Cross-Canada virtual care licensure requirements and best practices

By Louise Sweatman, BScN, RN, MSc, LLB, Director of Health Law Policy and Legal Counsel for the Canadian Medical Association, and Christine Laviolette, BHSc, JD, Senior Associate, BLG.¹

With the onset of the COVID-19 pandemic, Canada saw a significant increase in the provision of virtual care. Although not new, originating as care provided by the telephone, virtual care has evolved to also include video conferencing and secure messaging. With the click of a button, virtual care has allowed Canadians more convenient and faster access to health care providers. However, from a provider’s perspective, access to a patient across Canadian borders does not come with the same ease due to current provincial and territorial licensing requirements. Although there have been discussions regarding a pan-Canadian license,² there is no pan-Canadian approach to licensure for any health provider group allowing practice across the country under one license.³ This means that physicians and other regulated health professionals must comply with licensing requirements imposed by the regulatory college where they are licensed to practice (home) as well as the college of the jurisdiction where a patient receiving virtual care is located (away).

In the table below, we have summarized the licensing requirements for physicians practising virtual care across provincial or territorial borders. Below the table you will find tips and best practices for regulated health professionals wishing to practise virtual care across provinces and territories.

Table: Virtual care licensing requirements for Canadian physicians.⁴

	Home What does the jurisdiction - where the physician is licensed - say about its licensee providing virtual care to patients in an away jurisdiction?	Away What does the jurisdiction say about a non-jurisdictional physician5 providing virtual care to its residents/patients?
Alberta (AB)	Comply with the requirements of the jurisdiction in which the patient is located.	May practise if: a. total telemedicine events are limited to five times per year; or b. the telemedicine event is for emergency assessment or treatment of a patient The College of Physicians and Surgeons of Alberta and Nunavut have agreed to allow licensed Alberta physicians to provide virtual care services to patients in Nunavut without obtaining a license to practice there.
British Columbia	Comply with the requirements of the jurisdiction in which the patient is located.	Silent6/not specified.
Manitoba (MB)	Comply with the requirements of the jurisdiction in which the patient is located.	Full practicing class registration is required. The College of Physicians and Surgeons of Manitoba and Nunavut have agreed to allow licensed Manitoba physicians to provide virtual care services to patients in Nunavut without obtaining a license to practice there.
New Brunswick (N.B.)	Silent/not specified.	Get entered on the Telemedicine Provider List to provide occasional or limited telemedicine services.
Newfoundland & Labrador	Comply with the requirements of the jurisdiction in which the patient is located.	Silent/not specified.
Nova Scotia (N.S.)	Comply with the requirements of the jurisdiction in which the patient is located.	Comply with the requirements of their home licensing jurisdiction and with the requirements in every jurisdiction where they treat patients.
Nunavut	Silent/not specified.	Full license is required except those in Alberta, Manitoba, Ontario and the Northwest Territories (N.W.T.). Nunavut has entered into a memorandum of understanding with the College of Physicians and Surgeons of Alberta, of Manitoba, of Ontario and the Government of N.W.T. to permit health care delivery through telemedicine from these jurisdictions to residents of Nunavut without requiring a Nunavut medical license.
Northwest Territories	Silent/not specified.	Full class registration is required. The Government of N.W.T. and Nunavut have agreed to allow licensed N.W.T. physicians to provide virtual care services to patients in Nunavut without obtaining a license to practice there. A ministerial exemption has been passed for the pandemic waiving the requirement for licensure where there is a referral from a N.W.T. licensed physician.
Ontario	Comply with the requirements of the jurisdiction in which the patient is located.	Comply with the requirements of their home licensing jurisdiction. The College of Physicians and Surgeons of Ontario and Nunavut have agreed to allow licensed Ontario physicians to provide virtual care services to patients in Nunavut without obtaining a license to practice there.
Prince Edward Island	Comply with the requirements of the jurisdiction in which the patient is located.	Silent.
Québec	Comply with the requirements of the jurisdiction in which the patient is located.	Get entered on the Roll of the Order or hold an authorization issued by the Collège des médecins du Québec.
Saskatchewan (Sask.)	Comply with the requirements of the jurisdiction in which the patient is located.	Get a telemedicine licence unless the physician has provided care to a Sask. patient after that patient was referred by a Sask. physician and the physician intends to provide follow-up care in relation to the condition for which the patient was referred.
Yukon	Comply with the requirements of the jurisdiction in which the patient is located.	Comply with the requirements of their home licensing jurisdiction.

