Virtual care plays an important role in the health-care system by improving access to care and increasing efficiencies in the way it is delivered. As technology continues to evolve, it will bring new opportunities and advancements in the delivery of virtual care. At the same time, virtual care is not appropriate in every instance. Not all conditions can be treated virtually and not everyone has equal access to or is comfortable using technology.

CPSO’s Virtual Care policy sets expectations for physicians about the appropriate use of virtual care. This companion Advice document is intended to help physicians interpret their obligations as set out in the policy and provide guidance around how these expectations may be effectively discharged.

Virtual Care is the Practice of Medicine

Can you elaborate on the scope of the policy? What medical services are captured by the term “virtual care”?

Virtual care is defined in the policy as “any interaction between patients and/or members of their circle of care that occurs remotely, 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.”¹

This means that virtual care includes all medical services to patients (e.g., assessing, diagnosing, giving advice, teleradiology, telemonitoring, etc.) as well as inter-professional and intra-professional consultations (i.e., remote consultations between providers).

The principles set out in the policy are broadly applicable to all medical services conducted virtually, including services such as independent medical exams (IMEs) which are not for the provision of health care but are conducted for the purpose of a third party process.

If I have the competence to provide in-person care, do I have the competence to provide the same type of care virtually?

The provision of virtual care may require the use of new technology, as well as a modified approach to care that is distinct from in-person care and there may be a learning curve when you first begin to provide care virtually. For example, in the absence of seeing a patient in person, assessments done over the telephone or via videoconferencing might require you to ask additional or different questions than you would in person. As a result, some physicians might need additional training around the technical components of virtual care or time to adapt to the new approach to care. To ensure patient safety, the policy recognizes this distinct skillset and requires that physicians have the competence to provide care virtually.

The policy requires the standard of care to be maintained when providing virtual care. How can I meet the standard of care when delivering care virtually?

The standard of care remains the same whether you are providing in-person or virtual care. Meeting the standard of care in a virtual environment includes: continuing to obtain a relevant history, conducting appropriate examinations, ordering diagnostic tests, and making diagnoses and/or differential diagnoses, as appropriate. It involves continuing to explain the benefits and risks of treatment options, providing suitable treatment plans, and ensuring necessary follow-up. It also includes ensuring that patients referred to specialists are appropriately investigated and treated before a referral is made.

In most instances, if a physical examination is required in order to appropriately assess or treat the patient, then virtual care will not enable you to meet the standard of care in that instance. There are limited exceptions, however, such as during contagious disease outbreaks, or for a patient whose access might be otherwise limited to the point of risking patient harm. A risk-benefit analysis can help physicians determine whether the standard of care can be met with a virtual encounter.

Virtual Care and Patient Best Interest

Why doesn’t the policy specify the circumstances where virtual care would or would not be appropriate?

Every patient’s needs are unique, technology is continuously evolving, and a number of considerations will play into the type of care that is appropriate in each instance. Issues that might require in-person care today may be able to be treated virtually in the future. As a result, the policy recognizes that physicians will need to exercise professional judgment to make these determinations on a case-by-case basis.

Where can I find additional resources that can assist me in determining when virtual care is appropriate?

The Virtual Care Playbook is a resource developed by the Canadian Medical Association, the Royal College of Physicians and Surgeons of Canada, and the College of Family Physicians of Canada that can assist physicians in determining when virtual care is appropriate and what conditions may be appropriately treated virtually. With virtual care becoming more prevalent, CPSO anticipates that additional clinical practice guidelines will be developed to help support physician decision-making.

My patient and I disagree about whether virtual care or in-person care is warranted. How can disagreements be addressed?

Not all patients have access to technology, are comfortable using technology, or are able to receive care virtually. At the same time, not all patients have equal ability to make themselves available for in-person care or have the same access to local in-person options. As always, you will need to consider what is in your patient’s best interest and find a solution that satisfies the need for patient access, safety, and quality care, while prioritizing patient preference, where possible (i.e., where clinically appropriate and available).

Although physicians are ultimately responsible for determining which modality will result in the best outcome for patients, effective and sensitive communication in these instances can go a long way towards resolving disagreements, including explaining why the preferred modality is in the patient’s best interest (e.g., the limits or benefits of virtual care.)

Is it appropriate to use a ‘virtual-first’ approach in all instances?

