Virtual Care

Note: a glossary of terms can be found at the end of this document. Glossary terms are indicated in teal with a “^G” throughout this document.

PREAMBLE

The regulation and provision of virtual care^G is quickly evolving as the medical profession continues to learn about the strengths and limitations of virtual care delivery. CPSA will revisit this standard on a regular basis to keep pace with this evolution.

This standard of practice must be read in conjunction with the Continuity of Care and Episodic Care standards of practice, as providing virtual care establishes a physician-patient relationship.

CPSA recognizes the importance of virtual medicine in providing care and access to care, especially for patients in remote and underserviced areas, patients with disabilities, patients in institutional settings, limited psychosocial supports or economic means, and in a pandemic, or other state of emergency. Virtual medicine is to be used to optimize and complement in-person patient careⁱ.

Regulated members who provide virtual care are held to the same ethical and professional standards and legal obligations, and the standards of care remain the same, as they are in the provision of in-person care. Ideally, virtual care is a modality that should be thoughtfully used to promote continuity of care within the context of a therapeutic relationship^G. Regulated members providing virtual care need to be realistic about their ability to provide safe and effective care^G.

In addition, regulated members are expected to consult with the appropriate Medical Regulatory Authorities (i.e., where both they and the patient are located) and the Canadian Medical Protective Association or other applicable insurance provider for unique situations that include, but are not limited to, the provision of virtual care such as when either the physician or patient is temporarily^G outside of Canada, medical assistance in dying, involuntary psychiatric assessment, etc.

Note: For the purpose of this standard, virtual care includes medical services to patients as well as inter-professional and intra-professional consultations (e.g., assessing, diagnosing, giving advice, tele-radiology, etc.).

STANDARD

Prior to engaging in virtual care

1. A regulated member providing virtual care must do so to the same standard to which they provide care in person, in accordance with the obligations of the Code of Ethics and Professionalism and CPSA’s Standards of Practice and Code of Conduct.
2. Physicians providing virtual care to Alberta patients located in Alberta must be registered as members of CPSA.
3. Notwithstanding clause (2), an out-of-province physician who does not hold a valid and active practice permit with CPSA may provide virtual care to a patient located in Alberta:
   1. if the care sought is not readily available in Alberta (e.g., specialty care);
   2. to provide follow-up care or continuity of care for which an established physician-patient relationship exists; or
   3. if the virtual care encounter is for emergency assessment or treatment of the patient where there are no other care options available.
4. A regulated member providing virtual care must be aware of and comply with licensing requirements of the jurisdiction in which the patient is located.
5. A regulated member providing virtual care across the Alberta border must ensure they have appropriate liability insurance^G to provide care across jurisdictions.
6. A regulated member providing virtual care must first ensure they have a physical clinic, or an agreement with a physical clinic within reasonable travel proximity of the patient, to fulfill the need for in-person care when appropriate^G, required or requested by the patient.
7. A regulated member providing virtual care must:
   1. ensure they have sufficient training, knowledge, judgment and competency^G (including technological) to manage patient care virtually;
   2. consider the technologies available to the patient;
   3. adhere to best practices for technological security and use an appropriate platform or infrastructure suitable to engage in virtual care; and
   4. submit a Privacy Impact Assessment (PIA)ⁱⁱ to the Office of the Information and Privacy Commissioner of Alberta prior to adopting new information and communication technologies for the purposes of virtual care.

Ethical, professional and legal obligations

8. A regulated member providing virtual care must:
   1. provide the patient with their name, location and licensure status during the initial virtual care encounter;
   2. take reasonable steps to confirm the identity and location of the patient during each virtual care encounter;
   3. confirm the patient’s physical setting is appropriate given the context of the encounter and ensure consent to proceed, in accordance with the Informed Consent standard of practice;
   4. offer the patient the opportunity for in-person care; and
   5. ensure there is a plan in place to manage adverse events or emergencies and make patients aware of appropriate steps to take in these instances.

