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COVID-19 Guidance – Providing virtual care to patients

This temporary guidance is applicable for the duration of the COVID-19 pandemic and should not be used to normalize the practice of using virtual care and not seeing a patient personally. It should instead be used permissively in exceptional circumstances given the COVID-19 pandemic.

Page last updated on April 6, 2020, at 3:45 p.m. MT.

Background

As a result of the ongoing COVID-19 pandemic, ACP recognizes that seeing a patient personally may not be possible or advisable given the requirements of physical distancing and self-isolation. As community acquired cases of COVID-19 continue to rise, use of virtual care has the potential to reduce unnecessary patient contact in pharmacies where patients may put themselves, other patients, and pharmacy staff at risk. The use of virtual care provides pharmacists and pharmacy technicians the opportunity to interact with patients who are positive for COVID-19, those in self-isolation, and those who wish to minimise contact with others. This is an especially important consideration to support physical distancing between elderly or vulnerable patients.

The Standards of Practice for Pharmacists and Pharmacy Technicians (SPPPT) require that certain activities occur in person with the patient present. In order to meet patient needs and to help reduce the risk of exposure to pharmacy staff during the COVID-19 pandemic, ACP has provided temporary approval for pharmacists to prescribe without meeting the requirements noted in SPPPT 2.6, 12.2(a), 13.2(a), and 14.2. Despite this, pharmacists must use their professional judgement to determine if they can complete an appropriate assessment to make an informed decision and prescribe a treatment for a patient without seeing them.

ACP does not currently have a standard or guidelines to accommodate virtual care. If regulated members choose to use virtual technologies to provide patient care during the pandemic, nothing in this guidance relieves a pharmacist from their obligation to meet the Code of Ethics (CoE), all other applicable standards in the SPPPT, and all applicable privacy requirements, such as in the Health Information Act. Risk-based discretion must be exercised and, above all else, the pharmacist must

  • adhere to the principles of the Code of Ethics,
  • ensure the needs of the patient are placed first and foremost, and
  • take all reasonable steps to safeguard and prevent harm to patients.

Definitions

Virtual care - In pharmacy, any professional interaction between a regulated member and a patient that occurs remotely using an enabling technology.

Guidance for applying virtual care into practice

General

Virtual care may be considered when it is not practical or advisable for the patient or the patient’s agent to receive services at the pharmacy personally, or alternative options for distance delivery are not feasible or advisable.

Pharmacists or pharmacy technicians who provide virtual care must meet or exceed all applicable standards, guidance, and legislative requirements for in-person care. It is expected that pharmacists and pharmacy technicians will always use the Code of Ethics to guide them, practice within the scope of their training and expertise, and act in the best interest of their patients. 

A regulated member who provides virtual care must

  • take all reasonable steps to safeguard and maintain patient confidentiality, and
  • ensure that the means by which the regulated member is providing virtual care is functioning properly and maintains adequate connectivity to support the assessment or professional service provided.

Evaluate virtual care technologies

Virtual care is enabled by technology that permits the communication of health information between remote locations. Health-specific platforms are usually regulated (privacy and security compliant), while more readily available consumer applications are unregulated and do not provide health system-level privacy and security compliance. ACP recognizes that community pharmacies may not have access to regulated platforms, and in the extraordinary circumstances posed by the pandemic, the short-term use of unregulated virtual care technology may be justified. If an unregulated platform is used, encrypted applications are preferential to unencrypted applications.

A list of common virtual communication platforms that are not regulated includes (but is not limited to)

  • Skype and Teams by Microsoft,
  • FaceTime by Apple,
  • Zoom Basic (Zoom also has a regulated platform),
  • Google Hangouts,
  • WhatsApp by Facebook, and
  • Doxy.me.

These platforms are not secure and the benefits of using them must be weighed against the risks to privacy and confidentiality. Information transmitted using unregulated platforms should also be kept to a minimum and not include any unnecessary patient information. Texting and unencrypted emails must not be used to transmit personally identifying health information.

Pharmacists and pharmacy technicians must familiarize themselves with the security features and limitations of any virtual care technology used and must continually ensure their understanding and knowledge of these platforms is current and up to date.

