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Bulletin

Telemedicine: Making Delivery of Health Care Services Across Borders More Accessible to Canadians

Fasken
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Health Bulletin

Advances in technology have continued to allow the practise of medicine to evolve and provide more opportunities for innovative approaches to the delivery of health care in Canada. One example is the ability of physicians to provide medical treatment and advice to patients remotely, even to patients located outside of the physician's province ("across borders"). Despite the availability of advanced technologies to permit such treatment, Canada has a patchwork system that has not kept pace.

According to the Federation of Medical Regulatory Authorities of Canada, telemedicine ("Telemedicine") is the provision of medical expertise for the purpose of diagnosis and patient care by means of telecommunications and information technology where the patient and the provider are separated by distance. Telemedicine includes the provision of pathology, medical imaging and patient consultative services.[1] It may be provided through use of telephone and mobile phones, email, video and audio conferencing, remote monitoring and telerobotic procedures.[2]

The concept of Telemedicine in Canada is not new, having originally developed during the 1950s and 1960s.[3] The service, which improves access to health care and controls healthcare system costs, has been beset by regulatory and jurisdictional challenges which have created barriers and cross-border issues to physicians providing Telemedicine services.[4] Further, there is currently no national framework for Telemedicine, so requirements for physicians providing Telemedicine vary between the provinces and territories.[5]

Recently, several provincial Colleges for physicians have developed, revised, and/or clarified their Telemedicine policy with respect to a physician's ability to provide Telemedicine services across borders. While there are many issues to consider with respect to providing Telemedicine overall, this Bulletin will highlight some of the requirements for providing Telemedicine services across borders for Ontario, Alberta, British Columbia, and Québec.

Ontario

In addition to the general expectations for Telemedicine set out by the College of Physicians and Surgeons of Ontario ("CPSO"),[6] physicians are required to provide quality care to patients regardless of where physicians and patients are physically located.

Expectations for Ontario Physicians

The CPSO takes the position that it has jurisdiction over its members regardless of where (eg. physical location) or how (eg. in-person or via Telemedicine) they practise medicine. This means that the CPSO has the authority to investigate complaints made about an Ontario registered physician, regardless of whether that physician or his or her patient is physically located in Ontario.

If a physician provides Telemedicine services to patients in another province, territory or country, that physician is required to comply with the licensing requirements of that jurisdiction. It is important to note that the medical regulatory authority of the jurisdiction where the physician and/or patient are physically located when telemedicine is practised may require that the physician hold a medical licence in that jurisdiction.

Physicians may decide to consult with out-of-province physicians regarding their patients (eg. sending patient information such as diagnostic images to out-of-province physicians for an opinion) or refer patients to out-of-province physicians for Telemedicine services. Prior to doing so, physicians must take reasonable steps to assure themselves that the consultation or referral is appropriate (in addition to other considerations and measures outlined in the policy). Where physicians consult with or refer patients to out-of-province physicians for Telemedicine services, they must inform their patients that the out-of-province physicians are not physically located in Ontario, and may or may not be registered in Ontario.[7]

Expectations for Non-Ontario Physicians

The CPSO recognizes that Ontario patients may seek Telemedicine services from physicians who are physically located outside of Ontario and who are not registered with the CPSO, independent of any involvement of a physician registered with the CPSO.[8] Should this be the case, non-Ontario physicians are expected to comply with licensing and standard of care requirements in their own jurisdiction. Physicians who are not registered with the CPSO should keep in mind that in the event the CPSO becomes aware of concerns or complaints about Telemedicine care provided to an Ontario patient, the CPSO may share that information with the regulatory authority that has jurisdiction over the non-Ontario physician so that appropriate action can be taken by that regulatory authority.

Alberta

Physicians practicing in Alberta must be registered with the College of Physicians & Surgeons of Alberta ("CPSA").

Expectations for Alberta Physicians

According to the CPSA's policy, a physician who practises Telemedicine for a patient located within Alberta must ensure that he or she holds a valid and active Alberta practice permit with CPSA and adheres to the College Standards of Practice, Code of Conduct and Code of Ethics.[9] Additionally, a physician who holds a valid and active Alberta practice permit and practises Telemedicine for a patient located outside Alberta must comply with the licensing or registration requirements of the jurisdiction in which the patient is physically located.[10]

Expectations for Non-Alberta Physicians

A physician who does not hold a valid and active Alberta practice permit may practise Telemedicine for a patient located within Alberta if (a) the total number of Telemedicine events are limited to five (5) times per year or (b) the Telemedicine event is for emergency assessment or treatment of a patient.

British Columbia

Expectations for British Columbia Physicians

According to the policy of the College of Physicians and Surgeons of British Columbia ("CPSBC"), physicians providing Telemedicine, who are physically located in British Columbia, must be registered with the CPSBC and should be aware that CPSBC may address complaints relating to the provision of medical care and Telemedicine in other jurisdictions.[11]

It is also recommended that physicians in British Columbia advise patients that accessing medical care from a physician who is not located or registered in British Columbia may pose risks related to lack of appropriate medical licensure or training and that CPSBC may not be able to assist them with complaints relating to inappropriate medical care.

