Canada-Quebec Agreement on Virtual Care in Response to COVID-19

BETWEEN:

REFERRED to collectively as the "Parties", and individually as the "Party"

PREAMBLE

WHEREAS Canada and Quebec are in the midst of the COVID-19 pandemic, which has required provinces and territories to rapidly deploy virtual care services to meet health needs of Canadians;

WHEREAS Canada wishes to assist Quebec in expanding virtual care services to support improved access to publicly insured health care services for Quebecers and to further accelerate the use of virtual care services as a critical channel for delivering care during COVID-19;

WHEREAS funding to support the expansion of virtual care was announced by the Prime Minister of Canada on May 3, 2020, of which $150 million will flow to provinces and territories through bilateral agreements;

WHEREAS, on May 19, 2020, federal, provincial and territorial Deputy Ministers of Health agreed to the five priority areas for immediate action to support further embedding virtual care services within Canadian health systems, namely secure messaging and file transfer; secure videoconferencing; remote patient monitoring; patient access to their test results; back-end supports for integration and/or alignment of these new platforms or existing tools to meet the first four priorities.

WHEREAS these new federal investments must be guided by Quebec-supported principles that will prioritize user experience, data security/privacy, interoperability/data integration, and cross-jurisdictional solutions to accommodate patient flow;

WHEREAS the Government of Quebec is responsible for planning, managing and organizing Quebec's health care system, with federal funding aimed at supporting Quebec's work to augment virtual services as an essential medium of services during COVID-19;

WHEREAS Canada has established a transfer payment program called the Virtual Care COVID-19 Priorities Fund and authorizes the federal Health Minister to enter into agreements with provinces and territories to provide targeted funding to the provincial and territorial governments for the rapid deployment of virtual care in response to COVID-19 in keeping with the priorities agreed to by federal, provincial and territorial Deputy Ministers on May 19, 2020; and

WHEREAS Quebec agrees that data collection and public reporting of outcomes are key to reporting results to its population on its health system priorities, including virtual care;

NOW THEREFORE, Canada and Quebec agree as follows:

1.0 Purpose

1.1 The purpose of this Agreement is to enable Canada to provide Quebec with financial support that will rapidly deploy virtual care solutions, ensuring that Quebecers can continue to access high-quality care during COVID-19. This funding will support projects that will build on and enhance existing Quebec initiatives, capacity, and priorities.

2.0 Virtual Care

2.1 Objectives

2.1.1 Canada's funding will enable Quebec to accelerate implementation of interoperable and connected virtual tools and services in response to the COVID-19 pandemic and to take steps to embed virtual care as part of health care delivery.

2.2 Eligible Expenditures

2.2.1 Quebec agrees to allocate funds provided by Canada under this Agreement toward initiatives and actions within one or more of the following eligible areas of expenditures:

• secure messaging and file-transfer platforms or supports to enable end-to-end messaging;
• secure video-conferencing technology to deliver care to patients remotely;
• remote patient monitoring technologies;
• patient access to COVID-19 and other lab results; and,
• back-end supports for integration of new platforms and supports, including needed hardware.

2.2.2 Quebec agrees to use the funding provided by Canada under this Agreement for expenditures that are directly related to or required in order to carry out initiatives or actions, as identified in Quebec's Action Plan in appendix A, in the areas referred to in section 2.2.1, which may include:

• operating costs, including salaries and benefits; rent and utilities; materials and supplies; travel and accommodation; services;
• capital costs;
• training, professional development;
• data development and collection to support reporting;
• information technology and related investments; and,
• other costs that, in the opinion of the Parties, are essential for the completion of the initiatives and actions, and the achievement of results.

2.2.3 In developing initiatives in support of expanding virtual care as intended by this Agreement, Quebec, through internal management of its health system, will implement measures that respond to the needs identified, including the needs of underrepresented populations.

3.0 Effective Date, Duration

3.1 This Agreement will come into effect upon the last signature being affixed and will remain in effect until March 31, 2022, unless terminated in writing by Canada or Quebec in accordance with the terms and conditions set out in section 11.

3.2 Subject to sections 4.4 and 4.5, funding provided under this Agreement may be used by Quebec for expenditures described in section 2.2 that are incurred from April 1, 2020, to March 31, 2022.

3.3 Canada and Quebec concur that the purpose of this time-limited, one-time agreement is to help Quebec more rapidly deploy virtual care solutions and back-end support for integration of new platforms and supports, in keeping with the priorities agreed to by Deputy Ministers on May 19, 2020, and that Canada will not be responsible for any ongoing funding for enhanced initiatives established under this Agreement.

4.0 Financial Provisions

4.1 The contributions made under this Agreement are in addition to and not in lieu of those that Canada currently provides to Quebec under the Canada Health Transfer to support delivering health care services in Quebec.

