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Updated: May 2023
Widespread delivery of virtual care (including phone and video consultations) is transforming medical practice.
If my patient relocates to another jurisdiction but wants to continue receiving virtual care from me, what should I do?
Patients who relocate may request ongoing virtual care from their existing physician, although they could now be living several hours away or even outside of the province or territory in which the physician practices.
If a patient asks you to continue an existing doctor-patient relationship in these circumstances, you should be aware of the standards and guidelines of your medical regulatory authority (College), especially with respect to the areas of virtual clinics, telemedicine, and online prescribing. Some Colleges have published statements with respect to virtual care specifying that physicians must be able to assess patients in person when required, or to have an arrangement in place with another physician who can provide a timely in-person assessment. The Colleges also generally encourage physicians to use professional judgment and consider the standard of care when deciding whether to deliver medical services to a specific patient using virtual care or whether in-person care is required. If the patient will be residing outside of your community on a more permanent basis, it may be reasonable to suggest that the patient establish a relationship with a physician at their new location.
Physicians should also consider whether they have complied with applicable virtual care and/or telemedicine licensing requirements in the province in which the patient is located. These requirements vary between provinces. Where patients have relocated outside of Canada, eligibility for CMPA assistance should also be considered by referring to the question on “What is CMPA's approach to assisting members with matters related to virtual care?”
What is CMPA's approach to assisting members with matters related to virtual care?
In accordance with its usual principles of assistance, the CMPA will assist members with matters arising out of virtual care where the medico-legal problem or legal action is initiated in Canada. If members are contemplating providing virtual care to patients outside of Canada, members should contact the CMPA in advance, if time permits, and provide the details of the circumstances under which care will be provided.
- Patient and member in Canada. A virtual care encounter occurs between a patient ordinarily resident in Canada and a CMPA member. The patient and the member are in Canada at the time of the encounter, although they may not necessarily be in the same province/territory. If the medico-legal problem or legal action is initiated in Canada, the member is generally eligible for CMPA assistance.
- Patient and/or member temporarily outside Canada. A virtual care encounter occurs between a patient and a CMPA member, both of whom are ordinarily residents of Canada (and have an established doctor-patient relationship). At the time of the encounter, the patient or the member, or both, are temporarily located outside of Canada. The CMPA will consider providing assistance with a medico-legal problem or legal action in Canada, arising from urgent follow-up care to the existing patient.
- Patient residing outside Canada. A virtual care encounter occurs between a patient residing outside of Canada and a CMPA member located either in or outside Canada. In this scenario, the CMPA will generally not assist regardless of whether the medico-legal problem or legal action was initiated in Canada or elsewhere.
- Member residing outside Canada. Members who are located outside of Canada on a more permanent basis are at greater risk of being sued in that foreign jurisdiction. Where a member is residing outside of Canada on a long-term basis and providing virtual care to patients in Canada, the member will not generally be eligible for assistance regardless of whether the medico-legal problem or legal action was initiated in Canada or elsewhere.
If a patient is outside of Canada temporarily (e.g. on vacation, temporary employment, or students pursuing studies abroad) and phones or emails the physician's office regarding a medical problem related to a condition the physician is managing, the member would generally be eligible for assistance, as long as any medico-legal problem or legal action is initiated in Canada. Given the potential limitations of such communication, it may be prudent to consider advising the patient to seek local follow-up.
If a member is temporarily outside of Canada for a purpose other than providing care (e.g. on vacation, at a conference), the member would generally be eligible for assistance arising from providing any urgent follow-up care to an existing patient, as long as the medico-legal problem or legal action is initiated in Canada. While CMPA assistance is always discretionary, the CMPA generally considers a member to be “temporarily outside Canada” when they are away without the intention to be engaged in clinical care and where they are away for days or a few weeks (less than 30 days).
Can I use virtual care to offer medical assistance in dying services (MAID)?
