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Virtual Care

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Approved by Council: April 2007
Reviewed and Updated: December 2014, June 2022

Companion Resources: Advice to the Profession

 

Policies of the College of Physicians and Surgeons of Ontario (the “College”) set out expectations for the professional conduct of physicians practising in Ontario. Together with the Practice Guide and relevant legislation and case law, they will be used by the College and its Committees when considering physician practice or conduct.

Within policies, the terms ‘must’ and ‘advised’ are used to articulate the College’s expectations. When ‘advised’ is used, it indicates that physicians can use reasonable discretion when applying this expectation to practice.

Additional information, general advice, and/or best practices can be found in companion resources, such as Advice to the Profession documents.

 

Definitions

Virtual Care: Any interaction between patients and/or members of their circle of care1 that occurs remotely2, using any form of communication or information technology, including telephone, video conferencing, and digital messaging (e.g., secure messaging, emails, and text messaging) with the aim of facilitating or providing patient care.3

 

Policy

Virtual care is the practice of medicine

  1. When providing virtual care, physicians must continue to meet the standard of care and the existing legal and professional obligations that apply to care that is provided in person, including those pertaining to prescribing drugs, medical record-keeping, protecting personal health information, consent to treatment, continuity of care, and charging for insured and uninsured services.4
    1. For example, physicians providing virtual care must conduct any assessments, tests, or investigations that are required in order for them to appropriately provide treatment and must provide or arrange for appropriate follow-up care.5
  2. Physicians must ensure they have the competence to provide care virtually, including to effectively use the relevant technology.

Virtual Care and Patients’ Best Interests

Virtual care is not appropriate in every instance as not all conditions can be effectively treated virtually and not every patient has access to or will be comfortable using virtual care technology.

  1. Physicians must:
    1. use their professional judgment to determine whether virtual care is appropriate in each instance its use is contemplated; and
    2. only provide virtual care if it is in the patient’s best interest to do so. This means only providing virtual care when:
      1. the quality of care will not be compromised; or
      2. the potential benefits of providing virtual care outweigh the risks to the patient (e.g., during contagious disease outbreaks or for a patient whose access might be otherwise limited to the point of risking patient harm).6
  2. When determining whether virtual care is appropriate and in the patient’s best interest (i.e., can meet the conditions set out in 3(b) above), physicians must consider and ensure their decisions reflect the following factors:
    1. the nature of the presenting complaint and care required, including whether a physical examination is required in order to meet the standard of care;
    2. the patient’s existing health status and specific health-care needs;
    3. the patient’s specific circumstances and preferences (e.g., financial hardship, mobility limitations, distance required to travel to an in-person appointment, ability to take time off from work, or any language and/or communication barriers); and
    4. the technology available to the patient and their ability to effectively utilize the technology.
  3. Where clinically appropriate and available, physicians must prioritize patient preference for in-person or virtual care.

Establishing a physician-patient relationship

  1. Physicians providing virtual care must ensure the following is disclosed to all new patients:
    1. the physician’s identity,
    2. the physician’s contact information, and
    3. the physician’s licensure status (i.e., where they hold a medical licence).

Limitations of Virtual Care and Appropriate Action

  1. Physicians must:
    1. be mindful of the limitations of virtual care; and
    2. take appropriate action if, during the course of a virtual encounter it is determined that a patient requires in-person care, including:
      1. informing patients of the need for in-person care and the urgency with which it should be sought; and
      2. providing or assisting patients in accessing appropriate in-person care in a timely manner (e.g., through a coverage arrangement or by directing patients to local in-person options).
  2. Physicians must take appropriate action if, during the course of a virtual encounter the quality of the encounter becomes compromised (e.g., technology fails or security is compromised) and the patient’s best interests will no longer be served by continuing with the virtual encounter, including:
    1. ensuring the patient is followed-up with in a timely manner; and/or
    2. rescheduling the appointment, where necessary.

Appropriate Setting and Technology

  1. Where the virtual encounter is synchronous (i.e., involves real-time interaction with the patient), physicians must confirm the physical setting where the patient is receiving virtual care is appropriate and safe in the circumstances (i.e., taking into account the nature and purpose of the intended interaction).
    1. Physicians must take appropriate action if they determine that it is not appropriate or safe to proceed, such as explaining that they will be unable to proceed at that time and re-scheduling the appointment in a timely manner.
  2. Physicians providing virtual care must use technology that is fit for purpose, can facilitate a quality encounter, and enables the standard of care to be met, including technology that:
    1. allows physicians to gather the information needed to provide the care; and
    2. supports the sharing of high quality and reliable patient health information (e.g., diagnostic or other images that are of sufficient quality).

Maintaining Privacy, Security, and Confidentiality

The legal obligations to protect the privacy and confidentiality of patients’ personal health information (PHI) also exist when delivering virtual care.