Notify the Office of the Information and Privacy Commissioner (OIPC)

If a pharmacist is considering virtual care practices that have not been part of the pharmacy’s privacy impact assessment and that may have implications to patient privacy, OIPC requests that pharmacists notify the commissioner. This notification can be sent through email to OIPC and should include details of the virtual care program including security risks and safeguards for health information. More details can be found here.

Develop temporary policy and procedure

Before using virtual care, pharmacy licensees must develop appropriate temporary policies and procedures that specify

  • which technologies and equipment will be used,
  • how to maintain and ensure privacy and security training, and
  • a contingency plan for interruptions in data transmission and for confidentiality breaches.

Requirement to have onsite supervision

Regardless of whether a pharmacist or pharmacy technician chooses to provide virtual care to patients, per section 11.1 of the Pharmacy Drug Act, the licensee must ensure that a pharmacist is always present and supervising the practice of pharmacy when the public has access to the pharmacy.

Establish a professional relationship with the patient

Pharmacists must establish and maintain a professional relationship with each individual for whom they provide virtual care. Establishing a professional relationship means the pharmacist must speak directly with the patient, their agent, or their caregiver to

  • identify the health priorities of the individual,
  • determine what the patient understands about their medication and their condition, and
  • gather information about their health history and current medication use.

Whether the patient is new to the pharmacy, or if a pre-existing patient relationship exists, the pharmacist must confirm the identity of the patient or their agent before providing virtual care.

Obtain consent

Before providing any pharmacy services to a patient, a pharmacist must always obtain informed consent from the patient. A pharmacist must obtain two forms of informed consent before providing virtual care to a patient: informed consent to receiving [or “the provision of”] virtual care and informed consent to the collection, use, disclosure and storage of health information through the technology used to provide virtual care. Both forms of consent may be provided verbally, and both must be documented in the patient record of care. Pharmacists must confirm the patient understands and acknowledges the risks of virtual care, and if the patient does not agree to receive pharmacy services by virtual care, the pharmacist must provide other options, including transfer of care to another pharmacy.

Informed consent to virtual care

Pharmacists must confirm the patient understands and acknowledges the risks of virtual care and obtain the consent of the patient to receive care virtually.

Pharmacists must ensure that patients understand that virtual care limits the ability of the pharmacist to conduct a physical examination. This may prevent them from conducting an optimal assessment and, as a result, they may not be able or willing to perform certain patient care activities such as prescribing.

Informed consent to privacy aspects of virtual care

When providing virtual care to a patient, additional patient confidentiality concerns arise from the use of technology.  When using a virtual platform for health purposes, a pharmacist must ensure that they have explained the risks of using the technology and have obtained informed patient consent to use the technology from a patient confidentiality perspective. This is especially important if a pharmacist is using an unregulated technology.

At a minimum, a pharmacist using unregulated technology is expected to identify the platform being used and, before providing care, explain the risks and benefits of the technology, including that:

  • These technologies are being used as an extraordinary measure during the COVID-19 pandemic when regulated technology is not readily available. The need to keep people from congregating or attending pharmacies where they may be exposed to the COVID-19 virus may outweigh the risk of personal privacy breaches on both a personal and population health basis. If virtual care cannot be provided, it may not be possible for the pharmacist to provide care to the patient.
  • Unregulated virtual care technologies increase the risk that the patient’s personal health information may be intercepted or disclosed to third parties.
  • Virtual platforms including video, emails, calls, or texts are not secure in the same way as visiting a pharmacy in person.
  • The patient can help protect their privacy by using a private computer/device (i.e., not an employer's or third party's computer/device), a secure account, and a secure internet connection.

Further information on informed consent can be found on page 21 of ACP's Helping pharmacists and pharmacy technicians understand the Health Information Act.

Consent needed to record virtual care encounters

Pharmacists should not record virtual care encounters unless they have the informed consent of the patient and can ensure the information is kept secure from access by third parties.

