Virtual Care Guide — College of Physiotherapists of Alberta

Virtual Care Guide PDF

Introduction

Virtual Care is the delivery of physiotherapy services using any technology that enables communication between individuals in different locations, including teleconferencing, video conferencing, email, or text communications.

With that definition in mind, it is clear that virtual care has been provided for decades by health professions who employed telephone follow up visits for clients living in remote areas. Over the years, the use of technology as a mechanism to deliver health services has become increasingly common. As part of that trend, the technology and capabilities of virtual care have expanded to include video conferencing, remote monitoring, and other technologies.

The use of virtual care can enable increased access to physiotherapy services for individuals living in rural and remote areas. The number of physiotherapists living in urban areas is greater than the number of the general population living in urban settings.¹ And there are challenges in recruiting physiotherapists and other health professionals to work in rural and remote areas.^1,2

Although access to care has long been promoted as a reason to employ virtual care, at the start of 2020 relatively few physiotherapists were known to routinely provide virtual physiotherapy services. That changed rapidly with the onset of the COVID-19 pandemic.

Although much of the push towards virtual care prior to the pandemic was for rural communities, it was evident during the pandemic that it can enable access when in-person services are not possible for other reasons. Urban barriers to care such as commute times, work restrictions and physical location within an urban city, also exist. Virtual care is a valuable tool to any potential physiotherapy client as it may enable access to providers with unique skills, regardless of where the client or provider are physically located.

As part of the discussion around accessing care regardless of location, it should be mentioned that a common topic is cross-border virtual care services. You can find more information about cross-border virtual care services in Appendix A.

The purpose of this guide is to provide guidance as to how to fulfill the professional expectations established in the Standards of Practice for Physiotherapists in Alberta within this evolving environment. This guide will discuss:

The principles of virtual care
Different models of virtual care
How to meet regulatory expectations when using virtual care
Resources to help you get started with virtual care (appendices)

Throughout this guide we will share common questions posed to the College, in the form of scenarios to help illustrate potential issues and performance expectations.

Virtual Care Principles

Equivalent Care

Virtual care is a method of physiotherapy service delivery that is subject to the same Standards of Practice and professional expectations as in-person physiotherapy services. Clients receiving virtual services can expect that those services, though different in nature due to the virtual format of delivery, will be equivalent in their quality, safety, and effectiveness (i.e., “substantively similar”).

Client-Centred Care

The decision to offer virtual care is not based on the physiotherapist’s business model or preferences for service delivery. Virtual care is delivered due to the client’s needs and preferences. Regardless of client preference, virtual care must also be an appropriate method to deliver quality, safe, effective physiotherapy services which will address the client’s needs and goals.

Models of Care

To date, the College has heard from registrants regarding four different models or approaches to providing virtual care services.

One-to-one virtual care

The physiotherapist delivers virtual care to a single client, where those involved are located remote from each other, most often with the client receiving virtual care at their place of residence, or occasionally at their workplace.

Group virtual care

The physiotherapist delivers virtual care to a group of clients with a similar condition and similar treatment plans. All parties are remote to each other. Each client is receiving virtual care at their place of residence, or occasionally at their workplace.

In this model of care, all clients participating in the group may be able to see each other via video conferencing technologies and may also be able to observe other clients’ home environments. Clients participating in this model of virtual care must be advised of these considerations and agree to group virtual care.

Virtual care employing a physiotherapist support worker

There are two ways that physiotherapists typically deliver virtual care with the involvement of a physiotherapist support worker.

The physiotherapist works with a physiotherapist support worker in the delivery of physiotherapy services to a client who is co-located with the physiotherapist support worker. The physiotherapist support worker may be a mobile health-care provider who delivers physiotherapy services within the client’s home, the client may attend a remote health centre or other setting to receive physiotherapy services, or the client may be a resident or inpatient in a facility that does not have a physiotherapist on site.

In this model, the physiotherapist attends the physiotherapy appointment virtually, and physiotherapy services are provided with the physiotherapist support worker or facility-based staff member serving as the physiotherapist’s “hands,” providing services at the direction of the physiotherapist who directs the physiotherapist support worker’s actions in real time.

The physiotherapist may also assign services to a physiotherapist support worker when the client and the support worker are located remote from each other. In this model, the physiotherapist does not attend the physiotherapy appointment virtually and has instead assigned the virtual physiotherapy services to the physiotherapist support worker, in accordance with the requirements of the Supervision Standard of Practice.

As with all physiotherapy services delivered with the assistance of physiotherapist support workers, the supervising physiotherapist is accountable and responsible for the quality, safety, and effectiveness of the physiotherapy services provided and for the appropriateness of the assignment of services to the physiotherapist support worker.

Virtual consulting

The physiotherapist consultant employs virtual care technologies to interact with a physiotherapist and client co-located at a different location. The consultant provides their input into the client’s care and may interact directly with the client or with the treating physiotherapist, depending upon the situation and the client’s needs.

When virtual services are delivered into practice settings other than a client’s single-family home, other regulatory requirements may apply to the practice setting. If you are considering delivering virtual services into settings other than clients’ homes, speak to the College before starting.

Ask Yourself: Is Virtual Care Appropriate for This Client?

The Virtual Care Standard of Practice requires that the physiotherapist assess the appropriateness and method of providing virtual care on an ongoing basis, considering:

The client’s circumstances and preferences for physiotherapy service delivery.
The client’s diagnosis and treatment plan.
The physiotherapist’s ability to provide appropriate assessment and treatment of the client’s condition using virtual methods of physiotherapy service delivery.
Changes required to physiotherapy services to reflect virtual care considerations and constraints.
Relevant enabling or limiting factors that affect the ability to provide safe and effective virtual care.

Scenario 1: Sean is a physiotherapist who is considering providing virtual care to seniors residing in lodges in rural Alberta. He is concerned that many of his clients may have some level of hearing and/or vision loss. Sean is unsure whether he can provide virtual care to this patient population safely and effectively. What should Sean consider when determining whether he can provide virtual care to this patient population?

Scenario 2: Irena is a pelvic health physiotherapist who would like to start assessing clients virtually. She is considering whether she can actually do so since she is unable to perform an internal exam as part of a virtual care assessment and is unsure whether she would be able to meet the expectations for assessment found in the Standards of Practice. Is Irena able to provide virtual pelvic health services?