Québec

Telemedicine services are considered to be provided where the patient is physically located.

Expectations for Québec Physicians

According to the policy of the Collège des Médecins du Québec ("CMQ"), physicians who are registered to practise medicine with the CMQ may provide Telemedicine services to patients residing both in and out of Québec.

When providing Telemedicine services to patients outside of Québec, CMQ registered physicians must learn the terms and conditions applicable to the exercise of Telemedicine in the territory where the patient is located and comply with same.[12]

Expectations for Non-Québec Physicians

A non-Québec physician who provides Telemedicine services to patients residing in Québec must either be registered with the CMQ or apply to the CMQ for a special authorization to practise Telemedicine. A non-Québec physician providing Telemedicine services to patients residing in Québec is still required to comply with the registration requirements of the jurisdiction in which he or she is licensed to practise medicine.

What Does This Mean for Physicians?

Given the continued need for accessible, timely and innovative health care services, it is clear that Telemedicine will continue to play a role in patient care.

While this Bulletin focused on some of the across border requirements for Telemedicine services, it is important to note that there are many other considerations and information addressed in the various Telemedicine policies that physicians must be aware of and familiar with when providing Telemedicine services, including privacy and information security issues.

Physicians providing Telemedicine services will ultimately need to be aware of the registration and regulatory requirements in the jurisdiction in which they are registered to practise Telemedicine, but may also need to become familiar with the Telemedicine requirements and policies of other jurisdictions in which they provide Telemedicine services, for example, the laws of the jurisdiction in which the patient resides.

In summary:[13] 

Can a physician validly registered to practice medicine in the location below provide Telemedicine to patients residing in these provinces (across)?

Ontario

British Columbia

Alberta

Québec

Ontario

Yes

Yes, if compliant with BC licensing requirements

Yes, up to 5 Telemedicine events per year or Telemedicine event is for emergency assessment or treatment of patient

Yes, and (a) must be registered with CMQ or apply for special authorization and (b) comply with registration requirements of Ontario

British Columbia (BC)

Yes, and must also comply with BC licensing and standard of care requirements

Yes

Yes, up to 5 Telemedicine events per year or Telemedicine event is for emergency assessment or treatment of patient

Yes, and (a) must be registered with CMQ or apply for special authorization and (b) comply with registration requirements of BC

Alberta

Yes, and must comply with Alberta's and Ontario's registration/licensing and standard of care requirements

Yes, and must comply with BC licensing/registration requirements

Yes

Yes, and (a) must be registered with CMQ or apply for special authorization and (b) comply with registration requirements of Alberta

Québec

Yes, and must comply with Ontario's licensing and standard of care requirements as well as terms and conditions for practising Telemedicine in Ontario

Yes, if compliant with BC's terms and conditions of providing Telemedicine in BC

Yes, up to 5 Telemedicine events per year or Telemedicine event is for emergency assessment or treatment of patient

Yes

Other Country

Yes, and must comply with that other country's licensing and standard of care requirements

Yes (unless restricted by that other country's medical regulatory authority)

Yes, up to 5 Telemedicine events per year or Telemedicine event is for emergency assessment or treatment of patient

Yes, and (a) must be registered with CMQ or apply for special authorization and (b) comply with registration requirements of that other country

 


[1] Federation of Medical Regulatory Authorities of Canada, "FMRAC Policy on Telemedicine", Updated June 2010.

[2] College of Physicians and Surgeons of Ontario, "Telemedicine: Frequently Asked Questions" (PDF), Accessed March 10, 2016.

[3] Canadian Medical Association Journal, "Canada Produces its First MD Specializing in Telemedicine", 1998; 158:1341-2.

[4] Canadian Medical Protective Association, "Telemedicine - Opportunities, Challenges, and Obligations", Revised March 2015, Ameringer, C. "State-Base Licensure of Telemedicine: The Need for Uniformity but Not a National Scheme", 2011, Journal of Health Care Law & Policy, Volume 14(55), page 57.

[5] Physician Colleges that have a Telemedicine policy, statement, or guideline include: British Columbia, Alberta, Saskatchewan, Manitoba, Ontario, Québec, New Brunswick, Nova Scotia, Newfoundland and Labrador, and Yukon.

[6] For more information on general Telemedicine expectations, refer to the College of Physicians and Surgeons of Ontario's Policy Statement #3-14, "Telemedicine", Updated December 2014.

[7] The CPSO also recommends that physicians alert patients to the "Telemedicine: Patient Information Sheet" (PDF) and communicate the relevant content contained in that document.

[8] Supra, note 6.

[9] College of Physicians & Surgeons of Alberta, "Administration of Practice: Telemedicine" (PDF), Reissued June 5, 2014.

[10] Ibid.

[11] College of Physicians and Surgeons of British Columbia, "Professional Standards and Guidelines: Telemedicine" (PDF), March 2015.

[12] Collège des Médecins du Québec, "Le médecin, la telemedicine et les technologies de l'information et de la communication" (PDF - available in French only), February 2015.

[13] Again, we note that there are many other considerations and information addressed in the various Telemedicine policies that physicians must be aware of and familiar with when providing Telemedicine services in and out of the province in which they are registered.

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