While virtual care has been used in several provinces for decades (1), during the COVID pandemic the use of these models of care increased. Virtual care may be structured in different ways, with differing access points and staffing structures (2). In this article, we focus on the model of the in-person emergency department staffed with nurses with a virtual emergency physician.
Some emergency departments have made the difficult decision to close or reduce open hours as a result of staffing issues. This is especially true in rural or remote areas. A virtual emergency physician not physically located in the area can help address some aspects of service gaps and ensure rural patients have access to care locally (3). Provinces such as British Columbia, Nova Scotia, Newfoundland and Labrador, and Saskatchewan have already implemented their own virtual emergency care models (3).
Some of the challenges for emergency physicians providing virtual care include meeting licensing requirements, information gathering (4), and working virtually with a team. This article aims to help physicians understand the medico-legal and patient safety challenges of virtual emergency care (3).
Lisensing
Licensing requirements for physicians in Canada vary, and requirements should be considered with the Colleges in both the jurisdiction in which the physician is located and the jurisdiction in which the patient is located. Each of the provinces and territories will have their own requirements for whether a physician can provide care in that location (5). Many of the provincial and territorial medical regulatory Colleges also have specific webpages for their requirements for virtual care (6-9). CMPA also has a webpage specifically dedicated to virtual care issues. Topics include providing care to non-residents or when the patient or member is outside of Canada and also highlights the potential need for licensing in the province in which the patient resides (10).
The Physical Exam and Assessment
| An ED physician provides on-call virtual care for a remote ED. The physician connects virtually through a computer program and is contacted by the nurse one evening for a patient who presented with a rash. The internet for the videoconferencing system is choppy and the imaging is, at times, somewhat pixelated and makes it hard for the physician to see clearly. The physician diagnoses the rash as an allergic reaction and prescribes Benadryl. The patient returns the next day and the physician receives another call from the nurse who says that the patient’s rash has worsened and asks if the patient should stop taking Amoxicillin. The physician, who was unaware that the patient was taking the drug, learns that the patient had recently been diagnosed with strep throat. The physician wonders about their medico-legal liability when they only had access to a poor-quality image for identifying the type of rash. |
Providing virtual care for patients can bring several issues to the forefront for physicians: the challenge of performing a physical exam virtually, working with unfamiliar team members, and relying on technology that may be suboptimal at times.
When it comes to the physical exam, physicians rely on the assessment of other members of the healthcare team. Building trust with the team is an important consideration, especially when working with healthcare providers from other communities (11).
Physical exams may prove challenging when performed during a virtual visit. Nurses may feel uncomfortable providing assessments beyond their scope of practice (11) and physicians may worry about missing subtle signs or cues through the video or telephone calls (12) particularly in the absence of a proper physical examination. Audio or video quality may further hinder the physician’s ability to obtain the necessary information for making a full assessment (12). Communication with your team (including the patient) can be incredibly important in these situations. Be thorough with your questions for the patient or the nursing team and document your discussions. Colleges generally encourage physicians to use professional judgment and consider the standard of care when deciding whether to deliver medical services to a specific patient using telemedicine. In the case of virtual emergency departments, this means physicians should consider whether the patient’s medical history, including information about medications and allergies, is accessible. They should also consider whether an adequate assessment can be performed using telemedicine, and whether appropriate medication monitoring and follow-up care can be provided or arranged. The standard of care for treating patients virtually and in-person remain the same.
Technology can add a challenge if it is cumbersome or difficult for members of the healthcare team to use. It can also increase privacy and information security risks. Some programs have found success by incorporating available and timely IT support into their virtual ED programs (11). When faced with challenges that may hinder a physician’s ability to diagnose the patient, such as a technology failure, they should document those restrictions and reach out to the program’s IT team to see if they have any solutions or preventative steps for the future. It is important to remember that sharing patient information (including images) on a personal device can lead to privacy risks. Physicians should be aware of privacy regulations that are in place when providing virtual care.
How to reduce your medico-legal risk and improve patient safety
Virtual care has many benefits for those seeking healthcare in Canada, including improving accessibility for individuals who live in rural and remote communities (13). It also serves to prevent ED closures (3), which further reduces strain on neighbouring centres. But physicians may still worry that they are at an increased medico-legal risk when providing virtual care.