Physiotherapists are constantly adapting their skills and competencies to match the practice environment. Virtual care is no different in this respect. Prior to assessing a client virtually and continuing through the therapeutic relationship, the physiotherapist must use their professional judgment to determine if it is appropriate to assess and/or treat the patient through virtual means, taking into consideration the following questions:

Is virtual care the most appropriate available method to deliver services?
What is the client’s preferred method of service delivery?
Is an in-person physical examination required to complete the assessment and determine a diagnosis and treatment plan?
Can you deliver substantively similar care as in-person physiotherapy?
Does the client have physical, sensory, and/or cognitive impairments that prevent the delivery of safe and effective virtual care?
Do existing barriers create additional risk or decrease the quality of care that can be delivered virtually? This can include physical and other risks.

There are many aspects to a client’s life and a physiotherapist’s clinical capabilities that can create barriers to using virtual care to deliver physiotherapy services. Although the list is not all inclusive, it does shed light onto several identified areas that would indicate concerns regarding the appropriateness of providing virtual services.^3,4

Potential patient barriers for appropriateness of virtual care:

A recent significant change in the client’s level of impairment or function
Unwilling to participate in virtual care due to a lack of human contact or a desire for human contact
Physical, sensory, or cognitive needs that cannot be accommodated during virtual care
Need for caregiver assistance

The Virtual Care Standard of Practice requires that the physiotherapist:

Confirms that adequate technology and supports are available to the client to enable virtual care.
Confirms that the client has reliable internet access or phone connection and a private location from which to receive virtual care and if a private location is not available:

Takes reasonable action to manage client privacy.
Confirms client understanding of privacy risks within the available location and client informed consent to proceed with virtual care despite these risks.

Potential technology barriers to appropriateness of virtual care:

Digital literacy of the client or physiotherapist
Poor Wi-Fi connections or availability
Slow processing speed due to limitations on the device or network being used

Virtual care should not automatically be discounted as a service delivery option when in-person options are available. Clients may prefer to access physiotherapy services virtually even if they are able to attend in person. This can be due to many factors. However, there can be situations where virtual physiotherapy is not an appropriate treatment option. In such situations a physiotherapist would need to offer services in-person or identify service providers in the client’s area to refer the patient to and facilitate the transfer of care to the other treatment provider.

The Virtual Care Standard of Practice requires that the physiotherapist:

Discontinues virtual physiotherapy services and refers for in-person service provision when virtual physiotherapy services pose an undue risk to the patient’s safety or are ineffective or inappropriate for the patient’s condition.

Scenario 1 Conclusion: Sean considers the supports and resources in place at the senior’s lodge and what would have to be in place to provide services that are safe and effective for the residents. He discusses the potential risks and barriers to providing care with the management and staff at the senior’s lodge. They are able to provide support staff for the virtual appointments and they have plans in place to accommodate clients’ needs. Sean decides that with these resources in place he can proceed with delivery of virtual care to this setting and patient population.

Scenario 2 Conclusion: Irena considers whether her potential virtual care pelvic health clients could be appropriately assessed and treated via virtual care. She decides that while it may be feasible to treat a client’s pelvic health complaint virtually in some circumstances, she would need to complete an in-person pelvic health assessment first. She comes to the conclusion that she could not treat a condition without first performing an assessment appropriate to the nature of the client’s complaint and an internal pelvic health examination is fundamental to properly assessing her pelvic health clients.

Ask Yourself: Do I have the Competence to Provide Virtual Care?

The Virtual Care Standard of Practice requires that the physiotherapist:

Possess sufficient training, knowledge, judgment, and competency (including technological competency) to manage client care virtually.

As with any other aspect of practice, physiotherapists must consider if they have the knowledge, skills, and abilities to safely and effectively engage in virtual care. They should actively seek education to develop their knowledge and skills and to ensure they are using these technologies appropriately and effectively. Appendix C provides a self-assessment tool for physiotherapists to evaluate their readiness to provide virtual care and Appendix D provides links to some resources to help physiotherapists gain competence in delivering virtual care services.

Potential physiotherapist-related barriers for appropriateness of virtual care:

Ineffective communication (e.g., inappropriate referrals) due to poor identification of barriers or client’s willingness to receive virtual services
Failure to identify client barriers and create sufficient accommodations
Limited competency in understanding the technological and administrative requirements to perform virtual care appropriately
Limited competency in conducting virtual care assessments and treatments
Inability to complete comprehensive, accurate, and appropriate assessments of the client’s condition using virtual care modalities
Anticipated or common treatment recommendations not available via virtual care

To ensure their competence in the use of virtual care software or platforms physiotherapists should:

Understand the system’s capabilities and limitations
Have technology supports available if needed
Evaluate and develop individual eHealth competencies to support the use of these technologies (see resources found in Appendix D)

Physiotherapists must also develop their technological skills and competencies related to providing virtual care including but not limited to the following:

Assessing client conditions
Using valid, reliable, and standardized outcome measurement(s)
Developing of rapport and therapeutic relationship
Providing treatment using a third-party working under the direction of the physiotherapist
Instructing the client to carry out treatment under the direction of the physiotherapist
Identifying appropriate referral and communication mechanisms with colleagues and other health-care providers

Ask Yourself: How Will I Maintain Privacy?

The Privacy and Record Retention Standard of Practice requires that the physiotherapist:

Collect the least amount of information necessary to provide physiotherapy services

Privacy requirements for physiotherapists do not change, regardless of how services are delivered. You need to know which privacy legislation applies to your virtual care services and comply with the requirements of legislation. In some instances, multiple pieces of privacy legislation can apply. A full discussion of privacy legislation is beyond the scope of this document but here are some key things to know:

Private sector virtual care services where both the patient and the physiotherapist are located in Alberta are subject to the Personal Information Protection Act.
Public sector virtual care services where both the patient and the physiotherapist are located in Alberta are subject to the Health Information Act.
When transmitting private information across Canadian provincial or territorial borders the Health Information Act or Personal Information Protection Act (or equivalent) of both provinces or territories and The Personal Information Protection Electronic Documents Act (PIPEDA) can apply.5 Transmission of information includes the virtual session as well as email or other forms of communication between the client and the physiotherapist.

