Under Review: No
Issued by Council: Jan. 1, 2010 (Telemedicine)
Reissued by Council: Jan. 1, 2022 (Virtual Care); June 5, 2014
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.
The regulation and provision of virtual careG 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.
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 relationshipG. Regulated members providing virtual care need to be realistic about their ability to provide safe and effective careG.
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 temporarilyG 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.).
Prior to engaging in virtual care
- 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.
- Physicians providing virtual care to Alberta patients located in Alberta must be registered as members of CPSA.
- 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:
- if the care sought is not readily available in Alberta (e.g., specialty care);
- to provide follow-up care or continuity of care for which an established physician-patient relationship exists; or
- if the virtual care encounter is for emergency assessment or treatment of the patient where there are no other care options available.
- A regulated member providing virtual care must be aware of and comply with licensing requirements of the jurisdiction in which the patient is located.
- A regulated member providing virtual care across the Alberta border must ensure they have appropriate liability insuranceG to provide care across jurisdictions.
- 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 appropriateG, required or requested by the patient.
- A regulated member providing virtual care must:
- ensure they have sufficient training, knowledge, judgment and competencyG (including technological) to manage patient care virtually;
- consider the technologies available to the patient;
- adhere to best practices for technological security and use an appropriate platform or infrastructure suitable to engage in virtual care; and
- 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
- A regulated member providing virtual care must:
- provide the patient with their name, location and licensure status during the initial virtual care encounter;
- take reasonable steps to confirm the identity and location of the patient during each virtual care encounter;
- 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;
- offer the patient the opportunity for in-person care; and
- 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
- A regulated member providing virtual care must ensure virtual care allows appropriate assessmentG of the presenting problem.
- A regulated member providing virtual care must:
- 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;
- perform an appropriate assessment of the patient, including ordering necessary investigations, prior to initiating treatment or making a referral to another healthcare provider;
- communicate with other treating or referring healthcare providers and provide follow-up and after-hours care as medically appropriate, including:
- informing the patient of appropriate follow-up, in accordance with the Continuity of Care and Referral Consultation standards of practice;
- 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
- provide details of their findings, assessments, advice or treatment given when requested in accordance with the Responding to Third Party Requests standard of practice.
- 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
- 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.
- A regulated member must not prescribe opioids or other controlled medicationsG to patients unless:
- they have examined the patient in person;
- they have a longitudinal treating relationship with the patient; or
- they are in direct communication with another regulated-health professional who has examined the patient.
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.
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.
Other resources related to this standardAll Resources
Do I have to meet all three subclauses in clause 13 of CPSA’s Virtual Care standard before prescribing virtually?
No. The expectation is that at least one of these situations is met in order to prescribe opioids or other controlled substances.
Does my Alberta patient need to be in Alberta to receive virtual care?
Generally speaking, no. Providing virtual care to a patient while they are temporarily out of the province (e.g., vacation, work, school) is typically considered continuity of care. However, confirmation of liability protection should be obtained for patients who spend a large portion of their time out of the country (e.g., “snow birds” who are in the USA for months at a time).
How do I bill for virtual care provided to a patient who lives in another province?
I facilitate virtual care in group settings (e.g., mental health group counselling), do I have to be able to see patients in-person?
If patients cannot be seen in person, the expectation is that the physician would arrange in-person care in a timeframe appropriate for the urgency of the matter. Arrangements would need to be made with the next most appropriate healthcare provider/service to have the person assessed in person (e.g., confirming with the referring healthcare provider that they will see the patient in person if necessary and ensuring the patient understands this arrangement).
I provide services virtually to patients who live in other provinces, do I have to get licences in all of those provinces?
Each province’s College of Physicians & Surgeons has different virtual care/licensure requirements. Physicians are required to confirm with each province what the expectations are and comply accordingly.
I provide virtual care that involves prescribing medications to patients in remote areas where I have not examined the patient and don’t have a pre-existing longitudinal treating relationship (e.g., treatment of substance use disorder requiring OAT, long-acting stimulants, antiviral medication, etc.), do I have to stop this service?
Not necessarily. As long as follow-up care will be arranged or provided going forward, an urgent assessment for/induction of Schedule 1 or 2 drugs would generally meet the criteria for a longitudinal relationship. It is understood that management of this nature is not a one-time interaction without follow-up.
I provide virtual care through a healthcare app, do I have to stop if I can’t provide in-person care to every patient I see virtually?
No. We understand there are times when this is not feasible (e.g., patient lives in a remote location). The expectation is that the physician would arrange in-person care in a timeframe appropriate for the urgency of the matter. This might look like reaching out to the patient’s primary care provider or, if the patient does not have one, contacting local urgent care/emergency department to provide appropriate background information.
My Alberta patient has moved to another province, but wants to continue seeing me virtually, can I do this?
Each province’s College of Physicians & Surgeons has different virtual care/licensure requirements. The requirements of the college in the patient’s new province would need to be determined and followed. Additionally, arrangements would need to be made for the patient to be seen in-person when necessary.
What if I’m out of the province/country? Can I still provide virtual care to Alberta patients?
As long as in-person care can be arranged when necessary, this is acceptable; however, confirmation of liability protection should be obtained. The expectation is that the physician would arrange in-person care in a timeframe appropriate for the urgency of the matter.
About the Standards of Practice
The CPSA Standards of Practice are the minimum standards of professional behaviour and ethical conduct expected of all physicians registered in Alberta. Standards of practice are enforceable under the Health Professions Act and will be referenced in the management of complaints and in discipline hearings.
For questions or archived standards, policies and guidelines contact our Standards of Practice Advisor.