Telemedicine was gaining increased usage in some areas of Canada prior to COVID-19. With the onset of the pandemic and its limitation on personal interactions, the advantages of telemedicine have become more widely accepted by patients and the medical profession. The value of telemedicine is that it can improve access to care and increase efficiency in the delivery of healthcare. Various Colleges of Physicians and Surgeons (Colleges) in Canada have slightly different definitions of the practice of telemedicine, but in essence, telemedicine can be defined as a provision of medical diagnosis and patient care through electronic communication when the patient and the physician are in different locations.

The Federation of Medical Regulatory Authorities of Canada (FMRAC) assists in setting policies and protocols for the Colleges across Canada. In the regulation of the physicians, Colleges often adopt the protocol suggested by FMRAC.

The benefits of telemedicine for patients are that it can be more efficient and cost saving for them. While Canada’s health care is provided free to Canadians when seeking health care, there are still costs to Canadians, such as taking time away from work, travel expenses and child-care costs when having to attend a physician’s appointment in person. At least one survey done in Canada shows that patients have a very high favourable impression of the use of telemedicine.

Legally, Colleges in Canada’s provinces and territories set the standards of care for the practice of medicine. A review of the standards and policies issued by the Colleges show those are similar in nature for telemedicine. As with any physician and patient interaction, the best medical interest of the patient comes first. In telemedicine, the obligations of the physician from an ethical, professional and legal requirement are the same as for in-person care, but there are additional hurdles to overcome. 

The first hurdle for the physician to overcome is whether the physician is able to provide telemedicine to potential patients outside of the province or territory in which the physician is licensed. Physicians are only allowed to practice in the province or territory in which they hold a license. Therefore if patients and physicians are in different jurisdictions, physicians must ensure they are allowed to practice telemedicine in the patient’s jurisdiction. Most jurisdictions require physicians practicing outside their jurisdiction to comply with the licensing or registration requirements of the jurisdiction in which the patient is located.

Physicians are also required to ensure that they have sufficient training and competency to manage patient care through telemedicine. They must follow all ethical and legal requirements to obtain valid consent from patients beyond the usual consent required for an in-person attendance with a physician. Physicians must ensure their identities, locations and licensure status is known to the patient and be confident of the identity of the patient. If other health care providers are included in the consultation with the patient, the identities of all participants involved in the encounter must be disclosed and approved by the patient. The physician has to document this information in the patient’s record as well.

Another challenge of telemedicine is ensuring it enables adequate assessment of the patient’s presenting problem. As with an in-person encounter, the physician must provide an appropriate medical assessment of the patient based on the patient’s symptoms or condition, the patient’s past history, medications the patient is taking and also recognize the limitation of telemedicine. The physician must advise the patient of the appropriateness, limitation and privacy issues related to telemedicine. If the physician cannot, he/she is required to arrange for a timely in-person assessment.

Telemedicine does not eliminate the obligations of the physician for patient follow-up. Communication with referring and other treating physicians and the provision of follow-up as well as after-hours care is as necessary as medically appropriate for patients. If the physician determines that a patient must be referred to a another treating specialist, the physician must be certain the patient is adequately investigated and treated before a referral to the specialist. If a primary care assessment of the patient’s presentation would normally include a physical examination before the referral, the referring physician must ensure that one is done. Therefore, it may be necessary for the patient to physically attend an examination at the physician’s office. As in face-to-face encounters, the physician referring a patient to specialists must advise the patient how to assess primary care while awaiting their appointment with a specialist. Physicians must exercise extra caution in providing prescriptions or other treatment recommendations to patients via telemedicine. Some jurisdictions have set limitations regarding the prescribing of opioid medications and other psychotropic medications as well as the authorization for medicinal cannabis use.

Most jurisdictions limit the number of telemedicine encounters a physician can have with a patient when the patient is located outside the physician’s jurisdiction. The number of times for interacting with a particular patient can be increased in an emergency situation. Physicians must consider the nature of the services they are providing if there is the possibility of an adverse event or emergency, and only utilize telemedicine if there is a plan in place to manage such events.

All Canadian jurisdictions have established mechanisms for patients to lodge complaints with Colleges if a patient is dissatisfied with the physician encounter. Providing telemedicine services to a patient in another jurisdiction can result in a patient complaint to the College in the jurisdiction in which the physician is licensed. The College receiving the complaint will likely discuss the complaint with the College in the jurisdiction in which the patient resides.

Unlike the traditional in-person physician/patient interaction, telemedicine requires special consideration for privacy. The physicians must take reasonable steps to ensure that the hardware and software used is functioning properly and securely. Any support staff involved in operating the equipment should be adequately trained and competent to use it and the equipment should be up-to-date and reliable. Patients should be apprised of the possible limitations of their electronic devices and the potential for breach of their information through hacking or malfunctions of technology. In other words, reasonable measures must be taken by the physician and the patients to ensure that the medical information will not be intercepted by a third party. Medical record keeping is crucial, but more so in telemedicine given the added burden of additional requirements for the security of medical information.

In summary, COVID-19, has increased the awareness of the benefits of telemedicine and we see no indication of this lessening. Canadians use their devices for various types of services and many wish to use their devices for interactions with physicians. The risks of telemedicine must be balanced with its benefits. With the use of technology, the greater risk is in relation to the reliability of the technology employed and patient privacy. As telemedicine is in its infancy, we have yet to see the results of telemedicine-related complaints made to Colleges. It appears clear that the most obvious risk for a physician is if the telemedicine encounter with the patient was not appropriate for the patient’s presenting condition. Regardless, all indications point to the continuing flourishing of telemedicine because of its perceived efficiency.