During & after providing virtual care

9. A regulated member providing virtual care must ensure virtual care allows appropriate assessment^G of the presenting problem.
10. A regulated member providing virtual care must:
    1. create, maintain and provide a copy of the patient’s medical record in accordance with the Patient Record Content and Patient Record Retention standards of practice;
    2. perform an appropriate assessment of the patient, including ordering necessary investigations, prior to initiating treatment or making a referral to another healthcare provider;
    3. communicate with other treating or referring healthcare providers and provide follow-up and after-hours care as medically appropriate, including:
       1. informing the patient of appropriate follow-up, in accordance with the Continuity of Care and Referral Consultation standards of practice;
       2. having arrangements in place for receiving and responding to critical test results reported by a laboratory or imaging facility after regular working hours or in the regulated member’s absence; and
       3. provide details of their findings, assessments, advice or treatment given when requested in accordance with the Responding to Third Party Requests standard of practice.
11. A regulated member, including those involved in a team-based care environment, who copies another healthcare provider (e.g., when requesting an investigation, performing a procedure, providing treatment requiring follow-up, making a referral, etc.) must do so in accordance with the Continuity of Care standard of practice.

Prescribing & authorizing

12. A regulated member issuing a prescription, electronically or by other means, must do so in accordance with the Prescribing: Administration, Prescribing: Drugs Associated with Substance Use Disorder or Substance-Related Harms, Safe Prescribing for Opioid Use Disorder and Cannabis for Medical Purposes standards of practice.
13. A regulated member must not prescribe opioids or other controlled medications^G to patients unless:
    1. they have examined the patient in person;
    2. they have a longitudinal treating relationship with the patient; or
    3. they are in direct communication with another regulated-health professional who has examined the patient.

GLOSSARY

Appropriate assessment: based on the patient’s presenting concern, an appropriate assessment may include, but is not limited to, taking a patient history, physical exam or performing/ordering any necessary diagnostic tests, investigations or procedures that are required to help establish a diagnosis and/or guide management.

Appropriate liability protection: CMPA protection may not apply depending on where the regulated member is located and how long they have been/will be there and where the patient is located and how long they have been/will be there. Regulated members are expected to confirm coverage with their liability provider (e.g., the Canadian Medical Protective Association) or employer (if applicable) prior to providing virtual care.

Controlled medications: for the purpose of this standard, “controlled medications” includes all Schedule/Type 1 and 2 drugs.

Effective care: regulated members will need to consider the appropriateness of virtual care within the context of that particular patient’s health care (e.g., abnormal or critical investigation results that, if not addressed, could result in patient harm).

Temporarily: refers to situations where the person is out of the country, but retains residence in the province of Alberta the majority of the time (e.g., vacation, school, etc.).

Therapeutic relationship: a trust-based relationship between a patient and directed healthcare provider that is caring, positive and advances the best interests of the patient.

Sufficient training, knowledge, judgment and competency: regulated members providing virtual care are expected to be knowledgeable of and maintain competence in the technologies they use. Related training can be part of the regulated member’s plan to meet mandatory Continuing Professional Development (CPD) requirements. Contact MainPro+ or the Maintenance of Certification Program (as applicable) to determine credit eligibility for specific courses or programs.

Virtual care: for the purpose of this standard, “virtual care” is defined as any interaction between patients and members of their circle of care occurring remotely, using any form of communication or information technology with the aim of facilitating or maximizing the quality of patient care.

When appropriate: physicians must use their clinical judgment when considering whether virtual care is appropriate based on the patient’s location, presenting health concern, need for physical examination and the physician’s ability to arrange same, access to relevant patient information (e.g., pharmaceutical, laboratory, diagnostic imaging, etc.), and other available resources (e.g., technology, support staff, other healthcare services, etc.) while the physician is out of the province.

ACKNOWLEDGEMENTS

CPSA acknowledges the assistance of the College of Physicians and Surgeons of British Columbia and the College of Physicians and Surgeons of Manitoba in preparing this document.

[i] From CPSM’s Virtual Medicine standard of practice (November 1, 2021).

[ii] Per Section 64 of the Health Information Act.