It can be daunting to know that virtual care services are subject to multiple pieces of privacy legislation. There can be subtle differences in requirements from one piece of legislation to another. However, similarities exist between different pieces of privacy legislation which support a physiotherapist’s ability to meet the requirements.

Take the time to do your due diligence when selecting the tools you will use to provide virtual services, to make sure that they are built in a way and have capabilities that will help you meet your professional responsibilities. See Appendix B for more information on platform selection.

Scenario 3: Ashley is a physiotherapist working with a client named Jane who has been discharged home after a double mastectomy. Jane lives in a rural community and does not have access to high-speed internet at home. To do a virtual follow up visit to discuss how Jane’s transition home went and to review her exercise program, she needs faster internet access. The only place with fast enough internet is the municipal library.

Safeguards Used to Protect Private Information

The Virtual Care Standard of Practice requires that the physiotherapist:

Employs reasonable safeguards (physical, technical, and administrative) to protect the privacy and security of client information.

Physiotherapists who use virtual care to deliver services are required to use physical, technical and administrative safeguards to protect private client information from unauthorized access, use, alteration or destruction. The same is true of physiotherapists who provide in-person services. Below are some suggested types of safeguards that physiotherapists should consider to protect their client’s privacy while delivering virtual physiotherapy services.

Administrative

Develop training available to all new and current employees or contractors in how to use virtual care platforms as well as training in cybersecurity risks.
Maintain awareness of current and emerging risks to client privacy inherent to virtual care and the appropriate safeguards to address identified risks.
Develop policies and practices which:

Ensure that client records cannot be accessed by unauthorized users, tampered with, or destroyed.
Protect the transmission of information at both the originating and remote sites.
Establish role-based access to client health information.
Manage the use of mobile devices and personal devices for the delivery of virtual physiotherapy services.

Comply with all privacy and security requirements both during virtual care sessions and when in contact with the client through other electronic means, such as arranging appointments via email or text messaging.
Review all third-party provider contracts to ensure that they align with the regulatory and legislative requirements.

The Virtual Care Standard of Practice requires that the physiotherapist:

Has a professional, private location from which to provide virtual care.

Physical

Physiotherapist location:

Engage in virtual care in a private space not available to the public and on a secure network.
Verify the identity of the client prior to providing services.
Do not lend devices that contain personal health information to anyone who is not authorized to access that information.
Secure all devices used in the delivery of virtual care or used to store information related to virtual care when not in use. This can be a locked office, a locked drawer or cabinet, or in a locked briefcase when in transit.

Patient Location:

Identify potential privacy issues with the client’s location and ensures the client understand the risks and benefits of where they are engaging in the service being provided.
Review potential privacy issues and discusses the potential risks and benefits with regard to the client’s:

Location: Are they in a public space?
Wi-Fi connection: Is it a secure connection or a publicly accessible Wi-Fi?
The device they are using: Are they using a computer at a library or at a friend’s house?

Provide steps the client can take to verify the physiotherapist’s registration status and conduct history.

Technical

Use only organization/employer approved accounts and software for virtual care, emails, and other forms of communication.
Employ authentication and encryption technologies and secure transmission systems and storage mechanisms.
Employ strong, unique passwords and two-factor authentication when accessing platforms where private client information is stored.6
Regularly use and update applications with the latest security and anti-virus software.
Verify and authenticate a client’s identity before engaging in an email exchange, chat or videoconference. See Appendix E for more information about verification of identity in virtual care.
Maintain and monitor audit logs.

For more information on technical safeguards, review the resources in Appendix D.

Scenario 3 conclusion: What privacy issues are there with Jane and Ashley connecting virtually at the library and what safeguards might Ashley be able to use in order to provide care without compromising Jane’s privacy? Ashley and Jane communicate through phone and email to set up the appointment. They contact the library to reserve a private room in which Jane can set up her laptop so that others in the library can’t overhear their conversation. Ashley has discussed with the hosting platform that there are concerns with the security of being on the public Wi-Fi network, but they do have some technical safeguards in place that will make it challenging for someone to hack into their conversation. To the extent possible, Ashley makes sure that private information such as personal health numbers, client medical history, medications, etc. is communicated through more secure means prior to the appointment. Jane is aware of the risks involved, is happy with the measures Ashley has put in place, and consents to go forward with the virtual appointment.

Security and patient access to care need to be balanced. Physiotherapists must employ the most secure setting that enables service delivery. Where risks exist related to the security of the setting, the client has the right to make informed decisions about whether to access care and accept those risks or not.

Ask Yourself: Am I Prepared for a Patient Safety Incident?

The Virtual Care Standard of Practice requires that the physiotherapist:

Identifies risks related to virtual physiotherapy service provision.
Employs measures to mitigate risks specific to virtual care.
Develops patient safety incident management plans specific to the client for potential adverse events considering the physiotherapy services provided virtually and the client’s context.

Scenario 4: Jai is a physiotherapist working at a private practice. He looked at his schedule for next week and sees a new virtual assessment with a client named Parminder. When he reads through the intake form, he notices that Parminder has recently had an above knee amputation of her right leg. Jai prepares for the appointment and meets virtually with Parminder. As Jai goes through his objective assessment Parminder reports that she does not have anyone currently at home to assist her and she reports dizziness from the medications she is on. There are several concerns that Jai identifies that affect the ability to continue with the objective part of the assessment. Should Jai proceed with the assessment or inform Parminder that he must reschedule due to safety concerns?

Scenario 5: Bonnie works in post-operative care and has been seeing a client virtually who has been discharged home. On the third visit Bonnie notices that the client’s complaints and symptoms are changing and is concerned about the need for additional assessment.

Clients can expect to be safe in your care and in the practice environment. That over-arching expectation seems obvious; however, in the context of virtual care the necessary actions to achieve this goal can be less clear. The quality and safety of physiotherapy services must not be compromised by delivering virtual services that are inappropriate or unsafe.

You are required to:

Be familiar with the risks and harms associated with the assessments and treatments you use, including common and mild side effects and rare, severe harms.
Be familiar with sector- and environment-specific risks relevant to your practice setting and develop management plans to address these risks.
Develop plans and processes for managing patient safety incidents, and train people involved in the management of patient safety incidents in these plans and processes.
Track close calls and patient safety incidents that happen in the practice setting, using incident reports to refine patient safety incident management plans and adapt clinical practices to enhance client safety.

