POLICY: THE PRACTICE OF TELEMEDICINE
1. Definition of Telemedicine – What constitutes the practice of medicine?
Telemedicine: a medical service provided remotely via information and communication technology.1 Remotely: without physical contact and does not necessarily involve long distances.
WHAT CONSTITUTES THE PRACTICE OF MEDICINE IN SASKATCHEWAN?
Based upon the College’s interpretation of The Medical Profession Act, 1981, the College accepts that the practice of telemedicine is the practice of medicine in Saskatchewan. Based upon the College’s interpretation of The Medical Profession Act, 1981, the College accepts that a physician who is physically located in Saskatchewan, but who provides telemedicine services to patients located outside of Saskatchewan, is practising medicine in Saskatchewan.
The Medical Profession Act, 1981 states that a person need not be a licensed Saskatchewan physician to do any of the following:
a) provide telemedicine services in an emergency situation;
b) provide treatment in consultation with a Saskatchewan physician who has an ongoing relationship with the patient and who has agreed to supervise the patient’s treatment, including use of any prescribed medication; and,
c) provide services without any form of compensation.
Therefore, the College cannot require a physician who only provides these services to be licensed in Saskatchewan.
2. Licensure to practise medicine in Saskatchewan
The College accepts that a physician who practises telemedicine as defined above is practising medicine in Saskatchewan and is required by The Medical Profession Act, 1981 to be licensed with the College of Physicians and Surgeons to do so.
Based upon the College’s interpretation of The Medical Profession Act, 1981, the College accepts that a physician who is physically located in Saskatchewan, but who provides telemedicine services to patients located outside of Saskatchewan, is required by The Medical Profession Act, 1981 to be licensed with the College of Physicians and Surgeons to do so.
The College accepts that an expedited form of licensure should be available to physicians who are fully-qualified physicians, who meet the criteria for full registration in Saskatchewan, who are licensed without restrictions in another province and who only practise telemedicine in Saskatchewan on an occasional basis.
Such physicians will be required to meet the same requirements for CMPA membership or other insurance coverage as apply to other physicians licensed to practise in Saskatchewan.
The College offers a telemedicine licence to physicians who only practise medicine in Saskatchewan by telemedicine. The cost of such a licence is dependent on the number of telemedicine services that are provided by the physician. The licence is offered at no cost to physicians who will limit their practice of telemedicine to no more than twelve Saskatchewan patients per year. A licence is offered at a reduced cost for physicians who will limit their practice of telemedicine to no more than fifty-two Saskatchewan patients per year.
The College has exempted physicians from the requirement that they be licensed in Saskatchewan if they only provide follow-up care to patients who the physician has seen in the physician’s home province, under the conditions established by Regulatory Bylaw 2.11(d).
3. Saskatchewan-licensed physicians who practise telemedicine outside Saskatchewan
The College recognizes that a Canadian regulatory authority may, or may not, require physicians to become licensed in their provinces or territories in order to practise telemedicine with patients located in that province.
The College expects physicians that it licenses to meet the licensing requirements of another province or territory, if any, in order to practise telemedicine with patients in that province or territory.
The College considers it unprofessional conduct for a physician to provide telemedicine services in another province or territory unless the physician meets the licensing requirements of that province or territory.
4. Ethical, professional and legal obligations
The use of telemedicine does not alter the ethical, professional and legal obligations of physicians, including but not limited to:
b) the establishment of a patient-physician relationship;
c) informed consent (including consent to treatment and as related to telemedicine technologies);
d) privacy, confidentiality and security of patient information;
e) the appropriateness of the use of telemedicine;
f) prescribing issues; and
g) follow up with patients.
The College expects that physicians who use telemedicine will comply with relevant legislation and current regulatory policies and guidance in the physician’s province/territory of licensure, as well as those in the jurisdiction where the patient is located, including but not limited to:
b) conflict of interest;
c) advertising and communication with the public, as well as the sale of goods and services;
d) medical records; and
e) expectations of ongoing competence, including as it applies to current and evolving technologies used in telemedicine.
5. Standards of practice of telemedicine
1. General expectations
a) The College expects physicians who practise telemedicine in Saskatchewan to meet the same standards of practice, whether the physician is located within or without Saskatchewan.
b) The College expects that physicians who provide telemedicine services should, wherever possible, ensure that the care provided to the patient through telemedicine will provide the same level of care to the patient as would be provided if the physician was physically present.
c) The College expects that physicians who provide telemedicine services should provide all relevant information to the patient about the nature of the telemedicine services that are provided, including the nature of the limitations on those services, if any, and any extra risks that may be inherent in the provision of those services.
d) The College expects that when a physical examination is required or appropriate to diagnose or develop a treatment plan, physicians who provide telemedicine services will arrange for a physical examination of the patient, either in person or by proxy.
