“Virtual care is any interaction between patients and/or members of their circle of care, occurring remotely using any forms of communication or information technology with the aim of facilitating/maximizing the quality and effectiveness of patient care.”

Canadian Medical Association Virtual Care Task Force Report, February 2020

Virtual Care and the Chiropractic Scope of Practice

The COVID-19 pandemic has triggered accelerated adoption and normalization of virtual care. Virtual care (sometimes referred to as Telehealth) refers to the remote delivery of care to patients using information and communications technology. Virtual care can be delivered and received using a telephone (landline, mobile phone, smartphone) and/or real-time web-based audio or video conferencing applications on computers, tablets and smartphones.

The same standards of care and professionalism apply to virtual care as to an in-person visit. Virtual chiropractic care must be within the chiropractic scope of practice, and “comply with all College of Chiropractors of Ontario (CCO) regulations, standards of practice, policies and Guidelines.”^[1]

As of January 2021, CCO guidance on virtual care is temporary and CCO indicated that it will issue permanent guidance at a future date. Effective April 17, 2020, in addition to seeing patients for follow-up visits, chiropractors are permitted to see patients virtually on a first visit, which CCO defines as a visit with “an individual who does not have a pre-existing, in-person doctor/patient relationship with the member.” CCO deemed this to be essential for the effective delivery of care: “Without obtaining initial information from the patient, members cannot be in a position to advise if the patient requires urgent/emergency in-person treatment.”

While CCO’s standard for virtual care remains temporary, regulatory colleges in Alberta, Quebec, New Brunswick, PEI, and Newfoundland have all made their virtual care directives permanent. In Ontario, the Workplace Safety and Insurance Board (WSIB) is supporting virtual care for the delivery of programs and services.

Major national insurance carriers also indicated they will continue to cover virtual care for the foreseeable future. We recommend you check insurance provider websites periodically for updates. Patients should also confirm the details of coverage for virtual care with their insurance provider.

Privacy Requirements

When using video conferencing to connect with your patients, you must ensure that it meets Personal Health Information and Privacy Act, 2004 (PHIPA) requirements, including the use of encrypted video.

Fortunately, there are many different platforms that exist to support this. Ontario MD has put together a detailed list of many of the available virtual care options, with links for more information. To view the list, please visit Ontario MD and scroll to “Video Visit Platforms Created for Medical Care.”

Virtual Care Guidelines

In addition to CCO Return to Practice Guidance and President’s Messages, excellent supplementary resources have been developed to inform the virtual delivery of neuromusculoskeletal (nMSK) care.

The Canadian Chiropractic Guideline Initiative (CCGI) has produced three documents. The first, entitled Best Practices for Telehealth/Virtual Appointments identifies eight evidence-based recommendations for care that can be delivered virtually, including:

• Screening for risk factors of serious pathology
• Assessing barriers to recovery
• Conducting clinical assessments, including a thorough health review
• Providing patient education and self-management strategies
• Monitoring patient progress

Additionally, CCGI’s Clinical Guide for telehealth is designed to support the virtual delivery of chiropractic care. Its Patients Guide to virtual care assists in preparing patients for virtual appointments.

The Interprofessional Spine Assessment and Education Clinics (ISAEC) also developed a toolkit, entitled Low Back Rapid Access Clinic: Virtual Assessment and Education Toolkit. Each of these documents provide valuable detailed information.

For a discussion of virtual medical care in the publicly funded health care system, see Virtual Care: Recommendations for Scaling Up Virtual Medical Services Report of the Virtual Care Taskforce.

Virtual Chiropractic Care Checklist

Virtual care has many advantages including: overcoming physical distancing requirements; improving access to care for patients with mobility challenges and those living in remote, rural and underserved communities; and more timely and convenient care for patients. Used appropriately, virtual care may also result in lower health care costs.[2] However, virtual care also raises unique challenges and considerations, such as patient privacy and health and safety.

In recognition of these unique dimensions of virtual care, we adapted the CCGI’s Best Practices for Telehealth/Virtual Appointments into this Virtual Care Checklist to assist you in preparing for and conducting virtual appointments.

Patient and clinician location requirements

1. Ensure there is good lighting so that you and your patient can see one another.
2. Ensure that camera/device placement enables you to see your patient’s whole body so you can observe your patient performing any exercises or other movements that may be required for assessment, diagnosis and/or treatment.

Patient and clinician technological requirements

3. Ensure all electronics are plugged in or charged.
4. Ensure the Internet connection has sufficient connection speed and signal strength to enable clear and uninterrupted communication.
5. Ensure your patient has access to wireless earbuds or adequate computer speakers so that communication can continue while demonstrating or reviewing exercises.
6. Develop a contingency plan with your patient in case of technological issues (e.g., have the patient’s telephone number to continue a videoconferencing visit as a telephone call visit in case of disruption due to an inadequate or unstable Internet connection).

Prop and equipment requirements

7. Ensure your patient is wearing clothing appropriate to the conduct of the appointment, for example, loose clothing for ease of movement.
8. Ensure that your patient has sufficient space and flooring for exercises.
9. Ensure your patient has access to any necessary props for movements or exercises (e.g. wall or chair for balance, weights, resistance bands, etc.).
10. Ensure you have capacity for coexisting documentation, including informed verbal consent, space and flooring for exercise prescription.
11. Ensure you have access to supporting documents such as pictorial or video instructions.

Health and Safety

12. Ensure your patient has inspected the area for any possible health and safety hazards (e.g. trip hazards such as toys).
13. Ensure you have the address of the location of your patient, as well as local emergency contact information for them in case an emergency arises, and no one is with your patient to contact Emergency Medical Services (EMS).
14. Consider developing a pre-virtual care video for your patient to review prior to their assessment to help them prepare for the consultation, and review expectations.

Privacy and Consent

15. Ensure your patient and you have a private, quiet, space to conduct the appointment without interruption.
16. Ensure the technology being used to conduct the virtual visit is secure.
17. Verify the identity of your new patients.
18. Inform your patients of any limitations to examination, their right to privacy, their right to opt out at any time if they feel uncomfortable, and of any risks associated with virtual care.
19.  Give your disclosure and obtain your patient’s consent if the visit is being recorded.