Virtual Services

• Public Protection
• Guiding Principles
• Appropriateness of Virtual Services
• Security and Confidentiality
• Use of Technology
• Privacy Breaches
• Virtual Platforms
• Client Safety and Contingency Planning
• Jurisdiction
• Consent
• Record Keeping
• Professional Boundaries
• Group Sessions
• Remote Supervision of OTAs and Students
• Fees and Billing

The use of technology to deliver healthcare services has become increasingly prevalent as an alternative or addition to in-person services. Virtual services (formerly known as telepractice) refer to using information and communication technologies to provide occupational therapy services when clients and occupational therapists (OTs) are not together in-person (World Federation of Occupational Therapists, 2014). Virtual services can include phone calls, video conferencing, or other technology-assisted formats. Although this document is a resource for occupational therapists providing clinical services virtually, there may be some elements applicable to non-clinical services, such as privacy and security considerations for virtual meetings or the provision of education in an online workshop or webinar.

The public expects to receive safe, ethical, and competent occupational therapy services, regardless of the means of service delivery. In addition, occupational therapists should ensure that they are taking all reasonable measures to prevent adverse client outcomes during the provision of virtual services.

Occupational therapists must meet the same professional obligations for services delivered virtually as in-person, using clinical judgement to determine what activities can safely and appropriately be offered by virtual means while maintaining the client's best interest. The College expects occupational therapists to follow the Standards of Practice and remain informed about virtual service delivery, use of technology, and privacy and security measures associated with the selected virtual platform.

Occupational therapists must have the knowledge, skills, and abilities required to provide virtual services, and are best suited to determine if virtual service delivery will effectively address the needs of their clients. The appropriateness of virtual services should be based on client and environmental factors and align with the nature of the service. Client choice and preference, availability and accessibility of technology for both, and the client's physical, behavioural, cognitive, and sensory abilities must be considered. Understanding that there are limits to virtual services, occupational therapists must use their clinical judgement to decide what activities are suitable for online use. For example, occupational therapists delivering virtual services must consider whether the selection or adaptation of tools is right for online implementation. Occupational therapists should document any limitations associated with virtual service provision when making clinical decisions.

In determining the appropriateness of virtual services, occupational therapists should take a collaborative approach with clients / substitute decision-makers by discussing available options such as in-person, virtual, or a hybrid style of delivery. This could include having both in-person and virtual sessions, or when occupational therapists are gathering information in advance of, or following an appointment. Occupational therapists should be aware of resources or qualified healthcare providers in the client's location if virtual services are no longer meeting the client's healthcare needs. Occupational therapists who are employees should be familiar with, understand, and follow their employer's policies and procedures about virtual services.

Safeguarding personal health information (PHI) is critical. Under the Personal Health Information Protection Act, 2004 (PHIPA), occupational therapists offering virtual services must take reasonable measures to maintain confidentiality, protect PHI, and collect, use, and disclose only the PHI required. Protection against security and privacy attacks is a continuous responsibility, and occupational therapists should monitor and address any privacy and security threats. Occupational therapists are encouraged to develop and share any virtual service policies and procedures with clients, including details about the proposed service, along with any safeguards used to protect client privacy and confidentiality. Occupational therapists should put in place reasonable physical, technical, and administrative safeguards to protect PHI. If privacy cannot be adequately protected, in-person consultation or alternative communication technology should be used.

Occupational therapists are encouraged to review the Information and Privacy Commissioner of Ontario’s Privacy and Security Considerations for Virtual Health Care Visits (2021) in its entirety.

Occupational therapists should be proficient in the operation of the technology selected and manage unexpected interruptions or privacy breaches. When selecting technology for use in virtual services, occupational therapists must understand the capabilities and limitations of the technology, and the security of the technology for both client and therapist.

Occupational therapists must ensure that the technology used in virtual practice is sufficient to communicate effectively, conduct safe health services, and form an accurate professional opinion. Before proceeding with virtual services, occupational therapists are encouraged to consult with individuals with expertise in technology security to ensure client information is protected from theft, loss, unauthorized access, use, or disclosure. If using third-party IT service providers to deliver virtual services, occupational therapists should ensure that the service providers comply with the privacy and security measures outlined in privacy legislation.

Occupational therapist s should be prepared to respond in the event a privacy breach occurs during the virtual session. To learn more about what steps to take if a privacy breach occurs, occupational therapists should review College information here: coto.org/quality-practice/professional-conduct/privacy. The Information and Privacy Commissioner of Ontario also has a resource titled Responding to a Health Privacy Breach: Guidelines for the Health Sector (2021). Occupational therapists who are employees should be familiar with their employer's policies and procedures in the event of a privacy breach.

The College cannot recommend specific virtual platforms or technologies for the delivery of occupational therapy services. The College expects any platform chosen when providing virtual services to adhere to privacy legislation (i.e., PHIPA). Occupational therapists should be in communication with employers about approved virtual platforms. Occupational therapists can seek out assistance from other resources who may have additional information pertaining to choosing appropriate platforms for use in practice.

