Virtual Practice FAQs

Virtual practice is the provision of physiotherapy services at a distance, by an information or communication technology such as video conferencing, when an in-person visit is not possible. 

A patient can expect the same safe, effective, and ethical care as an in-person visit and the physiotherapist must comply with all regulatory requirements.  

Virtual practice may be appropriate if the patient cannot easily access an in-person visit due to a shortage of physiotherapy services available in the region where the patient lives or because of transportation or mobility concerns. Physiotherapists should use their professional judgment to determine if this model of care is the most appropriate available method to deliver physiotherapy care and that the patient is not exposed to any increased risk. Patients and physiotherapists alike need to recognize any limitations that virtual practice services present including privacy of personal health information, safety of the patient within the context of their home or work environment and the inability to perform a hands-on assessment and subsequent treatment. 

Virtual practice may be appropriate if a patient cannot easily attend in-person sessions because of things like a shortage of physiotherapists in their region, transportation or mobility issues, or a health pandemic that discourages physical contact. As regulated health professionals, physiotherapists must use their judgement to decide if virtual practice is an appropriate way to deliver safe and effective care to their patient.

Also check out the Canadian Alliance of Physiotherapy Regulators Guidelines for Telerehabilitation. 

PTs should ask themselves the following questions before making the decision to use virtual care with their patients:

 •  Do you have the skills and training to provide remote physiotherapy?

 •  Have you chosen a virtual platform that meets your legal, regulatory and privacy requirements?

 •  Do you have access to a space that is safe and will work well to deliver virtual care? Is it private and will you be able to safeguard your patient’s health care information during the session?

 •  If the patient is located in another province, are you registered to practice in that jurisdiction?

 •  Do you understand the how the College’s Standards apply in this setting?

 •  Can you confirm the patient’s identity?

 •  Are you prepared to manage an adverse event (a fall or medical emergency for example) should it occur while you are running a virtual session? PTs should have emergency contact information easily accessible and be prepared to call 911 and provide an address.

This list includes but is not limited to a range of different kinds of physiotherapy that can be provided remotely using technology:

1. Triaging or initial assessment (subjective and some objective components including outcome measures), ongoing assessments to monitor progress including use of objective assessment tools that are available in many software programs and apps.
2. Exercise prescription, supervised therapeutic exercise and appropriate progressions, gait assessment and re-education
3. Home-based modalities, including electrical stimulation and heat and cold applications, if the patient has the equipment at their home.
4. Self-administered techniques such as soft tissue massage or frictions under the direction of the physiotherapist, including patient education on how to do and at what intensity.
5. Support for self-management, education, coaching and reassurance for patients and for caregivers. This includes teaching patient’s families how to assist in performing stretches or guide home exercises.
6. Assessment of how patients are functioning and adapting in their home environments, including assessment of fall risks and other functional activities of daily living assessments.
7. Bracing, donning, removal and check in on fit and outcomes for bracing. 

Physiotherapists and patients partner in the care plan and collaboratively set goals. Progress during virtual visits should be tracked based on the patient-centred goals, using patient report outcome measures. This includes functional outcome measures and other measurements under the direction of the physiotherapist. Each measure should be assessed, including a predicted timeline and milestones to achieve these goals based on the identified prognosis for each unique patient.

Patients must always be able to rely on receiving safe and effective care from a physiotherapist, regardless of how the service is delivered.  

Tele-practice (also known as virtual care) has some challenges you need to plan for and in some cases attempt to mitigate. 

These include things like:

• Technology failures and challenges. Plan and practice. Be sure you have used the technology before and are comfortable guiding your patient through the process if they have questions.
• Communications limitations. You might encounter audio issues or language challenges. Be patient and approach this as an opportunity to solve new problems. 
• Medical emergencies. If your patient is experiencing a medical issue, be prepared to act. 

Yes, you are required to have liability insurance when providing virtual care (also known as tele-practice). The liability insurance requirements are the same as if you were providing in-person care.

You must meet the following liability insurance requirements:

• a minimum coverage of $5 million dollars for the annual policy period
• a liability limit of at least $5 million dollars per incident
• ·no additional terms, conditions or exclusions, other than standard
• ·no deductible
• tail insurance for a minimum of 10 years

Tail insurance means that while providing coverage for incidents occurring during your physiotherapy practice, it should also provide coverage for claims made up to 10 years after you stop practising; that is, patients may claim against your practice period after it ends.