4.2 Allocation to Quebec

4.2.1 In this Agreement, "Fiscal Year" means the period commencing on April 1 of any calendar year and terminating on March 31 of the immediately following calendar year.

4.2.2 Canada has designated a maximum one-time amount of funding to be transferred in total to all provinces and territories of $150,000,000.

4.2.3 The total amount to be paid to Quebec will be calculated using the following formula:

B + ((F - (N x 3,000,000)) x (K/L)), where:

• B is the base funding of $3,000,000;
• F is the total one-time funding amount available under this initiative;
• N is the number of jurisdictions (all 13) that will be provided the base funding of $3,000,000;
• K is the total population of Quebec, as determined using the July 1, 2019, population estimates from Statistics Canada;
• L is the total population of Canada, as determined using the July 1, 2019, population estimates from Statistics Canada.

4.2.4 Based on the formula described in section 4.2.3, Quebec's share of the amount identified in section 4.2.2 is:

Table 1: Quebec's Share of the Amount Identified in section 4.2.2

Amount to be paid to Quebec
$28,055,855.00

4.3 Payment

4.3.1 The total amount set out in section 4.2.4 will be paid by Canada to Quebec within approximately 30 business days of the Effective Date.

4.3.2 Subject to sections 4.3.4 and 4.4, Quebec agrees to spend the entire amount of Canada's contribution under this Agreement by no later than March 31, 2022. Any amount unexpended on March 31, 2023, is a debt due to Canada and must be repaid by Quebec within 60 days.

4.3.3 Payment of Canada's contribution referred to in section 4.2.4 is subject to the statutory appropriations under the Public Health Events of National Concern Payments Act.

4.4 Carry Forward

4.4.1 With notice to Canada, Quebec may retain and carry forward to the 2022-23 Fiscal Year up to 10 percent of the allocation paid to Quebec under section 4.2.4 that has not yet been spent on eligible expenditures, and use the amount for eligible expenditures incurred in 2022-23.

4.4.2 With mutual agreement in writing by the Parties, Quebec may retain and carry forward an amount exceeding 10 percent of the allocation paid to Quebec under section 4.2.4 that has not yet been spent on eligible expenditures, and use the amount for eligible expenditures incurred in 2022-23.

4.4.3 Quebec will report to Canada on the management and spending of the funds carried forward under sections 4.4.1 or 4.4.2 on a quarterly basis until funds are fully expended and reported.

4.5 Repayment of Overpayment

4.5.1 Canada and Quebec agree that every effort has been made to ensure that the calculation of Canada's contribution installment to Quebec is accurate.

4.5.2 In the event payment made to Quebec exceeds the amount to which Quebec is to be provided under this Agreement, the amount of the excess is a debt due to Canada and Quebec will repay the amount to Canada within 90 calendar days of written notice from Canada.

5.0 Annual Reports

5.1 On April 1, 2022, Quebec will submit an annual report on the status of the activities planned in Appendix A.

5.2 Reporting

5.2.1 By no later than October 1, 2022, in relation to Fiscal Year 2021-2022, Quebec will provide to Canada a certified annual financial statement of revenues received from Canada and expenses under this Agreement during the preceding Fiscal Year:

1. The revenue section of the statement will show the amount received from Canada under this Agreement during the Fiscal Year.
2. The total amount of funding used for eligible areas of expenditures activities under section 2.2.
3. If applicable, the amount carried forward by Quebec under section 4.4.
4. If applicable, the amount of any funds that are to be repaid to Canada under section 4.5.

5.2.2 Canada may, with prior written notice to Quebec, incorporate all or any part or parts of the financial report described into any public report that Canada may prepare for its own purposes, including any reports to the Parliament of Canada or reports that may be made public.

5.3 Audit

5.3.1 Quebec will ensure that expenditure information presented in the report required under section 5.2 is, in accordance with Quebec standard accounting practices, complete and accurate.

5.4 Evaluation

5.4.1 Responsibility for evaluation of programs rests with Quebec in accordance with its own evaluation policies and practices.

6.0 Communications

6.1 Canada and Quebec agree on the importance of communicating with citizens about the objectives of this Agreement in an open, transparent, effective and proactive manner through appropriate public information activities.

6.2 Canada will make the Bilateral Agreements on Virtual Care in Response to COVID-19 entered into with all provinces and territories, including any amendments, publicly available on a Government of Canada website.

6.3 Each government will give credit and visibility satisfactory to the other government when activities and or initiatives financed by/using funds provided under this Agreement are announced to the public.

6.4 Canada reserves the right to conduct public communications, announcements, events, outreach and promotional activities about the bilateral agreements.

