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 June 1, 2020, at 12:45 p.m. MT.
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.
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
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
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 must consider the following before adopting any new virtual care technologies:
Identity verification & notification
- What process is in place to reasonably confirm the identity of a patient in a manner that respects their privacy (for example, verification questions vs. scan of driver’s license)?
- How will patients be informed about the virtual care solution and any risks that may arise with its use, including what health information is being collected/retained and whether it will end up in their health record?
- Is there contact information for a patient to ask questions about the virtual care solution?
Security of the data
- Is the data secured in transmission by end to end encryption?
- Can the screen be shared without awareness of the pharmacist/pharmacy technician or patient?
- Does the service provider have reasonable safeguards in place to protect the data, including privacy policies, limits on who has access to the data, and to ensure it is physically and technically secured?
- Is the service provider required to inform the pharmacy if there is a breach?
- Is the data residing in Alberta, Canada or another jurisdiction with data protection laws?
Pharmacy access to the application & data
- What controls are in place to limit access to the application and data within the pharmacy, and are logs maintained that record accesses?
Use of the data
Management & retention of the data
- What data is retained by the service provider and for how long?
- Can the pharmacist meet legal requirements to respond to access and correction requests?
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, pharmacists must submit a privacy impact assessment (PIA) to the Office of the Information and Privacy Commissioner before implementation. Information on risks and how to mitigate them can be found in the OIPC document Advisory for Communicating with Patients Electronically
Due to the ongoing pandemic public health emergency, obtaining a timely PIA approval may be difficult. OIPC requests that pharmacists who are considering temporary new practices or systems that have implications for individuals’ privacy, at the very least, notify the Commissioner about the new practice or system via email. Pharmacists need to determine what are reasonable safeguards in these unique circumstances and be prepared to justify their decision.
Notification sent by email to OIPC should include the details of the pharmacy team’s assessment of the virtual care technology as outlined above in the Evaluate virtual care technologies section of this document. More information from OIPC on this process 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.
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.
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
- the risks and benefits associated with the provision of care through <virtual technology> ;
- 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
- the steps the patient should take to help protect their confidential information, including health information in using electronic technology.”
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.
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.
Relevant standards and legislation
Standards of Practice for Pharmacists and Pharmacy Technicians
Pharmacists and pharmacy technicians must establish and maintain professional relationships with their patients.
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.
A pharmacist who renews a prescription under Standard 12.1 must:
- see the patient personally before renewing the prescription, and
- 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.
In determining whether it is appropriate to prescribe for emergency purposes, a pharmacist must:
- personally see and assess the patient,
- explain the basis on which they intend to prescribe and obtain the patient’s informed consent,
- obtain sufficient information about the patient’s health status and disease or condition to make the decision to prescribe,
- assess whether the prescription will cause a drug therapy problem,
- be satisfied that the prescription will not place the patient at increased risk,
- 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
- comply with any directions of Council in relation to prescribing in an emergency.
A pharmacist who prescribes a Schedule 1 drug or blood product for a patient at initial access or to manage ongoing therapy must:
- see the patient personally at the time of prescribing,
- have seen the patient personally in the past and have developed a professional relationship over a period of time, or
- 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.