Virtual Medicine

I.     DEFINITION AND APPLICATION

Virtual Medicine, or Virtual Care, means the provision of medical care by means of electronic communication (telephone, video, email, text, or other internet hosted service or app) where the patient and the member are at different locations, including, but not limited to diagnosing, treating, advising, interviewing or examining the patient.

II.    ETHICAL, PROFESSIONAL, AND LEGAL OBLIGATIONS

1. Providing care by virtual medicine does not alter the ethical, professional, and legal obligations of members to provide good medical care.
   
   
2. The College 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 state of emergency.
   
   
3. Virtual medicine is to be used to optimize and complement in-person patient care.
   
   

III.   GENERAL PROVISION

Each member’s practice of medicine must include timely in-person care when clinically indicated or requested by the patient.  It is not acceptable to solely practice virtual medicine.  A blended care model balancing in-person and virtual medicine is required if providing virtual medicine.  The appropriate balance will depend on the circumstances.

IV.    PRIOR TO ENGAGING IN VIRTUAL MEDICINE

1.  Licensure
   1. Members must be aware of, and comply with, the licensing requirements in the Canadian jurisdiction in which the patient is located. Many jurisdictions require physicians to hold a license and have liability protection to treat a patient located in that jurisdiction.
      
      
   2. If providing care across a border, physicians must be familiar and comply with the legalities of licensure in that jurisdiction.
      
      
2. Establishing the Patient-Physician Relationship
   Members initiating virtual care must:

• • 1. disclose their identity to the patient and confirm confidentiality of the encounter;
       
       
    2. take reasonable steps to confirm the patient’s identity;
       
       
    3. ask the patient if the physical setting is appropriate given the context of the encounter and ensure consent to proceed;
       
       
    4. offer the patient the opportunity for in-person care; and
       
       
    5. ensure the contact process for virtual encounter is precise and accommodating for all concerned (specific time, expected contact numbers, alternative arrangements).
       
       

V.     DURING AND AFTER ENGAGING IN VIRTUAL MEDICINE

1.   Assess the Appropriateness of the Use of Virtual Medicine for Each Patient Encounter
      Members initiating virtual medicine must, based on the information available:

1. 1. assess the patient’s presenting condition and the appropriateness of virtual medicine to provide care; if not appropriate, then the member must recommend and offer an in-person assessment;
      
      
   2. ensure they have sufficient knowledge, skill, judgment, and competency (including technological) to manage patient care through virtual medicine;
      
      
   3. ensure they have satisfactory technology to provide virtual medicine; and
      
      
   4. use video technology if available, if in the best interest of the patient, and if preferred by the patient.
      
      
2. Provide Patient-Centred and Evidence-Based Medical Care
   Members providing virtual care must:

• 1. provide all elements of good medical care as required;
     
     
  2. have the ability themselves to provide a timely physical assessment of the patient or, alternatively, by pre-arrangement with another practitioner, unless such is not possible without endangering the patient. Thus, simply directing patients on to another healthcare facility, a walk-in clinic, or the Urgent Care or Emergency Department, in non-urgent or non-emergent circumstances in lieu of an in-person assessment by the member or a designate is not considered optimum care;
     
     
  3. ensure continuity of care and have the same obligations for patient follow-up as in in-person care;
     
     
  4. ensure patients referred to specialists are appropriately examined, investigated, and treated before referral unless such is not possible without endangering the patient;
     
     
  5. pay additional attention to ensuring the patient understands the information exchanged and is not hindered by the technology;
     
     
  6. adapt the technology for virtual medicine for patients who are deaf, hard of hearing, or visually impaired.
     
     

3.   Medical Records and the Privacy, Confidentiality, Security of, and Access to Patient Records

• 1. Members providing virtual medicine are required to create and maintain patient records the same as with in-person care.
     
     
  2. Members should usually have active access to the patient’s medical record while providing virtual medicine.
     
     
  3. Members must carefully consider the appropriateness of obtaining photos, or videos, from patients by electronic means and ensure there is consent for, lawful viewing, and confidential storage of such patient records.
     