While some risks of physiotherapy practice may not be relevant to virtual practice (e.g., adverse events related to spinal manipulation or dry needling), there are others that are unique to the virtual environment (e.g., managing a client fall when you are not co-located with client).

Whether starting a new virtual care practice or reviewing and updating an existing one, an essential step is to consider the potential safety incidents that are foreseeable or have previously occurred and to develop patient safety incident management plans that are specific to those risks and which take into consideration the unique challenges posed by virtual care.

Some examples include:

Failure of the technology used to provide services
Other emergencies (e.g., fire) at the client’s location
Client medical emergencies (e.g., falls, injuries, heart attack, stroke)

Safety and Technology Considerations

Virtual care delivery is dependent on the effective use of technology. The ability to effectively employ technology in practice is both a quality and a safety issue. Disruptions can occur due to user errors or due to platform instability. A disruption of a communication system could leave the client without direction at a critical moment or could result in the client not having access to assistance during a patient safety incident. It is expected that the physiotherapist would have a plan in place to address this potential issue prior to commencing virtual care services. For example, ensuring the client has a secondary contact method in the event of platform instability or disrupted transmission.

Adverse Event Response Considerations

In traditional practice (in-person service delivery in a clinic or hospital environment), if a client were to experience a medical emergency, you would call 911 or code blue to access emergency assistance. However, in a virtual practice, if you took the same action, you would activate emergency services where you are located, delaying care for the client and wasting emergency services resources.

Patient safety incident management plans must include contact information for first responders in the client’s community using designated (direct) phone numbers rather than 911. Patient safety incident management plans should also include:

Contact information for others within the client’s environment (care providers, family members), and client consent to contact these individuals in the event of an emergency or patient safety incident.
An alternative method of contacting the client and provide the client with an alternate way of contacting you (e.g., having telephone contact information in the event of an internet failure).
Procedures to follow to manage patient safety incidents while waiting for assistance to arrive.
Procedures for managing patient safety incidents that do not require assistance from a first responder such as a re-aggravation of a client’s injury, or a small bump or cut that occurred during a session.

The Virtual Care Standard of Practice requires that the physiotherapist:

Discontinues virtual physiotherapy services and refers for in-person service provision when virtual physiotherapy services pose an undue risk to the patient’s safety or are ineffective or inappropriate for the patient’s condition.

A physiotherapist may decide after reading the intake form and completing the assessment that the risks of proceeding further via virtual care may not be manageable. It may also become apparent that virtual care is ineffective or inappropriate for the client. At this point you must refer the client for in-person services.

Scenario 4 Conclusion: Jai and Parminder discuss some of the concerns about being able to safely assess Parminder. They agree that they will reschedule the appointment for when there is someone else at home in case Parminder becomes dizzy and needs assistance during the appointment. They set up some plans for how they will proceed at the next scheduled appointment and Jai decides they will call Parminder the day before to make sure everything is in place.

Scenario 5 Conclusion: Bonnie decides it is no longer safe to treat the client virtually and must schedule in-person care to continue. It was not the client’s preference but after Bonnie explains her concerns the client consents to come into the clinic.

Ask Yourself: How Can I Effectively Communicate During Virtual Care?

It is now fairly common to communicate with friends or family members through online platforms and you most likely have recognized some of the challenges of communicating online versus in-person. Interacting with other people whether through email, telephone, or video comes with changes in both verbal and non-verbal communication. Communicating online through virtual platforms changes how you and the client interact with one another. It is important for you to understand how best to communicate and actively listen in this environment to build a positive therapeutic relationship with the client. Below we have introduced identifiable communication barriers and techniques to help you effectively communicate with your clients.^7,8,9

Common communication barriers:^7,8

Nonverbal communication is more difficult using virtual care as often much of the client and therapist’s bodies are not visible on camera.
Increased issues with timing and flow of conversation such as talking over one another or longer pauses as you give each other the opportunity to talk.
Inability to adjust camera angles or position of the camera to be able to properly visualize the injured site or demonstrate exercises.
Clients may be hesitant to speak up or seem critical. Be aware of any indication of this so you can give the client an opportunity to address their concerns.

Strategies the client may use (what you may observe, and what it could indicate):^7,8

Clients will often use two strategies to raise concerns around their safety. Usually joking or reporting the concern that they couldn’t do the exercise or movement. The other is non-responses such as longer periods of silence or uncomfortable laughter when asked to do something they are unsure of.
Clients will also alter the pitch, tone, and volume of their voice to convey concerns, successes, or their feelings.

Techniques the physiotherapist may use to improve communication:^8,9

Establish a set of instructions or directions to position the client and their camera to see what you need during the history and assessment.
Adapt your communication style by allowing more pauses so the client has time to process information, provide feedback, and ask questions.
Check in more often with the client (“Does that make sense?” “Can you hear me or see me properly?”)
Evaluate your environment and the client’s and address potential issues that may create a barrier to communication. Is there distracting background visual or audio present (a ceiling fan, bright lights, louder clinic environment or a loud TV).
Dedicate extra review time at the end of the session for education, questions, follow up, etc.
Use technology to assist you, such as using screen sharing during client education or sending follow up emails with information packages or a review of what was discussed.
Alter your voice characteristics to make up for lack of body language. Pitch helps convey meaning, regulate conversational flow and signal the intensity of a message. Tone can be used to convey emotion and is an important part of building therapeutic relationships (warmer/positive tone associates with better interactions with clients).
Alter your speech rate as needed for your audience but slower is often better.

Ask Yourself: Do I know How to Obtain Informed Consent for Virtual Care?

The Virtual Care Standard of Practice requires that the physiotherapist:

Obtains the client’s informed consent specific to virtual physiotherapy service delivery, including informing the client of:

Any relevant limitations to physiotherapy service options available through virtual care.
Safety risks specific to virtual care.
Privacy risks specific to virtual care and the method of virtual care delivery.

