Virtual care is increasingly transforming the nature of healthcare, particularly with the rapid shift to telehealth and virtual care during the COVID-19 pandemic. Health profession regulators face intense pressures to facilitate virtual care while upholding their legislative mandate to protect the public. However, there are many legal and ethical complexities associated with regulating registrants who engage in virtual care. Regulatory activities in the public interest have changed to encompass the following: ensuring that standards provide necessary guidance for virtual care on topics such as consent, documentation, records management, and privacy;[1,2] changing entry-to-practice requirements to include digital competencies; facilitating interjurisdictional virtual care through reciprocal licensure, emergency licensure limited to virtual service provision, and liability insurance requirements;[3,4] and adapting continuing competence requirements and disciplinary procedures to reflect modern digital environments.[5] The need to reform regulatory practices to meet these challenges to ensure access to safe and high-quality services has become more urgent given the impact of the COVID-19 pandemic on health care and health professionals.
The mandate of health profession regulators is to protect patients and uphold the public interest. Regulators typically aim to meet this public protection mandate by setting entry to practice standards; maintaining a register of those who are licensed to practice; and monitoring and enforcing conduct, competency, and capacity in practice.[6] The goal is to protect the public against incompetence, negligence, and dishonesty by ensuring only those fit to practice safely are registered.[7] However, there has been debate and controversy about which activities should be included under this public interest mandate, and practices have varied over time.[8,9]
Virtual care is not new and over the last decade there has been increased reliance on virtual care globally.[4] However, the uptake of virtual care was accelerated by the COVID-19 pandemic. A study in Ontario, Canada found that virtual care use rose across the population, increasing from 1.6% of total ambulatory visits in the second quarter of 2019 to 70.6% in the second quarter of 2020.[10] This data is consistent with that coming out of the United States, where one study found that the update of virtual care increased from 4% before the pandemic to 35% during the pandemic.[10] This rapid scaling of virtual care is a major factor that distinguishes the regulatory response to the COVID-19 pandemic from previous public health crises or emergencies. As a result, health profession regulators face unprecedented pressure to facilitate this transition safely and effectively.
Critical to regulating virtual care is the issue of cross-jurisdictional practice. In Canada, where there is much variability in the approach to health profession regulation across provincial and territorial borders, this has been a significant barrier to equitable access to care during the COVID-19 pandemic. In the United States, where regulation is similarly under state jurisdiction, reforms have facilitated cross-jurisdictional practice during the pandemic, including modifying many in-state licensure requirements for telehealth[3] and relying on licensure compacts to enable telehealth.[11] In Canada, despite some regulatory reform around virtual care, variations in licensure requirements and scopes of practice, as well as difficulties ascertaining to which regulator professionals are accountable have continued to complicate virtual cross-jurisdictional care.[12-14]
Many reforms related to regulating virtual care were fast-tracked, but calls have already been made for regulatory frameworks to be subject to careful post-implementation reviews—a means to ensure the public is protected.[15] Others have argued that relaxing regulatory barriers during the pandemic (for example, expanding nursing scope of practice to address crisis surge capacity needs) demonstrates that these requirements were unnecessary for public protection in the first place[16] and have called for these changes to be retained even after the crisis subsides.[17,18] Whether these regulatory reforms contribute to public protection in the short, medium, and long term requires an understanding of the literature regarding regulating virtual care in the public interest.
The literature around regulating virtual care is diverse and spans health, social sciences, and law. A preliminary search of PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews, and JBI Evidence Synthesis was conducted and found no existing scoping reviews or systematic reviews on the topic. A scoping review will generate a broad overview of this topic to identify and summarize the range of evidence available.
Review Question and Objective
Our research question is: How is the public interest protected when regulating health professionals engaged in virtual care? The objective of this review is to examine the literature on how the public interest is protected when regulating health professionals engaged in virtual care, to discuss policy and practice implications related to health professional regulation of virtual care, and to make recommendations for future research.