Please check with your employer to see if their clinic or hospital has insurance coverage, and whether that coverage protects you. If it does not, it’s your responsibility to arrange your own.

Remember: If you work in multiple practice environments (at many clinics and/or hospitals), do not assume your insurance at one location covers you for the others. You may have to arrange coverage for other locations, either separately or jointly.

Liability Insurance Requirements

When choosing a technology it is important that the physiotherapist knows:

• Who can access the information.
• How to access the information.
• If the information is being recorded and saved by the technology provider and if so, how and why?
• Where the data is stored and how they manage security risks. There are legal implications if data is stored outside of Canada.
• What to do if there is a privacy breach.
• How data will be kept safe by the technology provider from loss, theft or unauthorized access.
• If the technology provider’s retention policies allow the PT to meet professional obligations.
• PTs should be aware of cyber security risks. This includes things like lost or stolen devices, insufficient protection on your devices, firewalls, virus protection, login access controls and use of unsecured Wi-Fi connections for example. PTs should take training to become competent in this area.
• How the technology works and how to troubleshoot if something goes wrong. PTs should test the equipment and practice using it before seeing patients. They should know how to use the audio and video functions and how to share their screen or files. PTs should consider creating a “how to document” outlining the steps to successfully use the technology for themselves and their patients.

The College cannot recommend a specific technology provider, but there are many available to health professionals. Be sure to look at the PHIPA and PIPEDA requirements when making your decision. 

The Ontario Telemedicine Network (OTN), Doxy, Zoom Health, Jane, Phzio, Physitrack, Physiotec, Clinicmaster, Mediseen, Dialogue and Embodia are examples of technologies that are available to physiotherapists. PTs should do their research and speak with the technology providers and peers to find a technology that addresses the issues outlined above.  

Wearable technology allows a person’s physical activities and behaviours to be monitored, as well as track physiological and biochemical parameters during daily life. Wearable technology can be used in many healthcare applications, including in physiotherapy. Examples include fitness trackers (a FitBit for example), smart health watches, and wearable ECG and blood pressure monitors.

PTs should consider the following if using wearable technology in their virtual practice:

• Ensure the patient consents to the use of wearable technology as part of their physiotherapy care.
• Patient confidentiality and data security are major concerns when using wearable devices as its challenging to ensure compliance with privacy legislation. Security must be evaluated against the relevant privacy requirements.
• Wearable devices may collect very large amounts of personal data due to their capacity for continuous data recording at high frequencies coupled with potential large population use. Not only can the data be used to improve personalized intervention, but it could also be used for analysis of population patterns. Be sure you know if the data collected could be used for things other than providing care to the patient, and ensure you inform the patient appropriately.

Wearable Technology Applications in Healthcare: A Literature Review

The consent conversation should be the same regardless of if the care is being provided in-person or virtually. The consent conversation that takes place with a patient during an assessment or treatment should include the benefits, risks, alternatives and possible outcomes should the patient not receive the treatment. The PT must get the patient’s consent to involve someone else in their care, like a PTA or student. The patient must also be informed that they have the choice to refuse care at any point during the session.

Virtual care does introduce some new elements to the consent conversation, such as:

• It might become too complicated or difficult to complete the assessment or treatment and either party can stop the session and discuss to how to move forward.
• The potential benefits, constraints, and risks of using technology. Things like privacy and security and ability to communicate during a virtual session.
• The patient should be reminded that they can ask the PT questions at any time.
• The PT should summarize the discussion at the end of the session and document this in the patient chart, including the patient’s consent.

More About Consent

Yes, it may be appropriate for physiotherapist assistants to be involved in delivering care virtually. The PTA may be in the same physical location as the patient or the physiotherapist, or may be in a virtual location. In either case, the requirements in the Working with Physiotherapist Assistants Standard apply.

The PT must get the patient’s consent to have the PTA involved in their care, ensure the physiotherapist assistant is competent to deliver the care assigned to them, and provide the appropriate level of supervision. PTs should never assign any activity to a PTA that requires any element of assessment. The invoice must include the name and job title of the physiotherapist assistant. There must be a written communication protocol that states how and when they will discuss patient care with the physiotherapist assistant, how to contact the physiotherapist, and how to contact the alternate supervisor if the physiotherapist cannot be reached.