A blanket virtual-first approach (i.e., triaging every patient with an initial virtual appointment) is not recommended in the absence of direction from the government (e.g., in relation to pandemics/public health measures). Use of a blanket virtual-first approach can delay necessary care and negatively impact patient safety as well as the system as a whole. Certain conditions will require in-person care and consideration needs to be given to the purpose and nature of the appointment at the point of scheduling or triaging.

Can I exclusively provide virtual care to patients?

Generally, virtual care is not meant to replace but to complement in-person care as there are limits to what can be done virtually and there are some patients that cannot be appropriately treated virtually. The standard of care is often difficult to meet in a completely virtual environment. For example, an exclusively virtual comprehensive primary care practice would not be able to meet the standard of care. Depending on the nature of the practice, meeting the standard of care will generally require physicians to provide some in-person care. A fully virtual practice might be possible in some limited circumstances (e.g., radiology, psychotherapy, etc.).

What are key expectations to be aware of when practising in a virtual walk-in clinic?

When practising virtually, you must continue to meet the same legal and professional obligations that apply to care that is provided in-person, including the expectations set out in other CPSO policies such as the Walk-in Clinics, Medical Records Documentation, and Medical Records Management policies.

Key expectations outlined in the Walk-in Clinics policy include:

• Determining whether it would be appropriate to sensitively remind patients about the benefits of seeing their primary care provider, if they have one, for care within their physician’s scope of practice;
• Communicating any limitations related to the episodic nature of walk-in clinic care to patients, as well as appropriate next steps to patients seeking care or services that are not provided; and
• Providing the patient’s primary care provider with a record of the encounter when the patient asks or when it is warranted from a patient safety perspective and consent has been obtained.

Key expectations related to medical record-keeping include:

• Having a written agreement that establishes custodianship and clear accountabilities regarding medical records, including enduring access for physicians and their patients (e.g., in the event you need to respond to a complaint or investigation); and
• Ensuring documentation is complete and comprehensive, containing:
  • all relevant information;
  • information that conveys the patient’s health status and concerns;
  • any pertinent details that may be useful to the physician or future health care professionals who may see the patient or review the medical record; and
  • documentation that supports the treatment or procedure provided (i.e., rationale for the treatment or the procedure is evident in the record).

For additional guidance regarding virtual walk-in clinics see the Canadian Medical Protective Association’s (CMPA) Thinking of working with virtual clinics? Consider these medical-legal issues.

Privacy, Security, and Informed Consent

Where can I find more information about how to comply with privacy and security obligations in a virtual environment?

The Information and Privacy Commissioner of Ontario has released comprehensive guidelines regarding Privacy and security considerations for virtual health care visits to assist health care providers in complying with their privacy and security obligations in a virtual environment. Key issues addressed in these guidelines include:

• Requirements to safeguard information, such as having an information security management framework with administrative, technical, and physical safeguards;
• Obligations related to electronic services providers and health information network providers;
• The importance of developing a virtual care policy and for providing privacy and security training for employees and agents (i.e., individuals working on behalf of physicians);
• The importance of conducting privacy impact assessments to identify and manage the privacy and information security risks associated with virtual care;
• The need for a privacy breach management protocol;
• Special considerations for various forms of virtual care (e.g., videoconferencing, emails, patient portals, etc.); and
• A reminder for physicians that the same record retention requirements apply to virtual interactions, and that patients continue to have the same access and correction rights when receiving virtual care as with in-person care.

Additional resources include:

• CMPA’s Protecting patient privacy when delivering care virtually, and
• OntarioMD and the Ontario Medical Association’s free online Virtual Care Privacy and Security Training Module designed to help ensure that physicians and their staff fully understand how to comply with privacy and security obligations in a virtual care environment.

When providing virtual care, am I allowed to use technology (e.g., platforms) that cannot guarantee privacy and security?

The policy recognizes that in some limited situations patients’ best interests might be served by using technology that is less secure (e.g., unencrypted) and sets out considerations to help physicians determine when using less secure technology might be appropriate. It also requires that if doing so, physicians obtain and document express patient consent (i.e., verbal or written). Ultimately, less secure technology may be best suited for minor tasks, such as scheduling appointments and appointment reminders, or for exceptional situations in which the patient is unable to receive virtual care using secure (e.g., encrypted) technology and consents to proceed with the technology available.

Where can I find more information about virtual care platforms that are appropriate for clinical use?

