Guidance: Remote (Virtual) Services, 2024

The use of technology to deliver healthcare services has become increasingly prevalent as an alternative or addition to in-person services. Remote services (also known as “telepractice,” “online care,” or “virtual care”) involve using information and communication technologies to provide occupational therapy services when clients and occupational therapists are not together in-person (World Federation of Occupational Therapists, 2014). Remote services can include phone calls, video conferencing, or other technology-assisted formats. Although this document is a resource for occupational therapists providing clinical services remotely, some elements may be 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. Occupational therapists should ensure that they are taking all reasonable measures to prevent adverse client outcomes during the provision of remote services.

Occupational therapists must meet the same professional obligations for services delivered remotely as for in-person services and determine what activities can safely and appropriately be offered remotely while prioritizing the client’s best interests. The College expects occupational therapists to follow the Standards of Practice and cross-jurisdictional regulatory requirements and remain informed about remote 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 remote services and determine whether remote service delivery will effectively address the needs of their clients.

When deciding on the appropriateness of remote services, occupational therapists should consider:

• Client factors, such as the client’s physical, behavioural, cognitive, and sensory abilities as well as digital literacy skills
• Environmental factors, such as physical space, supports available, safety, and privacy
• The nature of the service and the occupational therapist’s role
• Client choice and preference
• Availability and accessibility of technology (internet connectivity and device access) for both the occupational therapist and the client

When exploring remote services further, occupational therapists should:

• Take a collaborative approach with clients or substitute decision-makers by discussing available service options, such as in-person, remote, or a hybrid style. Promoting access to safe and effective care should be a part of the decision-making.
• Consider the limitations of remote services. Tools and approaches may need to be adapted for remote implementation. When making clinical decisions, document any limitations of remote service provision.
• If the client or the occupational therapist is located in another jurisdiction (outside of Ontario), be familiar with, understand, and follow their organization’s policies and procedures about remote services and any regulatory requirements.
• If remote services are no longer meeting the client’s healthcare needs, consider using alternative resources or referring the client to qualified healthcare providers in the client’s location.

Consent conversations for remote services should cover the same elements as for in-person services, which are outlined in the Standard for Consent, including knowledgeable consent for collecting, using, and disclosing personal health information (PHI).

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

• Any adjustments or modifications to the service plan
• Any restrictions around recording online sessions
• Consents for emergency contacts and procedures
• Any involvement by others in remote occupational therapy services and their role (for example, occupational therapy assistants and students, vendors, caregivers, and interpreters)
• Any fees associated with the remote services
• Risks, benefits, and limitations of remote services
• Risks and limitations associated with the use of technology and the particular platform
• Communication protocols during a virtual session

Occupational therapists who want to offer remote services to clients outside of Ontario are encouraged to contact the regulatory authority in that region, because other jurisdictions may have different requirements for providing remote services. This suggestion to contact the regulatory authority applies whether clients are temporarily or permanently located outside of Ontario. Similarly, occupational therapists who want to provide remote services while they themselves are located outside of Ontario also need to contact the regulator in that region and comply with any local requirements. Nonetheless, occupational therapists registered in Ontario are accountable to COTO. If a concern or complaint is put forth about their services, COTO is responsible for investigating.

Occupational therapists providing remote services to clients in a different jurisdiction are expected to do the following:

• Confirm regulatory requirements in the jurisdiction where the occupational therapist and the client will be located.
• Confirm the client’s identity and current location at every session.
• Inform the client of the occupational therapist’s location, the regulatory College where they 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 on the College webpage.
• Practise only within the limits of the license (registration) in the province or country where the occupational therapist is registered.
• Follow the regulatory code of ethics and applicable professional standards and guidelines in the province or country where the occupational therapist is registered.
• Ensure that professional liability insurance provides coverage for remote activities with clients located in other provinces or countries.
• Ensure that the occupational therapist has obtained adequate information about resources in the client’s current location.
• Discuss any additional risks and benefits of receiving remote services from an occupational therapist working from a different province or country.
• Have a contingency plan should remote services no longer be appropriate.

The most up-to-date information on jurisdiction for remote services can be found on the College’s webpage on Virtual Services.

Safeguarding PHI is critical. Under the Personal Health Information Protection Act, 2004, occupational therapists offering remote 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 (as needed) and share any remote 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 (2021a) in its entirety.

Occupational therapists should be prepared to respond in the event that a privacy breach occurs during a remote session. To learn more about what steps to take if a privacy breach occurs, occupational therapists should review College information here: New Requirements for Reporting Privacy Breaches in Effect October 1, 2017. The Information and Privacy Commissioner of Ontario also has a resource titled Responding to a Health Privacy Breach: Guidelines for the Health Sector (2021b). Finally, occupational therapists should be familiar with their organization’s policies and procedures on privacy breaches.

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 remote services, occupational therapists must understand the technology’s capabilities and limitations and its security for both clients and therapists. Occupational therapists must ensure that the technology used in remote practice is sufficient for them to communicate effectively, conduct safe healthcare services, and form an accurate professional opinion.