Virtual Practice

Physiotherapists use emails and phone calls in practice even when seeing patients in-person. However, emails and phone calls may be even more important when providing virtual care. These forms of communication help with triaging, the initial assessment components, treatment progression and compliance, patient education, coaching and to reassure patients and caregivers.

Whatever mode of communication is used with patients, the PT must make sure it's appropriate, private and the relevant information is captured in the patient record. 

When providing clinical advice or treatment related information by email, the PT should consider whether it's appropriate for the patient to receive this information electronically. The patient's personal health information must be kept private and secure and should not be shared with others without patient consent or other legal authority. 

Email considerations include: An email can be inadvertently sent to the wrong person, is often accessed on portable devices vulnerable to theft and loss, can be forwarded or changed without the knowledge or permission of the original sender, and be vulnerable to interception and hacking. 

Physiotherapists should the Information and Privacy Commissioner of Ontario advice on this issue: Fact Sheet on Communicating by Email.

Physiotherapists are expected to keep records regardless of how physiotherapy care is delivered – virtually or in-person. All physiotherapists must meet the expectations outlined in the College’s Record Keeping Standard. If the PT records audio or video of the session, they must have the patient’s consent to do so and the recording should be included in the patient’s record.

Record Keeping Standard

Any information relevant to patient care should be included in the record, regardless of how it is communicated.

The specifics of telephone and email advice or information should be recorded when it relates to the patient’s condition or clinical care. Information relating to changes in symptoms, condition or treatment provided should be documented to understand the care that was provided and the impact.

For example, information from a patient who telephoned or emailed to report an exacerbation of symptoms when a new exercise was added to their home program and any advice given should be included in the record. PTs should maintain a communication log in the patient’s record. Information that does not relate to the patient’s condition or care, such as how to submit an insurance claim form or where to get recommended equipment, does not need to be documented.

Record Keeping Standard

The College does not set the fee schedule for physiotherapy care in Ontario. This includes in-person or virtual sessions. Some physiotherapists charge by blocks of time while others charge based upon the service provided. Physiotherapists are expected to be transparent when it comes to their fee schedule. 

As with other healthcare professions, and in other sectors billing for time spent, providing interventions by email or phone is reasonable.

Invoices should be an accurate representation of the service provided to the patient. If the physiotherapy session was provided virtually it should say this on the invoice. 

If the PT is unable to enter the fact that it was a virtual physiotherapy session in an electronic invoice because of the format, it should be added as a note in the patient record.

The College is aware that some third-party payors are covering virtual assessments and treatment by physiotherapists.

Some insurers will only provide coverage if the physiotherapist and the patient are in the same province. PTs should investigate this further on their own before providing care to patients. PTs should make their patients aware if they know the session will not be covered by the insurer.

Patients should also verify this information and their claim coverage with third party payors before seeing a physiotherapist virtually..

View a list of health benefit insurers that have currently indicated they cover virtual physiotherapy.

Note: It is not clear if this coverage will continue after COVID-19 is resolved.

Yes. If the patient's permanent address is in Ontario and the care can be appropriately managed virtually, the physiotherapist can continue to provide care while the patient is out of the province.

You must consider that other provinces / countries may require registration in their jurisdiction to deliver any virtual healthcare to a patient living or visiting that jurisdiction. We know it can be challenging to find details of overseas regulatory requirements.

Still, it is your responsibility to make your enquiries in the relevant jurisdiction and register if required. If you do not comply with any legal or regulatory obligations in the jurisdictions that require it, you may be subject to a complaint.

You should also contact your liability insurer to confirm that your coverage allows for out-of-country virtual care.

You can learn more about the requirements in Canadian provinces here. 

See a list of countries where physiotherapists are regulated here. 

An Independent Practice Certificate of Registration - Cross Border Physiotherapy is available to physiotherapists who currently practice in another Canadian province and who wish to provide care to Ontario patients, whether virtually or in-person.

Anyone holding a Cross Border Certificate may only provide care to Ontario patients in the following circumstances:

• If they are continuing to provide care that began in another province and the patient would benefit from continued and time-limited service in Ontario or if the services are not available in Ontario but would benefit patients.
• Physiotherapists must meet the Standards of their home province, as well as the province where they are delivering care.

A similar Certificate of Registration is available in all other Canadian provinces. View a list of all provincial physiotherapy regulators.