In addition to the informed consent obtained for physiotherapy care in general, you also need to obtain informed consent for the delivery of virtual physiotherapy services and specific virtual care considerations such as:

Explicit consent to virtual services rather than in-person physiotherapy.
For transmission and potential recording and storage of personal information via virtual care platforms and the privacy considerations related to such transmission, recording and storage.
For participation of others in the delivery of physiotherapy care (e.g., family member or unregulated health provider to assist in delivery of services).

To make an informed decision, clients must be aware of the available treatment options, including options to receive in-person care. Clients need to be aware that although there are many effective and appropriate physiotherapy options available to treat a given condition, some of these options may not be available to them when receiving virtual care.

This means communicating benefits, limitations, risks and potential harms of virtual care in a meaningful way when seeking client informed consent for virtual assessment or treatment. This will require that physiotherapists are well versed in these considerations and that physiotherapists can effectively communicate this information to the client.

The client has the right to decide between any “trade offs” involved in opting for virtual service delivery (i.e., not having to travel and take time off work balanced against the inability to receive a specific treatment approach.) This is the part of the informed consent discussion that is specific to virtual care and differs from in-person care.

After taking the time to review these with the client, they may decide that virtual care is the best available physiotherapy option for them.

Physiotherapy services must adhere to College Standards. The physiotherapist cannot seek consent for, and the client cannot consent to, assessment or treatment that is inadequate or that does not meet the Standards under any circumstances.

Ask Yourself: Do I Know How to Accurately Assess Clients Receiving Virtual Care?

Physiotherapy services must include a history, physical examination, and a treatment plan that is appropriate for the client. Although virtual care is appropriate for many injuries and conditions it is important to realize that fundamentally, physiotherapists do not provide treatment of any condition without performing an assessment appropriate to the client complaint.

Self-Report Measures

Self-report measures can be a great place to start when trying to identify the client’s perception of their injury or condition as well as their perceived functional limitations. Self-report outcome measures are readily available, many at no cost to use in practice, and are tested for reliability and validity specific to the client population. However, it is important to note that self-report measures alone are not sufficient for a complete assessment.

Objective Measures

Providing virtual care does not prevent the use of objective measures or a physical assessment, nor alter the requirement to do so. Although your ability to perform manual muscle testing or a straight leg raise may be challenged, you can still perform many objective measures to give you a clear clinical picture. There are options to modify in-person objective measures to use them virtually. Seek to gain competency in these areas as you would any other area of practice. See Appendix D for clinical practice resource links.

There are also current and emerging technologies and tools that you can implement into your virtual care assessment. Examples include programs that allow client ROM measurement through the tablet or laptop camera, and wearable motion sensor systems that can relay data for use in objective measures. AI and virtual reality are also becoming more common in the delivery of virtual services. As with any technology you implement into your practice, it is important that you do your due diligence to ensure it is reliable, valid, safe, and appropriate for use with your client population.

Ask Yourself: Do I Know How to Document Virtual Care Interactions?

The Documentation Standard of Practice requires that the physiotherapist document the mechanism of service delivery (e.g., virtual, in-person)

The documentation of physiotherapy services delivered virtually are subject to the same Standards of Practice as in-person services. However, due to the nature of virtual care, additional documentation and recordkeeping considerations must be addressed.

Documentation Expectations

You are required to:

Retain any video or audio recordings as part of the client record.
Evaluate any information gathered from a third-party source (such as a non- physiotherapist health provider physically co-located with the client), to determine its reliability and accuracy and the ability to incorporate the information into the assessment or treatment.
Maintain written records summarizing all client treatments and communications .
Comply with the documentation Standards of both jurisdictions when virtual care is delivered across borders.
Retain clinical or financial records for the longer required period of time when delivering services across borders and retention periods differ between jurisdictions.

The Virtual Care Standard of Practice requires that the physiotherapist:

Confirms the location of the client and documents the client’s location in the client’s record for each virtual care interaction.

Recording Virtual Physiotherapy Sessions

Some virtual care platforms will come with the option to record the virtual session, while others will record virtual sessions automatically. Physiotherapists often ask whether they are required to record virtual sessions and how to manage the option to do so.

It is important to point out that the Standards of Practice do not require a physiotherapist to record virtual physiotherapy assessments or treatments.

Since it is not mandatory, you need to decide the relevance and importance of generating a recording. When choosing a virtual care platform, you need to decide what your individual or practice site needs are, and whether the ability to turn the recording option on or off is important to your practice.

However, if a recording is created, it becomes part of the client’s official record and needs to be retained for the same duration as any other part of the client’s chart and in a format that can be accessed by you or the client. This has implications for record access, storage, security, retention and destruction, when the time comes.

The recording does not replace the chart note that summarizes what you observed and your interpretation of what those observations mean. You still need to complete your usual written documentation.

One other thing to keep in mind is that you need to disclose that the session is being recorded. Within the private sector, you also need to obtain consent from the client to make a recording. Clients have the right to know that their physiotherapy intervention is being recorded and that the recording will be retained. The client also has the right to access this portion of their health record, like any other part of the record.

Ask Yourself: How Will I Appropriately Supervise Virtual Services?

Being a supervisor or being supervised involves the same expectations whether it is for in-person or virtual care. Physiotherapy support workers may be actively involved in the delivery of virtual services.

In cases where the support worker is co-located with the client while the physiotherapist is located remote to the client, the College’s perspective is that the physiotherapist is directing care and is providing services with the assistance of the physiotherapist support worker, but is not “supervising” the service as supervision is generally understood within the physiotherapy community. Services in this instance are delivered with the direct, real-time involvement of the physiotherapist.

In other cases, the physiotherapist support worker may be applying virtual care technology to deliver physiotherapy services remotely, under indirect supervision of the physiotherapist.

As with all physiotherapy services delivered by a physiotherapist support worker, the physiotherapist retains accountability for the assignment of services and for providing appropriate supervision to ensure the client receives quality, safe, and effective physiotherapy care. The main considerations for appropriate supervision in virtual care are listed below.