  1. All physicians must take reasonable steps to protect PHI, including protection against theft, loss, and unauthorized access, use, and disclosure of PHI.7 When providing virtual care, physicians must:
    1. take reasonable steps to accurately identify the patient (e.g., verify their name and date of birth);8
    2. conduct the encounter in a private setting, where applicable;
    3. disclose the identities of all participants that will be present during the encounter;
    4. ask the patient whether they are in a reasonably private setting and are comfortable discussing or sharing their PHI at that time; and
    5. use secure information and communication technology (e.g., platforms that are protected by encryption), unless it is in the patient’s best interest to do otherwise, taking into account:
      • the nature and purpose of the encounter, including the degree of sensitivity of the PHI being shared;
      • the availability (or lack thereof) of alternative technology;
      • the volume of information and frequency of use;
      • patient expectations; and
      • any emergency or other urgent circumstances.9
  2. If using less secure technology (e.g., unencrypted platforms), physicians must obtain and document the patient’s express (i.e., verbal or written) consent to do so.10

Obtaining Informed Consent for Virtual Care

  1. Physicians must ensure informed consent is obtained from the patient or their substitute decision maker (SDM) for the delivery of care using a virtual modality, which will require informing patients or their SDM of the benefits, limitations, and potential risks of a virtual encounter, including:
    1. those related to privacy (e.g., potential for privacy breaches); and
    2. any clinical limitations to providing virtual care and the potential requirement for in-person follow-up.11
  2. Physicians must obtain informed consent during the initial virtual encounter and each time the benefits, limitations, and potential risks change (e.g., if the virtual modality used changes, or if the nature of the care significantly changes).

CPSO Members Providing Virtual Care Across Borders12

  1. When providing or assisting in the provision of virtual care to a patient in another province, territory, or country, physicians must:
    1. comply with the licensing requirements of that jurisdiction;13 and
    2. ensure they have appropriate liability protection.14

Licensing Requirements when Providing Virtual Care to Ontario Patients 

  1. Physicians providing virtual care to Ontario patients located in Ontario15 must hold a valid and active certificate of registration with the CPSO, unless the provision of virtual care from a physician licensed elsewhere is in the patient’s best interest;16 for example, the care sought is:
    1. not readily available in Ontario (e.g., specialty care);
    2. provided within an existing physician-patient relationship and intended to bridge a gap in care; or
    3. for urgent or emergency assessment or treatment of a patient.17
 

Endnotes

1. For more information about who is included in the circle of care, please see CPSO’s Protecting Personal Health Information policy.

2. Remotely means without physical contact and does not necessarily involve long distances. Patients, patient information and/or physicians may be separated by space (e.g. not in the same physical location) and/or time (e.g. not in real time).

3. This definition was adapted from Shaw, J., Jamieson, T., Agarwal, P., Griffin, B., Wong, I., & Bhatia, R.S. (2018). Virtual care policy recommendation for patient-centred primary care: findings of a consensus policy dialogue using a nominal group technique. Journal of Telemedicine and Telecare, 24(9), 608-615.

4. Relevant legal obligations include privacy and confidentiality requirements as set out in the Personal Health Information Protection Act, 2004, S.O. 2004, c. 3, Sched. A (hereinafter PHIPA), and General, Ontario Regulation 329/04, enacted under PHIPA, consent requirements in the Health Care Consent Act, 1996, S.O. 1996, c. 2, Sched. A, and mandatory liability coverage in s. 50.2 of the General By-Law. Professional obligations are set out in CPSO’s Practice Guide and policies.

5. For more information on what it means to meet the standard of care when delivering care virtually, please see the Advice to the Profession: Virtual Care document.

6. In some exceptional circumstances it may be appropriate to provide virtual care even when in-person care would generally be required to meet the standard of care. These circumstances are generally limited to instances where virtual care promotes patient or public safety. In these circumstances the potential benefits of patient or public safety override the potential risk to quality of care.

7. PHIPA, s. 12 (1).

8. What is reasonable will differ if the encounter takes place within the context of an existing physician-patient relationship compared with a new patient.

9. For more information on privacy and security safeguards see the Advice to the Profession: Virtual Care document.

10. For the purposes of this policy, the telephone is considered secure technology.

11. For more information about obtaining informed consent see the Advice to the Profession: Virtual Care document.

12. CPSO maintains jurisdiction over its members regardless of where (i.e., physical location) or how (i.e., in-person or virtually) they practise medicine, and will investigate any complaints made about a member, regardless of whether the member or patient is physically located in Ontario.

13. The medical regulatory authority of the jurisdiction where the physician and/or patient are physically located may also require that physicians hold an appropriate medical licence in that jurisdiction.

14. Physicians can consult the Canadian Medical Protective Association (CMPA) and the Ministry of Health for more information on liability protection and billing in these circumstances.

15. For guidance related to treating Ontario patients who are temporarily out of the province, please see the Advice to the Profession: Virtual Care document.

16. This provision does not permit physicians licensed in other jurisdictions to circumvent Ontario licensing requirements and primarily practise in Ontario. It is intended to allow the provision of limited virtual care by physicians licensed in other jurisdictions in circumstances where it will serve a patient’s best interests.

17. CPSO reserves the right to take action against physicians who are providing virtual care to Ontario patients in accordance with Provision #16 if they are not meeting the standard of practice. If CPSO becomes aware of concerns about virtual care provided to an Ontario patient by a physician who is not licensed in Ontario it may share that information with the regulatory authority that has jurisdiction over the member, so that appropriate action can be taken by that regulatory authority.