Or contact the College’s Practice Advice service for additional guidance. advice@collegept.org or 1-800-583-5885 ext. 241 

Learn more: Cross Border Physiotherapy

A virtual visit should include the same quality of care as an in-person session. The physiotherapist and the patient will adjust the assessment process and treatment plans to ensure that quality care is still being delivered. During virtual sessions there is no hands-on treatment and devices and modalities will not be used. 

Even though the visit is taking place virtually, the physiotherapist is still required to use the same level of knowledge, skills and judgement as they would if the session was an in-person session. 

The College does not set the fee schedule for physiotherapy care in Ontario. Some PTs charge by blocks of time and others by the service provided. There is no reason that the fee charged would be less for a virtual session than for an in-person assessment or treatment. 

There should be a note in the record and on the invoice to identify that the care was provided virtually (by tele-practice). The physiotherapist is expected to meet all of their professional obligations as outlined in the standards of the profession. 

Many interventions and modalities can be provided virtually, this includes but is not limited to:

• Triaging, initial assessment (subjective and some objective components including outcome measures), ongoing assessments to monitor progress including use of objective assessment tools that are available in many software programs and apps.
• Exercise prescription, supervised therapeutic exercise and appropriate progressions
• Home-based modalities, including electrical stimulation and heat and cold applications, as long as the patient has the equipment at their home.
• Self-administered techniques such as soft tissue massage or frictions under the direction of the physiotherapist, including patient education on how to do and at what intensity.
• Support for self-management, education, coaching and reassurance for patients and for caregivers. This includes teaching patient’s families how to assist in performing stretches or guide home exercises.
• Assessment of how patients are functioning and adapting in their home environments, including assessment of fall risks and other functional activities of daily living assessments.
• Bracing, donning, removal and check in on fit and outcomes for bracing. 

Physiotherapists partner with their patients in their care plan and practice collaborative goal setting. Progress during a virtual visit should be tracked based on the patient-centred goals using patient report outcome measures, including functional outcome measures and other measurements under the direction of the physiotherapist. Each should be assessed including a predicted timeline and milestones to achieve these goals based on the identified prognosis for each unique patient. 

A virtual initial assessment can be considered to be acceptable, depending upon the condition or injury being assessed. 

A physiotherapist must determine if a patient meet the eligibility criteria, including the ability to participate (without physical, cognitive or language barriers or technology limitations) and has given informed consent to a virtual visit. 

It is important to be aware that both the PT and the patient can stop the session at any time and recommend an in-person session. The physiotherapist must advise the patient of this at the beginning of each session. If it becomes clear during a virtual assessment that certain factors are making it too complicated or difficult to complete the assessment, either party can stop the session and determine next steps. Apps and other tools are available to assist with outcome measures and assessment protocols when delivering virtual care.

Emails and phone calls with patients currently happens in practice. They are an important part of virtual care. These kinds of communication can help with triaging, the initial components of an assessment, treatment progression and compliance, patient education, coaching and to give reassurance to patients and caregivers, as well as system navigation and other interventions.  

As with other healthcare professions and in other sectors billing for time spent providing these interventions by email or phone is reasonable.

Virtual practice is permitted by the College for all other physiotherapy care if the care provided (like any other care) meets all the College standards, and it is in the best interest of the patient. Virtual care is not new and was used by PTs before the pandemic.

Some physiotherapy may be delivered virtually in a group setting, but that does not exempt a physiotherapist from meeting all the College Standards and rules. You can see a list of those rules here.

Therefore, a physiotherapist must do things like:

• Discuss the privacy and confidentiality risks and the precautions taken with each patient.
• Get the patient's consent in the same way they would for an in-person assessment or treatment. In the case of virtual practice, they must be sure the patient understands explicitly how the assessment or treatment will work using technology.
• The PT must document the discussion they had with the patient in the patient's record.
• The Record Keeping Standard applies in the same way whether the care is delivered face-to-face, in a group, or virtually. The patient assessment, diagnosis, goals of the treatment and a treatment plan must be charted. The PT should make it clear in the patient's record and invoice if treatment was delivered virtually and in a group.
• The College cannot recommend physiotherapy fees. All costs must be transparent to the patient and have been agreed to before the service is provided. The invoice or patient record should indicate group treatment and that the treatment was delivered virtually.
• The decision as to whether something is covered by insurance, whether virtual and/or group therapy classes, is the decision of each insurance carrier.

Key take away:

If physiotherapy is delivered virtually, in a group or even one-on-one, all College standards must be met by the physiotherapist in the same way

Please, see some helpful FAQs about telerehabilitation posted on our website.