There must be a period of direct supervision: The supervising physiotherapist must complete a period of direct supervision so that they can assess the support worker’s technical and non-technical skills in the delivery of physiotherapy services. This includes assessment of the skills required to deliver virtual care safely and effectively.
As described in the Supervision Guide for Alberta Physiotherapists, “Historically, the College of Physiotherapists of Alberta has defined the “treatment room” to be the treatment cubicle, room, or gym. However, within telerehabilitation practice, the treatment room is seen to be the virtual treatment environment, and direct supervision can be achieved when all three parties (patient, supervisee, and supervisor) attend the treatment session virtually.”
There must be an assessment of the competency of the physiotherapist support worker: The supervising physiotherapist must take the time to assess the competencies of those they are supervising. This could include the competency related to the use of the virtual care platform, and the competencies required to provide physiotherapy services in general. The supervisor must only assign those services which the support worker can competently provide.
The supervisor must not supervise any activity that they are not competent to perform themselves: The supervisor must also recognize whether or not they are competent to deliver virtual care and which clients they are competent to work with. If they are not competent to deliver virtual services, then they must not be supervising the provision of virtual care.
The supervisor must engage in regular client re-assessment: The use of valid, reliable, objective measures is essential to evaluating the client’s progress when virtual care is provided by a physiotherapist support worker.

Physiotherapists are also expected to be familiar with general supervision expectations outlined in the Standards of Practice, Supervision Guide, and other resources found on the College of Physiotherapists of Alberta’s website.

Appendix A: Cross Border

In Canada the regulation of physiotherapists is a provincial or territorial government matter. Each jurisdiction’s regulator is responsible for registering physiotherapists, issuing practice permits, developing Standards of Practice and managing client complaints. This means that although the use of virtual care can occur across jurisdictional borders, physiotherapists need to be aware of the relevant legislation, Standards of Practice, and other requirements that apply to their practice. Physiotherapists are advised to contact the regulatory body where they are registered as well as that of the province or territory where their client is located to understand the rules that apply to the services they plan to provide before they start delivering physiotherapy services across provincial or territorial borders.

The Virtual Care Standard of Practice states that, regarding the provision of virtual care across jurisdictional borders, the physiotherapist:

Who is providing physiotherapy services virtually to clients in Alberta must be registered with the College of Physiotherapists of Alberta.
Advises the client of where they are registered.
Is aware of and complies with licensing requirements in the jurisdiction where the client is located, in addition to the physiotherapist’s primary or home jurisdiction.

If crossing international borders during the delivery of virtual care, the College’s direction is that the physiotherapist must contact the regulatory body in the other country to understand the requirements that apply to the services they plan to provide.

Your registration covers the services delivered by you when you and your client are in Alberta; however, when your client is in a different province, territory or country you need to confirm with the other jurisdiction if you require full registration, a courtesy or temporary registration, or other.

Whether your client is a permanent resident in the other jurisdiction, or has temporarily relocated, you must check in with the jurisdiction’s regulator to find out what is required of you. When communicating with the other jurisdiction’s regulator, physiotherapists are advised to be transparent and provide detailed information regarding:

The number of clients they intend to treat via virtual care in the other jurisdiction.
The nature and extent of any pre-existing therapeutic relationships between the physiotherapist and the client.
The purpose of the virtual interaction (e.g., follow up of a client previously seen in person, provision of a unique service offering not available within the client’s jurisdiction).

Appendix B: Platform Selection

The CPTA looks to the expertise of Canada Health Infoway for insight into virtual care platform specifications and assessment/selection and encourages registrants to do the same.

Digital Health Solutions Procurement Toolkit
Clinician Change Virtual Care Toolkit
Evaluation Toolkit

Selecting the best platform for your practice setting for the provision of virtual services is an important step in delivering quality, safe, and effective physiotherapy services. As stated previously, you are responsible to practice in compliance with all legislation relevant to your practice, and in the case of services provided across jurisdictional borders, you must be aware of and comply with the legislation in both jurisdictions.

You retain this responsibility when you contract with third-party service providers, including virtual care platform providers. When selecting virtual care platforms or portals, you must evaluate the system and confirm that both the system specifications and your contractual agreements with the third-party platform provider will enable you to meet your legislated responsibilities.

What should you look for in a platform?

While it is beyond the expertise of the CPTA to provide detailed information on system specifications and platform specifications, key elements to review include:

Data storage: How and where is data stored? Does the data storage comply with relevant privacy legislation requirements? What does your data storage agreement look like? How does the provider destroy data once it has passed the required timelines for retention? What is your role in the destruction of client files?
Privacy and security: What are the physical, technical, and administrative safeguards in place within the platform to provide protection of your client’s personal health information? Does the platform provide options like secure messaging, end-to-end encryption, encrypted emails, or other communication tools for booking and billing? How does the platform track your use of it? Does the platform provider or its staff have access to private patient health information?
User interface: How easy is the platform to use by your clients? This may depend on the demographic you most often treat. Consider if your minimally tech savvy client could easily access the platform and interact with you without barriers. View yourself as a user and consider how easy it is for you to schedule appointments, interact with, and treat your clients.
Integrations: Incorporation of client education and exercise programs, the ability to screen share, the ability to easily operate the camera, microphone and other technology to view and instruct the client are all important considerations. Start by identifying your needs when selecting a platform. This can depend on your level of comfort with technology, your clients’ needs and wants and the other systems the practice site has in use. What other integrations do you need to provide quality and effective care? Are there ways to improve your workflow and efficiency with client care?
Support: What support is available to support platform implementation and ongoing use, including initial training and help in the event of urgent technical issues? How are staff trained in the use of the platform? Are there limited hours or accessibility for immediate tech support if you are having difficulties?

Appendix C: Are You Ready?

Self-Assessment

Below is a checklist of items you should be considering when evaluating your own competence to provide physiotherapy services online.

Do you understand the legal and regulatory requirements to provide physiotherapy services in Alberta?
Do you understand that the legal and regulatory requirements change outside the province of Alberta and if delivering virtual care across borders must contact the jurisdiction in which your client is located, even temporarily?
Do you have specific patient safety incident policies and procedures in place specific to the risks associated with virtual physiotherapy services?
Do you have policies and resources in place for emergency contacts and onward referral procedures for your clients?
Do you have policies in place to provide effective client and family support to provide education and recommendations for your client’s treatment plan?
Do you understand the virtual care platform’s capabilities and limitations?
Do you have sufficient staff and resources to manage the administrative and technical aspects of virtual care such as scheduling, coordinating referrals, and sending communications?
Do you have policies and procedures in place to properly obtain and document the clients informed consent prior to receiving virtual care and ongoing consent during care?
Do you have procedures in place for clients, providers, and staff to provide feedback on their experience with virtual care?
Do you have sufficient technological requirements to support virtual care services, such as connectivity, platforms, computers, etc.?
Do you have the required physical space and equipment at both your site and the client’s site to ensure safe, quality and effective services that meet the privacy requirements?
Do you have privacy policies in place that address use of technical safeguards and adherence to best practices etc.?