Before proceeding with remote services, occupational therapists are encouraged to consult with individuals with expertise in technology security, to ensure that client information is protected from theft, loss, and unauthorized access, use, and disclosure. If using third party information technology service providers to deliver remote services, occupational therapists should ensure that the service providers comply with the privacy and security measures outlined in privacy legislation.

The College cannot recommend specific virtual platforms or technologies for the delivery of occupational therapy services. However, the College expects that any platform chosen for online services will adhere to privacy legislation (for example, the Personal Health Information Protection Act, 2004). Occupational therapists should communicate with employers about approved virtual platforms. Occupational therapists can also seek assistance from resources such as Ontario Health’s Virtual Visits Verification Standard (2023).

Adverse or unanticipated events such as medical emergencies or the deterioration of a client’s physical, emotional, or cognitive condition may occur during a remote session. Prior to initiating a session, an occupational therapist should confirm the client’s current location or address and have a plan or protocol in place to deal with unexpected events (for example, emergency contact information or the number for local first responders in the client’s current location). If technical difficulties arise, the occupational therapist should ensure that they have technical support or a plan to quickly recontact the client.

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

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

As with all services, occupational therapists must establish and maintain professional boundaries with clients and follow the Standard for Professional Boundaries and the Prevention of Sexual Abuse when providing remote services. Remote practice brings the potential for more informal interaction. Occupational therapists should be alert to signs of boundary crossings and continuously monitor self-behaviours. This monitoring includes avoiding excessive displays of their own personal life, which may shift the dynamics of the therapeutic relationship. Finally, occupational therapists should avoid communicating with clients using personal email addresses, social media platforms, and other 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 access code for each session or a secure password.

Other ideas include:

• Suggesting that participants be in a private location during the session
• Asking participants to display only their first names in the platform
• Asking that participants mute their microphone when not participating
• Setting expectations around the use of cameras and platform dialogue functions
• Being clear about any recording restrictions

As with in-person services, occupational therapists must maintain their accountability and responsibility in the supervision of students and occupational therapy assistants if they are involved in remote service delivery. Remote supervision has limitations. For example, if a student or occupational therapy assistant is physically present with the client but the occupational therapist is providing services remotely, the therapist will be unable to provide hands-on assistance or modifications or physically assist with safety issues during a treatment session. Internet connectivity or camera angles may also present challenges. Occupational therapists must follow the Standard for the Supervision of Students and Occupational Therapy Assistants and determine whether client care can be delivered safely by students or occupational therapy assistants under this model of supervision.

College of Occupational Therapists of Ontario. (n.d.). Concerns or complaints about an occupational therapist. https://www.coto.org/clientsandthepublic/questions-concerns-complaints

College of Occupational Therapists of Ontario. (n.d.). Providing virtual (remote) services. https://www.coto.org/registrants/practice-support/virtual-services

College of Occupational Therapists of Ontario. (2017). New requirements for reporting privacy breaches in effect October 1, 2017. https://www.coto.org/news/news-details/2017/09/19/reporting-privacy-breaches

College of Occupational Therapists of Ontario. (2023). Standard for Consent (Rev. ed). https://www.coto.org/standards-and-resources/resources/standard-for-consent-2023

College of Occupational Therapists of Ontario. (2023). Standard for Professional Boundaries and the Prevention of Sexual Abuse (Rev. ed.). https://www.coto.org/standards-and-resources/resources/standard-for-professional-boundaries-and-the-prevention-of-sexual-abuse-2023

College of Occupational Therapists of Ontario. (2023). Standard for Record Keeping (Rev. ed.). https://www.coto.org/standards-and-resources/resources/standard-for-record-keeping-2023

College of Occupational Therapists of Ontario. (2023). Standard for the Supervision of Students and Occupational Therapy Assistants (Rev. ed.). https://www.coto.org/standards-and-resources/resources/standard-for-the-supervision-of-students-and-occupational-therapy-assistants-2023

College of Occupational Therapists of Ontario. (2023). Standards of Practice (Rev. ed.). https://www.coto.org/standards-and-resources/resources/standards-of-practice-2023

Information and Privacy Commissioner of Ontario. (2021a). Privacy and security considerations for virtual health care visits: Guidelines for the health sector. https://www.ipc.on.ca/wp-content/uploads/2021/02/virtual-health-care-visits.pdf

Information and Privacy Commissioner of Ontario. (2021b). Responding to a health privacy breach: Guidelines for the health sector. https://www.ipc.on.ca/wp-content/uploads/2018/10/health-privacy-breach-guidelines.pdf

Ontario Health. (2023). Virtual visits verification standard. https://www.ontariohealth.ca/system-planning/digital-standards/virtual-visits-verification

Personal Health Information Protection Act, 2004, Statutes of Ontario (2004, c. 3, Sched. A). Retrieved from the Government of Ontario website: https://www.ontario.ca/laws/statute/04p03

World Federation of Occupational Therapists. (2014). World Federation of Occupational Therapists’ position statement on telehealth. International Journal of Telerehabilitation, 6(1), 37–39.