where all regulated health professionals providing care in the setting are HICs. In this case, each individual would be independently responsible for carrying out the obligations of the HIC, which includes assuring that information practices align with requirements and standards of practice, like secure storage of records and client access to their own records.
- A private practice with a single owner/operator who designates the practice itself is the HIC. In this case, the practice owner/operator would be responsible for naming a contact person who is responsible for carrying out the obligations of the HIC and ensuring that any individuals operating within the setting are abiding by requirements and standards like maintaining the clinical records after therapy ends and reporting breaches of confidentiality if they happen within the setting.
Designating how the practice will address the role of the HIC at the outset of the business arrangement serves a number of purposes, some of which are listed below. There is no benefit to avoiding this task, as the obligations of the HIC will apply even when one is not explicitly identified and even when one fails to recognize when they are considered a HIC. Designating a HIC:
- Enables a more thorough informed consent process with respect to collection, use and disclosure of client personal health information.
- Clarifies who is responsible for specific information practices within the setting, and to what extent.
- Determines appropriate courses of action when there are questions or issues that arise with respect to management of the records or handling of a client’s personal health information.
Informed consent to treatment
A client should be made aware of the nature of their relationship with the practice and with their therapist before any assessment or treatment is provided, as this information may be material to a client’s decision to agree to treatment. For example, if the business arrangements within the private practice mean that the client is considered the client of the practice, as opposed to the client of any particular therapist, then the client should be informed of this. They should be made aware of any limitations this may present in, for instance, their ability to transfer between providers within that practice or to continue care with a therapist who leaves that practice. Learn more by reviewing Standard 3.2: Consent linked in Related Resources below.
Consent to collection, use and disclosure of PHI and management of clinical records
Registrants need to obtain informed consent from clients with respect to the collection, use and disclosure of their personal health information. Explaining who has access to the record and for what purposes helps the client understand how their information is ordinarily collected, used or disclosed in the setting. The client should also know who to contact for information about- or access to their clinical records. For example, if an RP in a group private practice is responsible for maintaining their own clinical records, the therapist would likely explain to their client that the therapist themselves is the contact person. In a scenario where the practice itself has taken on the role of the HIC, then the therapist might provide the contact information of a person designated by the practice owner/operator.
Ending business arrangements
Planning for the end of the business arrangement can help to avoid confusion and conflict, it can also promote effective management of care for the departing therapist’s clients.
Standards 6.3: Discontinuing Services and 6.4: Closing, Selling or Relocating a Practice (linked in Related Resources below) provide fairly specific guidance here. For example, unless there is an appropriate reason to do otherwise, registrants must:
- Make reasonable efforts to provide advanced notice to clients
- Provide a reason for discontinuing services
- Discuss alternate arrangements for services in light of the range of options available, which are likely to include: whether it will be possible to continue with the current therapist in another location, whether the client wishes to continue with a different therapist or alternate service in the current setting or somewhere else
- Refer the client appropriately
The Standard on discontinuing services indicates that a relationship between a client and their therapist should be able to continue as long as the client is benefitting from the therapy and wishes to continue receiving services. It also provides a number of legitimate reasons for discontinuing services. With this in mind, a registrant should not agree to business arrangements that place unreasonable restrictions on a client’s ability to receive services from their preferred provider, nor should they actively solicit clients who chose to receive services from another provider.
When a business relationship ends, arrangements may need to be made for the clinical records, keeping in mind who has been identified as the HIC and ensure the arrangements abide by record-keeping obligations. For example, if each party in the practice is operating independently as a HIC, then the registrant remains responsible for assuring the ongoing management of the clinical records accords with the Professional Practice Standards. If another person is the HIC, then the records would remain with that person. See Standard 5.1: Clinical Records and 5.6: Storage, Security and Retrieval linked in Related Resources below, for general information about record-keeping practices. It should be clear to clients where their records will be maintained and who to contact in order to request access.
Case Study
Teri, RP, has a growing private practice. She wants to bring on Mika, RP (Qualifying), who would provide services for some new clients. Teri provides a contract to Mika and asks her to sign it. While reviewing it, Mika noticed a clause that suggested that Mika would not be able to solicit clients of the practice, even after her business relationship with the practice ends. Another clause suggested that if/when Mika’s business arrangement with the practice ended, she would not be able to provide services to clients that she saw in the practice for a period of two years.
Mika called Teri to talk about what would happen with clients if their business arrangement ever ended. Mika explained that when she ended her last internship, there were clients who still needed treatment and who really wanted to continue working with her. Mika was able to work out an arrangement with the internship supervisor so that she could continue working with those few clients for a few more sessions until treatment was concluded.
Teri explained that clients who contact the practice to receive services are considered the clients of the practice, and so if Mika planned to move on from the practice, Mika would need to explain to any clients who wanted to continue receiving treatment that they would be referred to another RP in the practice.
Mika wasn’t comfortable with this arrangement. She turned to the Professional Practice Standards and saw that when it comes to discontinuing services, an RP has to work in a client’s best interests at all times. Also, the relationship should continue as long as the client is benefitting from the therapy and wishes to continue. Mika asked herself if she would be meeting the standard of practice if she agreed to the terms of the contract as they were currently set out. Mika reasoned that, in a private practice, a client’s options to receive services from their preferred provider should only be limited if there is a good enough reason for doing so. She contacted Teri to discuss the matter again. She resolved that if Teri wasn’t able to offer more flexibility on this matter, she wouldn’t feel comfortable entering into a business arrangement at this time.