Appendix D: Resources to Gain E-Health Competency

There are many resources available to help you deliver virtual care including: Organizing safe and effective objective measures for assessment
Building and implementing treatment plans
Building rapport and developing a positive therapeutic relationship with your virtual clients

We have provided some of these resources below to help you get started, but you are encouraged to seek out other resources as a significant number of research articles and resources are published each year. Many are available online and can be accessed for free.

Resources for Clinical Practice

Trevor Russell is a researcher from Australia who has published significant amounts of information for practitioners. You can find more information on him and his work by following this link. https://about.uq.edu.au/experts/891

Researchers affiliated with the Centre for Research in Telerehabilitation are another source of research evidence into the use of virtual technology for the remote delivery of health services.

Resources for implementation

Resources for privacy safeguards

Appendix E: Resources to Gain E-Health Competency

The Risk Management and Safety Standard of Practice requires that the physiotherapist verifies clients’ identities to confirm that the correct physiotherapy services are provided.

The requirement to verify a client’s identity is intended to prevent individuals from receiving care that is unsafe or inappropriate for their condition; however, there is also a risk of fraud and misrepresentation that is addressed by verifying a person’s identity.

All physiotherapists are expected to take appropriate steps to verify the identity of clients. Physiotherapists should also expect that their clients will want to verify the physiotherapist’s identity and credentials. This appendix provides an overview of the rationale and describes recommended measures a physiotherapist can employ to fulfill this requirement.

Why Verify Your Identity and Your Client’s Identity?

In recent years there have been instances of fraud and misrepresentation in which a member of the public has impersonated a regulated health professional. This poses a risk to the client that they are not receiving appropriate care from a duly qualified physiotherapist or other regulated health professional. It is important that clients be able to verify that their health providers are who they claim to be.

Health benefits fraud, including identity fraud, is increasing.^10,11 Physiotherapists are encouraged to verify their clients’ identities at the start of the physiotherapy relationship. The purpose of verifying the client’s identity is:

To ensure that the client receiving care is who they say they are.
To help mitigate fraudulent billing to third party payers, and harm to insurance beneficiaries (e.g., in the case of misappropriation of benefits).
To ensure that any physiotherapy documentation that ultimately becomes part of the provincial electronic medical record is added to the correct person’s health record.

Reasonable Measures

As with other risks in practice, physiotherapists are expected to employ reasonable measures to mitigate identified risks. What constitutes a reasonable measure to verify a person’s identity can vary depending on practice setting and the context of practice. For example, the virtual care environment can make it easier for individuals to misrepresent their identities and can pose challenges to verification of both client and physiotherapist identities.

In contrast, in smaller communities where a physiotherapist may know and have long-standing relationships with their clients as peers, neighbours or community members, identity verification may be less of a concern. However, it is important that all physiotherapists consider the risks in their practice setting and context and what constitutes reasonable identity verification to address those risks.

How Can a Client Confirm a Physiotherapist’s Identity?

All health professionals are encouraged to introduce themselves following the N.O.D. principle of providing their name, occupation and duty (e.g., I’m Julia, I am the physiotherapist who will be assessing your knee today).¹² This provides clarity to the client, so they know that they are speaking with their health professional and not an administrative support person, for example. Displaying your official workplace identification, if these exist in your practice setting, can also help the client to verify that you are who you say you are.

Both the College and physiotherapists themselves need to encourage clients to confirm the registration status, credentials, and practice locations of the physiotherapist by reviewing the information available on the “Verify a Physiotherapist” portion of the College’s website.

With in-person service delivery, the Verify a Physiotherapist information, paired with a receipt with the physiotherapist’s registration number and the correlation between the physiotherapist’s reported practice locations and the location where services were delivered, when combined, provide reasonable verification that the physiotherapist is who they report to be.

However, given that the physiotherapist’s full name, registration number, and practice location(s) are publicly available through the College’s website, there is a greater risk of impersonation in the virtual practice environment and verification of the physiotherapist’s identity within the virtual environment is not as easily achieved.

To address this concern, physiotherapists are encouraged to display their practice permit at the start of the virtual visit so that the client can verify that the person presenting themselves as a physiotherapist is indeed a physiotherapist. The practice permit is available through the physiotherapist’s member profile and is not a public document. By comparing the information on the permit, including the physiotherapist’s registration number, against the information in the Verify a Physiotherapist database the client can reasonably verify the physiotherapist’s identity.

Physiotherapists are cautioned against distributing copies of their practice permit.

Another option is for the physiotherapist to display their physiotherapy entry to practice degree, provided the name on the degree matches the name on their practice permit. The degree, when combined with the information in Verify a Physiotherapist can be used to reasonably verify the physiotherapist’s identity.

How Can a Physiotherapist Confirm a Client’s Identity?

In the public health system, the recognized practice for confirming an client’s identity involves viewing the client’s government issued identification at the time of registration. In the public health system, this process typically involves an administrative staff member reviewing the adult client’s government issued identification and Alberta Health Care Card at the time of admission. (For clients who are under age 18, it is typical to view only the client’s Alberta Health Care Card.) Part of this process involves checking for the validity of the identification by checking known features of the document type such as holograms, watermarks, and logos.¹³

Physiotherapists working in the private sector are encouraged to consider their current processes for identity verification during new client intake. It is recommended that the physiotherapist or a designated staff member engage in a comparable practice to that of the public sector by viewing the client’s government issued identification and Alberta Health Care Card or third-party insurance card to confirm the client’s identity.

Another accepted identity verification method involves comparing the information in a secure database (e.g., a client’s AHS electronic health record, Netcare) against the client’s verbally reported information (i.e., asking the client to state various patient identifiers like their full name and date of birth and confirming that the information matches what is recorded in the database.) If a private sector physiotherapy practice has access to a secure database, they can also consider using the client’s verbal report as described above to verify their client’s identity. This approach can be employed for identity verification in both in-person and virtual practice environments; however, many private practice settings do not have access to this type of database.