     

 VI.    PRESCRIBING AND AUTHORIZING

1.   Members using virtual medicine must:

• 1. conduct an assessment in accordance with the standard of care before prescribing or authorizing a drug, substance, or device, and only proceed to do so if appropriate;
     
     
  2. exercise caution when providing prescriptions or other treatment recommendations to patients they have not personally examined;
     
     
  3. not prescribe opioids or benzodiazepines or Z-Drugs or authorize cannabis for medical purposes to a patient whom they have not examined in person, or with whom they do not have an ongoing treating relationship, unless they are in direct communication with another regulated healthcare professional who has examined the patient.
     
     

VII.   CONTEXTUAL INFORMATION AND RESOURCES

1. Virtual Medicine not Meeting the Standard of Care
   The requirement is to provide timely in-person medical care.  Examples of virtual medicine that do not meet the standard are:

• 1. Physicians not offering in-person appointments, including during a pandemic, unless advised by a health authority to not see patients in person.
     
     
  2. Virtual medicine based businesses that do not offer timely in-person appointments by the same physician or another specifically delegated practitioner.
     
     
  3. Physicians unnecessarily restricting in-person visits with patients or having very limited in-person appointments.
     
     

Good medical care usually requires in-person assessments unless for refills or chronic care for longstanding patients.

Video technology, if available, if in the best interest of the patient, and if preferred by the patient, is the preferred option.  However, if a video option is unavailable, or refused by the patient, default to a telephone may suffice if deemed safe for the patient.

2. Virtual Care for Distant Rural and Remote
   The College recognizes the importance of virtual medicine for many patients living in some distant rural and remote areas, especially those residing in First Nations settings.  Virtual medicine has enabled these patients to access health care with greater ease.  Physicians treating patients residing in these areas are encouraged to continue using virtual medicine so long as it is safe for the patient and provides good medical care.
   
   

3. Virtual Care for Opioid Agonist Treatment
   For Opioid Agonist Treatment, the College recognizes the importance of virtual medicine providing immediate medical care in situations where in-person care might not otherwise be possible.  Access to continuous good medical care (whether virtual or in-person) is in the best interest of this unique patient group receiving opioid agonist treatment.
   
   

  VIII.  Legal and Regulatory Context

Any virtual care which is provided within the province of New Brunswick will be expected to keep to the same standards as all other physician/patient contacts.  The physician should not exceed the scope of their licence and must respect any restrictions on it.  Issues arising from such practice will be dealt with, as usual, by the College in New Brunswick. 

If a New Brunswick physician wishes to provide virtual care into another jurisdiction, they must have the legal authority to do so.  In some provinces there is no limit on such access and in others no access at all is allowed.  Providing such service without the legal authority to do so could attract a range of consequences, including a charge of illegal practice, an injunction against illegal practice, or a complaint to the College in New Brunswick.

 IX.   Physicians who wish to provide virtual CARE to New Brunswick patients

This is allowed for any physician with a licence in New Brunswick.  In addition, those without a licence may be registered on a Virtual Care Provider list by completing a form and registering such with the College.  Note that such does not mean services are covered directly, or indirectly, by New Brunswick Medicare.

Such listing has the following requirements:

1. The physician is licensed with a medical regulatory authority acceptable to Council. There should be no restrictions on such licensure which would impact the intended virtual care services.
   
   
2. The physician will maintain such licensure at all times when providing the intended virtual care service.
   
   
3. The intended virtual care services will be of a nature and frequency acceptable to Council.
   
   
4. The physician asserts, and provides evidence, when requested, of appropriate malpractice coverage or such other assistance, including membership with the Canadian Medical Protective Association, as necessary in regards to the intended virtual care service.
   
   
5. The physician agrees to make reasonable efforts to comply with any statutes, regulations, rules, or policies which would apply if the intended service was provided in person within the province.
   
   
6. The physician agrees to make no effort to require any New Brunswick resident, as a precondition of receiving the intended service, to agree to any release regarding choice of laws or forum, should any legal action arise from the provision of the virtual care service. 
   
   
7. The physician agrees to accept the authority of the medical regulatory authority of their home jurisdiction to consider any complaint which may arise from the provision of this virtual care service.

Listing will be for the calendar year and will be renewable.

Practising virtual care into New Brunswick without the authority to do so could result in a complaint to the physician’s home jurisdiction. 

Complaints arising from the practice of telehealth into New Brunswick will be dealt with by the physician’s home jurisdiction with assistance, as necessary, from the New Brunswick College.

New Brunswick physicians practising into another jurisdiction should be respectful and follow, so far as possible, any legal or regulatory provisions applying to patient care in the into that jurisdiction. 

2/22