To assist health care providers in selecting virtual care solutions appropriate for clinical use, Ontario Health has established a provincial standard and launched a verification process for virtual care solutions. For a list of verified virtual visit solutions (i.e., videoconferencing and secure messaging solutions that comply with provincial requirements), see their website.

What do I need to know about informed consent for the use of virtual care?

Consent includes informing patients about the benefits, risks, and limitations of virtual care (e.g., those related to privacy and any clinical limitations), providing an opportunity for patients to ask questions, and receiving agreement from the patient to proceed with the virtual encounter.

Consent can be express (either verbal or written) or implied (i.e., proceeding with the encounter after an overview of the benefits, risks, and limitations have been identified). The nature of the interaction and degree of sensitivity of the personal health information being shared during the virtual encounter are key considerations when determining whether express or implied consent would be required in each instance. The higher the degree of sensitivity, the more likely express consent will be necessary. 

The other element of consent is documentation which can take the form of a signed consent form that captures the identified benefits, risks, and limitations of virtual care or written notes in the patient’s (electronic) medical record that capture the discussion with the patient about the use of virtual care.

Although the policy does require documenting consent in circumstances where less secure technology is used to deliver virtual care, it does not require documentation of consent for the use of virtual care in every instance. Documentation is recommended as a best practice, particularly where patients express concern or raise questions about receiving virtual care.

For more information on informed consent please see the CMPA’s Virtual care: What about consent? and the CMA’s Virtual Care Playbook which includes a sample disclosure to patients.

Can someone other than the physician obtain informed consent for the delivery of virtual care?

Yes. The policy requires ensuring that informed consent is obtained for the delivery of care using a virtual modality. This means that consent can be obtained prior to or during the virtual encounter and can be obtained by someone working on behalf of the physician. It is ultimately up to the physician to ensure this expectation has been met.

Practice Issues

Can I delegate controlled acts remotely?

Controlled acts can be delegated remotely provided that the standard of care is met and the Delegation of Controlled Acts policy is complied with.

What do I need to know when considering opioid prescriptions or treatment via virtual care?

In addition to the general expectations regarding prescribing, CPSO’s Prescribing Drugs policy also contains expectations specific to prescriptions for narcotic and other controlled substances which must be complied with.

Opioids have a unique risk profile, including the potential for misuse, abuse, and diversion. When determining whether it is appropriate to prescribe opioids virtually, you need to consider whether you can appropriately assess and mitigate those risks in the absence of an in-person assessment.

Providing Virtual Care Across Borders

Am I allowed to provide virtual care to Ontario patients who are temporarily out of the province or country?

If the policy expectations can be met, CPSO permits Ontario physicians to treat Ontario patients who are temporarily located outside of Ontario or Canada, where required to support continuity of care, patient safety, or patient best interest (e.g., providing follow-up care, communicating test results, answering questions about medications, etc.).

However, many jurisdictions consider the care to occur where the patient is physically located, and physicians will also need to be aware of and comply with the licensing requirements of the jurisdiction where the patient is receiving virtual care.

There may be specific rules regarding liability protection and billing in these circumstances. Physicians with questions about liability protection and billing can contact the CMPA and the Ministry of Health respectively for more information.

Is it permissible for physicians licensed in Ontario to treat Ontario patients when the physician is temporarily located outside of Ontario or Canada?

It depends. Licensing requirements vary between jurisdictions. Providing virtual care that supports continuity of care, patient safety, or patient best interests to existing patients while the physician is temporarily out of the province is permissible from the CPSO’s perspective when this is allowed by the jurisdiction where the physician is located at the time and the standard of care is met.

There may be specific rules regarding liability protection and billing in these circumstances and physicians with questions about liability protection and billing can contact the CMPA and the Ministry of Health for more information.

If I am licensed in another jurisdiction, am I required to hold a certificate of registration in Ontario when providing virtual care to a patient who is temporarily located in Ontario?

No. Physicians licensed in other jurisdictions are not required to hold a certificate of registration in Ontario when providing virtual care to patients who ordinarily reside in that jurisdiction but are temporarily located in Ontario (e.g., who are on vacation in Ontario).

Where can I learn more about the CMPA’s approach to liability protection in scenarios requiring cross-border virtual care?

Information on the CMPA's approach to assisting members with matters related to (cross-border) virtual care can be found in their guidance document Principles of assistance: Practising Telehealth.

Endnote

^1. 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.