Using Government Identification to Verify Client Identities in Virtual Care

While it may be possible to review a driver’s license in person and check for the validity of the document, how can this be achieved in virtual practice?

The Law Societies of British Columbia and Ontario and the Government of Canada have all published recommendations for verifying a person’s identity during a virtual interaction. These recommendations involve having the client scan their government issued identification and following a process to authenticate that identification by using a technology to compare features of the scanned document (such as holograms, watermarks, and barcodes) against the known features of the document type.^14,15,16

The recommendations stemming from the legal and financial sectors are informative as physiotherapists consider the range of measures available to verify client identities in virtual care. However, the College recognizes that the risks encountered in these sectors (e.g., money laundering, misappropriation of trust funds) differ significantly from the risks encountered in physiotherapy practice. The College’s perspective is that the measures employed by registrants to verify client identities should match the risks encountered in physiotherapy practice and be feasible for physiotherapists and patients alike.

Recommendations

The College recommends employing one of the following approaches to verify client identities at the start of the patient-physiotherapist relationship:

When interacting in person with clients, ask to see government issued identification to confirm the client’s identity (e.g., driver’s license and Alberta health care card).
In the virtual environment, request that the client display two pieces of identification that include their name, date of birth or address (e.g., Alberta Health Care Card, Third Party Insurer Card, driver’s license or government issued photo identification, or a bill).
If the physiotherapist has access to secure databases that contain patient health and registration information, have the client state at least two (2) patient identifiers (e.g., name, date of birth) and confirm that the information provided matches the information recorded in the database.

References

The Conference Board of Canada. The Market Profile of Physiotherapists in Canada. 2017. Ottawa. https://physiotherapy.ca/app/uploads/2022/08/8695_profile-of-physiotherapists-in-canada_br.pdf
Koebisch, SH., Rix, JM., Holmes, MM. Recruitment and retention of healthcare professionals in rural Canada: A systematic review. Canadian Journal of Rural Medicine 25(2):p 67-78, Apr–Jun 2020. DOI: 10.4103/CJRM.CJRM_43_19
Seuren LM, Gilbert A, Ramdharry G, Walumbe J, Shaw SE. Video analysis of communication by physiotherapists and clients in video consultations: a qualitative study using conversation analysis. Physiotherapy. 2024;123:30-37. doi:10.1016/j.physio.2023.10.002
Haines KJ, Sawyer A, McKinnon C, Donovan A, Michael C, Cimoli C, Gregory M, Berney S, Berlowitz DJ. Barriers and enablers to telehealth use by physiotherapists during the COVID-19 pandemic. Physiotherapy. 2023 Mar;118:12-19. doi: 10.1016/j.physio.2022.09.003
Office of the Information and Privacy Commissioner of Canada. The Personal Information Protection and Electronic Documents Act (PIPEDA). Available at https://www.priv.gc.ca/en/privacy-topics/privacy-laws-in-canada/the-personal-information-protection-and-electronic-documents-act-pipeda/r_o_p/02_05_d_26/. Accessed October 24, 2024.
National Institute of Standards and Technology, US Department of Commerce. Small business cybersecurity corner: Multi-factor authentication. (2022). Available at https://www.nist.gov/itl/smallbusinesscyber/guidance-topic/multi-factor-authentication. Accessed Oct 29 2024
Wright HH, O’Shea MC, Sekula J, Mitchell LJ. Assessment of communication skills using telehealth: considerations for educators. Front Med (Lausanne). 2022 Aug 1;9:841309. doi: 10.3389/fmed.2022.841309
Danaher, T. S., Berry, L. L., Howard, C., Moore, S. G., & Attai, D. J. (2023). Improving How Clinicians Communicate With Clients: An Integrative Review and Framework. Journal of Service Research, 26(4), 493-510. https://doi.org/10.1177/10946705231190018
Curran V, Hollett A, Peddle E. Training for virtual care: What do the experts think? Digital Health. 2023;9. doi:10.1177/20552076231179028
Araullo K. Canadian insurers face gaps in fraud detection – Gen Re. November 28, 2024. Reinsurance News. Available at https://www.insurancebusinessmag.com/reinsurance/news/breaking-news/canadian-insurers-face-gaps-in-fraud-detection--gen-re-515856.aspx#:~:text=By%20Kenneth%20Araullo,higher%20functioning%20in%20disability%20claims. Accessed March 12, 2025.
Medavie Blue Cross. Fraud requires extra vigilance to protect benefit plans. March 17, 2022. Available at https://www.medaviebc.ca/en/insights/posts/protect-benefit-plans-from-fraud#:~:text=Fraud%20Requires%20Extra%20Vigilance%20to%20Protect%20Benefit%20Plans,-Posted%20by%20Medavie&text=Technology%20is%20an%20indispensable%20tool,mere%20fraction%20of%20the%2. Accessed March 12, 2025.
Alberta Health Services. Virtual Health Recommendations: Provider and patient identity verification in virtual care. Available at https://www.albertahealthservices.ca/assets/info/ppih/if-ppih-covid-19-vh-patient-provider-ident-ver.pdf. Accessed March 12, 2025.
Alberta Health and Alberta Health Services. Provincial registration standards and practices manual. Version 4.0 (2020). Available at https://open.alberta.ca/dataset/ee7ec79b-9d1a-4151-ae79-784b7489b772/resource/4328fa96-7a27-4163-9ce8-06f4953e01e6/download/health-provincial-registration-standards-and-practices-manual-version-4.pdf. Accessed March 12, 2025.
Law Society of British Columbia. Practice Resource: Guidance for virtual verification of your client’s identity using government-issued photo ID and technology. Available at https://www.lawsociety.bc.ca/Website/media/Shared/docs/practice/resources/CIV-virtual-verification.pdf. Accessed March 12, 2025.
Law Society of Ontario. Virtual verification with authentication method. (2024). Available at https://lso.ca/lawyers/practice-supports-and-resources/topics/the-lawyer-client-relationship/identification-and-verification/virtual-verification-of-client-identity. Accessed March 12, 2025.
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Page updated: 02/04/2025

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