Documenting consent

Consent may be provided verbally or in writing and patient consent must be documented in the patient record of care. Consent must be received and documented by the attending pharmacist at every virtual patient encounter. An example might include the following: “<Name of pharmacist > provided <patient name> with information concerning the risks and benefits of providing virtual care. Before giving consent, the patient confirmed that the patient understood

  1. the risks and benefits associated with the provision of care through <virtual technology> ;
  2. the risks to the confidentiality of the patient’s health information associated with the use of <virtual technology>, including the risk of unauthorized disclosure or interception of personal health information; and
  3. the steps the patient should take to help protect their confidential information, including health information in using electronic technology.”

Assessment

When pharmacists assess a patient using virtual care, they must use their professional judgement to determine if there is enough information available to them to make a sufficiently informed decision. If it is determined that a patient requires a physical assessment, or otherwise cannot be adequately and safety assessed using virtual means, other options must be considered.

When assessing using virtual care, pharmacists must:

  • Consider the limitations of the technology or method of communication used and evaluate the clinical activity being conducted to ensure the pharmacist can reasonably
    • access any information required to make a clinical assessment,
    • complete a thorough clinical assessment of the patient,
    • identify and take appropriate action for any drug therapy problems,
    • conduct follow up on the care they have provided, and
    • ensure the privacy and confidentiality of the patient are maintained.
  • Reflect on whether they have the knowledge and information necessary to treat the patient’s condition. If not, they must determine whether to consult with, collaborate with, or refer the patient to another member of the patent’s health team or an alternative

If it is determined that it is appropriate to proceed, the pharmacist must then perform a thorough patient assessment, including reviewing patient health information on Netcare and the pharmacy patient record, and proceed in accordance with the SPPPT and the CoE.

Documentation

In addition to the documentation required by the SPPPT, a pharmacist or pharmacy technician who delivers virtual care must document

  • the reason for providing virtual care services;
  • the time, date, and method of technology used to provide virtual care services;
  • any disruptions in service that occurred, and the actions taken as a result; and
  • confirmation of the patient’s verbal consent to be assessed using virtual technology.

Sending prescriptions by text or email

Prescriptions may only be transmitted from a prescriber to a pharmacy by a secure means approved by ACP. Prescriptions may not be emailed to pharmacies from prescribers or from patients.

Relevant standards and legislation

Standards of Practice for Pharmacists and Pharmacy Technicians

Standard 2

Pharmacists and pharmacy technicians must establish and maintain professional relationships with their patients.

Standard 2.6

Nothing in this standard relieves a pharmacist or a pharmacy technician from the duty to see a patient personally where specifically required elsewhere in these standards.

Standard 12.2

A pharmacist who renews a prescription under Standard 12.1 must:

  1. see the patient personally before renewing the prescription, and
  2. only prescribe the minimum amount of the drug necessary to give the patient sufficient time to attend the pharmacy that dispensed the original prescription or see the prescriber of the original prescription.

Standard 13.2

In determining whether it is appropriate to prescribe for emergency purposes, a pharmacist must:

  1. personally see and assess the patient,
  2. explain the basis on which they intend to prescribe and obtain the patient’s informed consent,
  3. obtain sufficient information about the patient’s health status and disease or condition to make the decision to prescribe,
  4. assess whether the prescription will cause a drug therapy problem,
  5. be satisfied that the prescription will not place the patient at increased risk,
  6. be satisfied that the intended use of any drug or blood product prescribed is for an approved use as described in Standard 11.6, and
  7. comply with any directions of Council in relation to prescribing in an emergency.

Standard 14.2

A pharmacist who prescribes a Schedule 1 drug or blood product for a patient at initial access or to manage ongoing therapy must:

  1. see the patient personally at the time of prescribing,
  2. have seen the patient personally in the past and have developed a professional relationship over a period of time, or
  3. have a strong collaborative relationship with a regulated health professional acting within the scope of their profession who regularly sees the patient in person.

Pharmacy and Drug Act

Pharmacist in attendance - Section 11.1

Unless the regulations authorize otherwise, a licensee must ensure that there is always a pharmacist who is registered in either the clinical register category or the courtesy register category of the college’s regulated members register present and supervising the practice of pharmacy at the licensed pharmacy when the public has access to the licensed pharmacy.