2. Establishing the Patient-Physician Relationship
Physicians using telemedicine to provide medical services to patients:
a) are expected to disclose their identity, location and licensure status to the patient;
b) must take appropriate steps to confirm the identity of the patient;
c) should explain in plain language the appropriateness and limitations of medical services provided by telemedicine;
d) must obtain, document and maintain all aspects of informed patient consent in a telemedicine encounter; and
e) have the same obligations for patient follow up in telemedicine as in a face-to-face consultation.
3. Medical Records and the Privacy, Confidentiality, Security of and Access to Patient Information
Physicians are required to create and maintain a medical record as part of the provision of a telemedicine service. The requirement to create such a record is the same whether the care is provided face-to-face or via telemedicine. As such, physicians are expected to comply with the College’s requirements for the privacy, confidentiality and security of patient information, including but not limited to:
a) medical record-keeping, including documentation, retention, transmission, archival and retrieval;
b) enduring patient access to their medical records; and
c) the availability of the medical record to other health care professionals for the necessary provision of patient care and follow up.
4. Assessing the Appropriateness of the Use of Telemedicine for Each Patient
Physicians using telemedicine to provide medical services to patients are expected to:
a) ensure they have sufficient training and competency to manage patients through telemedicine;
b) assess patients’ presenting condition and the appropriateness of telemedicine to provide care;
c) take reasonable steps to assess all available resources that are required to provide medical services, including patient information2, the technology, the presence of support staff (both where the physician is located and where the patient is located), linkages with other services (e.g. laboratory), etc., and proceed only if those resources are available, safe and secure, and can be used effectively and in a private manner;
d) if the nature of the services provided is such that there is a possibility of an adverse event or emergency, only utilize telemedicine if there is a plan in place to manage any such adverse event and/or emergency. Patients must be advised of the appropriate steps to take in these instances.
5. Prescribing practices
Physicians using telemedicine to provide medical services to patients are expected to:
a) conduct an assessment in accordance with standards of care before prescribing or authorizing any drug, substance or device and only proceed if appropriate;
b) be aware of jurisdictional requirements pertaining to controlled substances and the authorization or prescribing of cannabis and all substances that can be abused.
6. Participation in quality assurance mechanisms of the College
The College expects physicians who practise telemedicine in Saskatchewan, other than physicians who are licensed on an alternative form of licensure to provide telemedicine services to a limited number of patients, to participate in all quality assurance activities established by the College in the physicians’ area of practice.
7. Complaint investigation
The College accepts the responsibility to investigate complaints about the conduct of physicians that it licenses who practise telemedicine in another Canadian province or territory.
If a complaint is received about a physician who is registered in Saskatchewan, and in another province or territory, the College will discuss the investigation with the regulatory authority in the other province or territory where the physician is registered, and will attempt to co-operate to allow the investigation to be primarily conducted by the most appropriate regulatory authority. The Saskatchewan College will co-operate with the other regulatory body, including sharing the information from the investigation to the extent it is legally permissible to do so.
8. Other relevant College policies and bylaws
Physicians who provide telemedicine should be aware of, and comply with, the following College Policies and Guidelines:
a) Uninsured Services
b) Performing Office-based Non-insured Procedures
c) Clinics That Provide Care to Patients Who Are Not Regular Patients of the Clinic
d) Complementary and Alternative Therapies
e) Conflict of Interest
f) Informed Consent and Determining Capacity to Consent
g) Medical Practice Coverage
h) Patient-Physician Communication Using Electronic Communications
i) Patient-Physician Relationships
j) Physician Disclosure of Adverse Events and Errors That Occur in the Course of Patient Care
k) Sale of Products by Physicians
Physicians who provide telemedicine should be aware of, and comply with, the following College bylaws:
l) Code of Conduct for Saskatchewan Physicians, College Regulatory Bylaw 7.2
m) Code of Ethics for Saskatchewan Physicians, College Regulatory Bylaw 7.1
n) Licensure for purposes of telemedicine, College Regulatory Bylaw 2.11
o) Conflict of Interest College Regulatory Bylaw 9.1
p) Licensing and Registration Fees Payable to the College – College Administrative Bylaw 9.1(g)
1 Reference: Europe Economics. Regulatory Approaches to Telemedicine. Updated 18 May 2018.
Note: For the purpose of this Policy, this includes medical services to patients as well as interprofessional and intraprofessional consultations (e.g., assessing, diagnosing, giving advice, teleradiology, etc.).
2 This includes but is not limited to pharmaceutical, laboratory, diagnostic imaging or hospital discharge information, etc.
Council November 2007
Approved by Council, September 2010
Reviewed and confirmed by Council November 2013
Reviewed and confirmed by Council November 2016
Reviewed and confirmed by Council November 2019
To be reviewed: November 2022