 

All provinces and territories, except N.W.T., Nunavut and N.B. indicate that a physician providing services from their “home” jurisdiction to a patient in another jurisdiction must comply with the requirements of the jurisdiction in which the patient is located. Where vast differences occur are with respect to out-of-province physicians providing care to patients in a province where they are not licensed.

The range covers:

• no additional licensing requirements;
• no additional requirements if limited to a certain quantity of virtual encounters (e.g., AB);
• getting enrolled on a telemedicine roster (e.g., N.B.);
• full licensure (e.g., MB); and
• full licensure in all provinces wherever the physician has treated patients (e.g., N.S.).

Tips and best practices for physicians when practicing virtual care across provincial borders

1. Make sure virtual care is appropriate

Ensure that virtual care is appropriate for the patient given the nature of the consult and the patient’s condition.⁷ Consider the limitations of the technology given the patient’s needs (e.g., is the visual clear enough to assess a skin condition?).

Conduct the most fulsome examination enabled by the technology (e.g., use video function to examine mobility where required).

Be conscious of the circumstances and ask pointed and specific clarification questions (e.g., if calling by phone only, ask who is calling and who the patient is).

Determine whether it is appropriate to develop a plan to ensure the patient has access to care if an emergency were to arise. This could require confirming the patient’s location, family health team or available local resources, contact information for the applicable health care providers or emergency responders, and possibly making referrals to available local professionals.

2. Make sure you are covered

The Canadian Medical Protective Association (CMPA) covers members for medical-legal problems arising from virtual care encounters involving a physician and patient located in different provinces.⁸ However, members are generally not eligible for CMPA assistance when issues arise from care provided to patients outside of Canada. To assess coverage, the CMPA considers the patient’s location at the time of the virtual care appointment to be the “location where the care is provided.”⁹ As such, it is critical to first confirm the patient’s location to ensure CMPA protects you in the event of any resulting issues. During a catastrophic event, if a member failed to obtain a license, the CMPA will use its discretion but “the member will generally be eligible for assistance.”¹⁰

3. Be aware of the governing standards and guidelines concerning virtual care

Be aware of the governing standards and guidelines concerning virtual care, including privacy and security, consent, documentation and online prescribing.

Be aware that multiple privacy and health record-keeping statutes may apply and you must comply with all of them.

Confirm patient ID and ensure the setting is as private as possible.

4. Track out-of-province virtual care encounters

As noted in the table above, in Alberta physicians are restricted to the number of virtual care encounters an out-of-province or territory physician can provide without requiring a license. The practice is limited to five virtual care consults per year unless the service is required for the emergency assessment or treatment of a patient.¹¹ Given these restrictions, you should confirm and record your patient’s location, track the number of virtual care encounters provided in the patient’s jurisdiction, and document if the encounter was an emergency.

5. Inform yourself of the local resources to ensure continuity of care

The proliferation of virtual care both supports and raises continuity of care concerns. With increased mobility of Canadians and advent of technology, the expectation is that family physicians should become “lifetime” physicians maintaining the physician-patient relationship regardless of the physical location of the patient or the physician. On the other hand, if virtual care services are used episodically where care is delivered by a random physician with no access to a patient’s records, continuity of care is compromised. When working with an out-of-province patient, take steps to ensure you have a full picture of the patient’s family health team and the local resources available to support the patient’s care.

6. Maintain detailed and up-to-date records for all virtual care encounters

As part of the patient’s record, you should document your virtual care encounters with patients in the same way you would in any in-person interactions. If relevant, forward your documentation to the family physician health team or provide a copy to the patient.

 

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¹ Special thanks to BLG student Courtney Po for her research assistance.

² Letter to the Provincial and Territorial Ministers of Health, May 27, 2021 signed by 11 national health organizations.

³ The Canadian Medical Association has initiated work on a pan-Canadian license model (e.g., a Canada Medical Doctor license) that does not require a Constitutional change.

⁴ Current as of publication.

⁵ That is, licensed in another province/territory.

⁶ Excluding a comment about having appropriate liability insurance.

⁷ Canadian Medical Association, College of Family Physicians of Canada, Royal College of Physicians and Surgeons of Canada (March 2020), “Virtual Care Playbook”

⁸ CMPA (March 2021), “Practising Telehealth – Eligibility for Assistance”.

⁹ CMPA (March 2021), “Practising Telehealth – Eligibility for Assistance”.

¹⁰ CMPA (March 2020), “Public health emergencies and catastrophic events”.

¹¹ CPSA (2021), “Apply for Telemedicine Registration”.