There are certain requirements that remain the same, whether treating a patient virtually or in-person: physicians must still ensure that they meet the standard of care with their patients; that patients understand the limitations of the assessment and any necessary follow-up suggested; and that patients are aware when they should seek further care, including when they need to be seen in-person by a physician (14). Physicians providing virtual care to other communities should take steps to ensure that they have an appropriate license, and that they communicate well with the healthcare team. They also should attempt to ensure that appropriate security protocols are in place to protect patient information that is transmitted electronically and address any technological issues with the IT team when appropriate.
Key Takeaways
- Virtual care can have great benefits, in particular for small and rural communities
- Virtual care can add extra challenges, like performing physical exams from a distance and relying on a team member for their assessments
- Physicians can best minimize medico-legal risk through increased communication with the patient and on-site team, ensuring the patient is aware of the treatment plan. They also should document the discussion, treatment plan and follow-up.
References
1. Brunet F, Malas K, Desrosiers ME. Will telemedicine survive after COVID-19? Healthc Manage Forum. 2021;34(5):256-9.
2. Hall JN, Ackery AD, Dainty KN, Gill PS, Lim R, Masood S, et al. Designs, facilitators, barriers, and lessons learned during the implementation of emergency department led virtual urgent care programs in Ontario, Canada. Front Digit Health. 2022;4:946734.
3. Dubois S. Provinces are relying on virtual doctors to keep smaller ERs open. Here’s how it works: CBC Radio; 2025 [Available from: https://www.cbc.ca/radio/whitecoat/provinces-virtual-doctors-1.7425965.
4. Haimi M, Brammli-Greenberg S, Baron-Epel O, Waisman Y. Assessing patient safety in a pediatric telemedicine setting: a multi-methods study. BMC Med Inform Decis Mak. 2020;20(1):63.
5. Laviolette C, Ryan, Holly. A 2023 update on virtual care in Canada 2023 [Available from: https://www.blg.com/en/insights/2023/06/a-2023-update-on-virtual-care-in-canada.
6. College of Physicians and Surgeons of Ontario. Advice to the Profession Virtual Care [Available from: https://www.cpso.on.ca/en/Physicians/Policies-Guidance/Policies/Virtual-Care/Advice-to-the-Profession-Virtual-Care.
7. College of Physicians and Surgeons of British Columbia. Practice Standard: Virtual Care 2013 revised 2023 [Available from: https://www.cpsbc.ca/files/pdf/PSG-Virtual-Care.pdf.
8. College of Physicians and Surgeons of Alberta. Standards of Practice: Virtual Care 2010 Reissued 2022 [Available from: https://cpsa.ca/wp-content/uploads/2021/12/Virtual-Care.pdf.
9. College of Physicians and Surgeons of Saskatchewan. Policy: Virtual Care 2010 Amended 2023 [Available from: https://www.cps.sk.ca/iMIS/Documents/Legislation/Policies/POLICY%20-%20Virtual%20Care.pdf.
10. Canadian Medical Protective Association. Providing Virtual Care (Including Telehealth) 2006 Revised 2023 [Available from: https://www.cmpa-acpm.ca/en/membership/protection-for-members/principles-of-assistance/providing-virtual-care-including-telehealth.
11. Novak Lauscher H, Blacklaws B, Pritchard E, Wang EJ, Stewart K, Beselt J, et al. Real-Time Virtual Support as an Emergency Department Strategy for Rural, Remote, and Indigenous Communities in British Columbia: Descriptive Case Study. J Med Internet Res. 2023;25:e45451.
12. Murphy DR, Kadiyala H, Wei L, Singh H. An electronic trigger to detect telemedicine-related diagnostic errors. J Telemed Telecare. 2024:1357633×241236570.
13. Novak Lauscher H, Stewart K, Markham R, Pawlovich J, Mah J, Hunt M, et al. Real-time virtual supports improving health equity and access in British Columbia. Healthc Manage Forum. 2023;36(5):285-92.
14. Canadian Medical Protective Association. Providing safe care — virtually and in-person 2021 [Available from: https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2021/providing-safe-care-virtually-and-in-person.
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