6.5 Quebec reserves the right to conduct public communications, announcements, events, outreach and promotional activities related to this Agreement.

6.6 The Parties agree to give each other 10 days advance notice and advance copies of public communication related to this Agreement and to results of initiatives undertaken with funding provided under this Agreement.

7.0 Dispute Resolution

7.1 Canada and Quebec are committed to working together and avoiding disputes through government-to-government information exchange, advance notice, early consultation, and discussion, clarification, and resolution of issues, as they arise.

7.2 If at any time either Canada or Quebec is of the opinion that the other Party has failed to comply with any of its obligations or undertakings under this Agreement or is in breach of any term or condition of the Agreement, Canada or Quebec, as the case may be, may notify the other Party in writing of the issue, failure or breach. Upon such notice, Canada and Quebec will endeavour to resolve the issue in dispute bilaterally through the Associate Assistant Deputy Minister of the Strategic Policy Branch, Health Canada, and the Associate Deputy Minister, Information Technology Branch, Ministry of Health and Social Services of Quebec, as named in the notice section below.

7.3 If either Designated Official concludes that the dispute cannot be resolved by the Designated Officials, then the dispute will be referred to the Deputy Ministers of Health for Canada and Quebec, and if it cannot be resolved by them, then the federal Health Minister and Quebec Minister of Health and Social Services will endeavour to resolve the dispute.

8.0 Amendments

8.1 Amendments to this Agreement and to Appendix A may be made at any time upon mutual consent of the Parties. To be valid, any such amendments will be in writing and signed, in the case of Canada, by the federal Health Minister, and in the case of Quebec, by the Minister of Health and Social Services and by the Minister Responsible for Canadian Relations and the Canadian Francophonie.

9.0 Termination and Expiration

9.1 Canada may terminate this Agreement at any time if the terms of this Agreement are not respected by Quebec by giving at least 6 months written notice of its intention to terminate. Quebec may terminate this Agreement at any time if the terms of this Agreement are not respected by Canada by giving at least 6 months written notice of its intention to terminate.

9.2 As of the effective date of termination of this Agreement under section 9.1, Canada shall have no obligation to make any further payments to Quebec after the date of effective termination.

9.3 Upon termination of this Agreement under section 9.1, Quebec will repay any federal funds provided pursuant to the Agreement that have not or will not be used in accordance with section 2.2 of this Agreement.

9.4 Sections 4.4, 5.2, 5.3, and 6 of this Agreement survive the termination or expiration of this Agreement.

10.0 Notice

10.1 Any notice, information or document provided for under this Agreement will be effectively given if delivered or sent by letter, postage or other charges prepaid. Any notice that is delivered will have been received upon delivery; and, except in periods of postal disruption, any notice mailed will be deemed to have been received eight calendar days after being mailed.

The address for notice or communication to Canada will be:

Health Canada
70 Colombine Drive
11th Floor, Brooke Claxton Building
Ottawa, Ontario K1A 0K9
Attention: Jocelyne Voisin, Assoc. Assistant Deputy Minister
Email: jocelyne.voisin2@canada.ca

The address for notice or communication to Quebec will be:

Ministry of Health and Social Services
930, chemin Sainte-Foy, 6e étage
Quebec (Québec) G1S 2L4
Attention: Luc Bouchard, Associate Deputy Minister
Email: luc.bouchard@msss.gouv.qc.ca

11.0 General

11.1 This Agreement, including the Appendix, comprises the entire Bilateral Agreement on Virtual Care in Response to COVID-19 entered into by the Parties with respect to the subject matter hereof.

11.2 This Agreement will be governed by and interpreted according to the existing laws of Quebec.

11.3 No member of the House of Commons or of the Senate of Canada or of the Legislature of Quebec will be admitted to any share or part of this Agreement, or to any benefit arising therefrom.

11.4 If for any reason a provision of this Agreement that is not a fundamental term is found by a court of competent jurisdiction to be or to have become invalid or unenforceable, in whole or in part, it will be deemed to be severable and will be deleted from this Agreement, but all the other provisions of this Agreement will continue to be valid and enforceable.

11.5 This Agreement may be executed in counterparts, in which case (i) the counterparts together will constitute one agreement, and (ii) communication of execution by fax transmission or emailed in PDF will constitute good delivery.