Adverse or unanticipated events such as medical emergencies or the deterioration of the client's physical, emotional, or cognitive condition may occur during the session. Occupational therapists should confirm the current location/address of the client. Occupational therapists should have a plan in place or develop protocols to deal with unexpected events (emergency contact information or the number for local first responders in the client's current location). If technical difficulties arise, occupational therapists should have access to technical support so they can quickly recontact the client.

The College only has jurisdiction over occupational therapy practice in Ontario. The College’s position is that “practise” occurs where the occupational therapist is located and registered, not where the client is located.

Occupational Therapists Registered in Other Provinces

Occupational therapists registered in other provinces who want to provide virtual services to clients in Ontario can do so based on their existing registration in the province they are located. However, they must be transparent with clients about where they are located and registered and must follow the rules and regulations that apply to the license they hold. Occupational therapists from other provinces must obtain temporary or general registration in Ontario to provide in-person services to clients located in Ontario.

Occupational Therapists Registered in Ontario wanting to provide Virtual Services to clients in other Provinces or Countries

Other jurisdictions may have different requirements for providing virtual services. Ontario occupational therapists should contact the regulator in the province or country where the client is located to confirm requirements to deliver virtual services.

Occupational therapists registered in Ontario who offer virtual services to clients in other jurisdictions are accountable to COTO. If there is a concern or complaint about their services, COTO can investigate.

Considerations for occupational therapists when providing virtual services to clients in a different jurisdiction (province or country):

• Confirm registration requirements in the jurisdiction where you will be practising
• Inform the client of your location and the regulatory College where you hold registration and the process to report concerns or complaints. For occupational therapists registered in Ontario, clients can be directed to information about filing a complaint here: coto.org/you-and-your-ot/questions-concerns-complaints
• Confirm client identity and current location
• Practice within the limits of the license of registration in province where you are registered
• Ensure your professional liability insurance provides coverage for virtual activities with clients located in other provinces or countries
• Ensure you have adequate information about resources in the current location of the client
• Discuss any additional risks and benefits of receiving virtual services from an occupational therapist working from a different province
• Have a contingency plan should virtual services no longer be appropriate.

Consent conversations for virtual services should cover the same elements as for in-person services, outlined in the Standards for Consent, including knowledgeable consent for collecting, using, and disclosing personal health information.

Consent discussions specific to virtual services may also need to include the following:

• Any adjustments or modifications to the virtual service plan
• Any restrictions around recording sessions
• Consents about emergency contacts and procedures
• Others involved in virtual occupational therapy services and their role (for example: occupational
therapist assistants [OTAs] or students, vendors, caregivers, interpreters etc.)
• Any fees associated with the virtual services
• Risks, benefits, and limitations of participating virtually
• Risks and limitations associated with the use of technology and other features of the platform
• Communication protocols during a virtual session

Occupational therapists providing virtual services must maintain accurate client records as outlined in the Standards for Record Keeping. This involves documenting relevant information in the clinical record, including noting what services were provided virtually, the platform used, and any supporting rationale required.

As with all services, occupational therapists must establish and maintain professional boundaries with clients and follow the Standards for Professional Boundaries when providing virtual services. Virtual practice brings the potential for more informal interaction; occupational therapists should be alert to signs of boundary crossings and continuously monitor self-behaviours. Occupational therapists should be mindful of the environment in which virtual services occur and avoid excessive displays of their own personal life, which may shift the dynamics of the therapeutic relationship. Finally, occupational therapists should be cautious and avoid communicating with clients using personal email addresses, unencrypted or unsecured cloud-based messaging or video conferencing platforms.

Occupational therapists play a critical role in ensuring individual privacy and confidentiality during online group sessions. By sharing expectations for group conduct and taking all reasonable measures to prevent unauthorized access and disclosure of information, occupational therapists will assist attendees to feel safe when participating in group formats. Occupational therapists can consider implementing options such as restricting access to only authenticated users - for example, providing a unique PIN for each session or a secure password. Other ideas include:

• Suggesting that participants be in a private area during the session
• Asking that participants mute their microphone when not participating
• Setting expectations around the use of cameras and any platform dialogue functions.

As with in-person services, occupational therapists must maintain their accountability and responsibility in the supervision of occupational therapist assistants (OTAs) and students if they are involved in virtual service delivery. Occupational therapists engaging in virtual supervision of OTAs or students should follow the Standards for the Supervision of Occupational Therapist Assistants and Standards for the Supervision of Students.

Occupational therapists must be transparent about all fees associated with virtual practice and indicate on bills that virtual services were delivered.

College of Occupational Therapists of Ontario. (2015). Standards for Professional Boundaries.

College of Occupational Therapists of Ontario. (2016). Standards for Record Keeping.

College of Occupational Therapists of Ontario. (2017). Standards for Consent.

College of Occupational Therapists of Ontario. (2018). Standards for the Supervision of Occupational Therapist Assistants.

College of Occupational Therapists of Ontario. (2018). Standards for the Supervision of Students.

Information and Privacy Commissioner of Ontario. (2021). Privacy and security considerations for virtual

Information and Privacy Commissioner of Ontario. (2021). Responding to a health privacy breach: Guidelines

World Federation of Occupational Therapists. (2014). World Federation of Occupational Therapists' position