Since MAID remains a highly regulated procedure governed by the Criminal Code, physicians must continue to ensure compliance with all legal requirements for the provision of MAID. This includes ensuring that any delivery of virtual care is performed with all participants located in Canada.
Physicians will also want to be aware of their College’s policies and standards, hospital/ health authority policies and public health measures that may impact the delivery of MAID services due to the pandemic. Some Colleges invite physicians to consider virtual assessments in the context of MAID, suggesting that virtual assessments may be possible in accordance with the College policies. Patients self-administering oral medications as a means of receiving MAID without a physician present create unique challenges that need to be considered on a case-by-case basis.
A patient’s request for MAID must be made before one independent witness. Witnesses participating in a virtual manner may also be an option if careful arrangements are made to ensure compliance with statutory requirements.
As always, physicians should carefully document the MAID process, including what aspects of the process were delivered through virtual care. Given the additional difficulties related to the provision of MAID through virtual care, members are encouraged to contact CMPA to obtain case-specific medico-legal advice.
Can I use virtual care to complete an application for involuntary psychiatric assessment (e.g. Form 1 in Ontario)?
The mental health statutes across Canada typically provide that a physician who signs an application for an involuntary psychiatric assessment must “examine” or “personally examine” the person who is the subject of the application and make careful inquiry into all of the facts necessary for the physician to form the opinion as to the nature and quality of the mental disorder of the person.
There is no express requirement in the legislation that the physician must be in the same location as the patient when conducting the examination. The terms “examine” and “personally examine” are also not defined terms in the legislation. We are not aware of any court that has commented on whether these terms expressly permit the use of telemedicine to conduct examinations for the purpose of completing an application for an involuntary psychiatric assessment.
In some jurisdictions, larger telemedicine networks have – for several years now – provided physicians with the ability to conduct examinations for the purpose of completing an application for involuntary psychiatric assessments (e.g. Ontario Telemedicine Network). There is commentary from certain healthcare organizations that telemedicine is appropriate for this purpose.
Most provincial governments have introduced temporary billing codes that permit physicians to more flexibly bill for virtual visits, including psychiatric assessments.
It is important to bear in mind that the “personal examination” requirement is a statutory safeguard given the serious deprivation of liberty at stake. It is therefore vital that telemedicine examinations only be conducted if they permit the physician to assess the facts, make the inquiries and form the opinions required to complete an application for involuntary psychiatric assessment.
When practising virtual care, when is a member considered to be “temporarily outside of Canada”?
The CMPA’s Principles of Assistance for Providing virtual care (including telehealth) contemplate that when patients or physicians, or both, are temporarily outside of Canada, issues concerning continuity of care and physician obligations may arise. An example of such a scenario would be a physician who, while briefly overseas for a conference or holiday, is asked to deal with urgent follow-up care related to an existing patient in Canada regarding a condition for which the physician was already involved. In these circumstances, members are generally eligible for CMPA assistance, provided the medico-legal problem or legal action is initiated in Canada. Members are reminded that the CMPA does not generally provide assistance to members with medico-legal matters arising outside of Canada.
The Principles of Assistance for Providing virtual care (including telehealth) were not drafted to deal with circumstances where members live permanently or move to another jurisdiction for an extended period. Members who are located outside of Canada on a more permanent basis are at greater risk of being sued in that foreign jurisdiction. Where a member is residing outside of Canada on a long term basis and providing virtual care to patients in Canada, the member will not generally be eligible for assistance regardless of whether the medico-legal problem or legal action was initiated in Canada or elsewhere. While CMPA assistance is always discretionary, the CMPA generally considers a member to be “temporarily outside Canada” when they are away without the intention to be engaged in clinical care and where they are away for days or a few weeks (less than 30 days). Members who are located outside of Canada during the extenuating circumstances of the pandemic are encouraged to contact the CMPA to discuss their eligibility for assistance.
Whenever members are providing care from outside of Canada, they should ensure they have addressed any potential licensure issues with the regulator in the jurisdiction in which they are residing.
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