For the Government of Canada, singed by the Minister of Health - date: August 14, 2021

For the Government of Quebec, signed by the Minister of Health and Social Services - date: August 14, 2021, and the Minister Responsible for Canadian Relations and Canadian Francophonie – date: August 14, 2021

APPENDIX A

Virtual care initiatives to be funded under this Agreement:

Quebec Virtual Ophthalmology Solution:

Project summary:

The aim of the project is to acquire and implement a tele-ophthalmology solution using artificial intelligence. The first phase of the project focuses on the implementation of a Quebec-based service of diabetic retinopathy screening at distance (DRSD) to identify and manage patients with type 2 diabetes. Retinal photos using OCT will be taken at 101 imaging sites in 18 Quebec regions. The use of this solution will be extended to the management of various diseases such as glaucoma and age-related macular degeneration (AMD).

Background:

Inefficient use of health care services combined with a limited number of ophthalmologists and the absence of a strategy significantly limit access to an ophthalmic examination. This puts the population with sight-threatening diseases such as DR or glaucoma at risk. In the advanced stages, these diseases can cause significant vision loss or even blindness. The first goal of this initiative is to establish a Quebec-based DRSD service to identify and manage patients with type 2 diabetes in the early stages and avoid complications such as blindness. The second phase of the project will allow the follow-up and remote monitoring of those suspected to have glaucoma or other eye diseases through a virtual network fostering professional collaboration between optometrists and ophthalmologists.

Objectives:

• To increase accessibility to telescreening for people with type 2 diabetes;
• To refer patients to specialized services in a timely manner, particularly ophthalmology services, and avoid complications that can lead to blindness;
• To reduce unnecessary clinic referrals to ophthalmologists and increase the efficiency of ophthalmology clinics;
• To integrate artificial intelligence to reduce costs and support diagnosis and data analysis.

Project duration:

The project will begin on April 1, 2021, and end on March 31, 2023.

Project costs:

The total cost of the project is $39,227,125, of which Canada will contribute $21,174,555.

Performance metrics:

• Measure A - The solution is ready (see description below): - 1 specialist (ophthalmologist) conducted an asynchronous virtual consultation for a patient;
  - An abbreviated clinical report per consultation was prepared electronically.
• Measure B - Number of ophthalmologists trained and connected to the platform.
• Measure C - Number of functional cameras connected to the platform.

Virtual Ophthalmology Care (VOC) Total cost of project $M	Fiscal year 2020-21	Fiscal year 2021-22	Fiscal year 2022-23	Total
Total funding from Health Canada	$0.11M	$15.04M	$6.02M	$21.17M
Other sources of revenue (specify)
MHSS (VOC)				$18.05M
Total other sources of revenue				$18.05M
Total project budget				$39.22M

Quebec Virtual Care and Services Platform:

Project summary:

Acquisition and deployment of a Quebec-based system for managing virtual care and services requests, that integrates all types of teleconsultations (real-time, non-real-time, with or without a user), and is intended for all types of health professionals practising in Quebec and members of the RAMQ. The following will be the first services to be implemented:

• Real-time and non-real-time services and activities (e.g., dermatology, psychiatry, oncology, pharmacy and wound care).
• Migration of current clinical teleconsultation services (26 specialties and approximately 1,300 users).

Background:

In Quebec, the current continuum of care and the exchange of information within institutions are provided by clinical information systems specific to these institutions when present, and paper-based otherwise. The exchange of clinical information between different service delivery entities is still largely paper-based. Furthermore, the diversity, multiplicity and maturity of the systems used in the RSSS institutions present real obstacles to the standardized electronic exchange of information. These difficulties represent barriers to the adoption and use of a virtual service model. The acquisition and deployment of a unique virtual care solution aim to address these issues.

Objectives:

• To improve access to specialized and ultra-specialized services for targeted clients (decrease delays and waiting lists);
• To optimize the use of medical resources and improve the cost-benefit ratio compared to in-person visits.

Project duration:

The project started on May 25, 2021, and will end on November 19, 2022.

Project costs:

The total cost of the project is $11,011,300, of which Canada will contribute $6,881,300.

Performance metrics:

Measure A - The solution is ready (see description below):

• - 1 specialist (dermatologist) conducted a synchronous virtual consultation with 1 patient;
• - 1 specialist (dermatologist) conducted a synchronous virtual consultation with 1 family physician regarding a case;
• - 1 specialist (dermatologist) conducted a synchronous virtual consultation with 1 family physician regarding a patient;
• - In each case, a clinical report was shared electronically with the patient.

Measure B - Number of dermatologists who conducted at least one synchronous or asynchronous virtual consultation.

Measure C - Number of patients who received virtual consultations (synchronous or asynchronous).

Virtual Care Platform (VCP) Total cost of project $M	Fiscal year 2020-21	Fiscal year 2021-22	Fiscal year 2022-23	Total
Total funding from Health Canada		$3.49M	$3.39M	$6.88M
Other sources of revenue (specify)
Canada Health Infoway				$3.18M
MHSS				$0.95M
Total other sources of revenue				$4.13M
Total project budget				$11.01M