Virtual Care Standards and Guidelines

Purpose 

The Virtual Care Standards and Guidelines for Dietitians in Ontario is meant to be used with relevant legislation, the Code of Ethics, and other College Standards and Guidelines. This document is intended to serve dietitians, the College and its committees when considering dietitian practice or conduct.
 
What are Standard statements?
Standard statements explain the minimum level of performance expectations for the professional conduct of dietitians while using virtual care, followed by a list of how the Standard is demonstrated in practice.
 
Practice Guidelines differ from Standard statements.
The practice guidelines articulate best practice suggestions for safe, competent, and ethical dietetic practice. These are “should do” recommendations versus the “must do” expectations of Standard statements.

Definition 

Virtual care (also referred to as telepractice, telehealth, e-health, e-services) provides dietetic services, including nutrition assessment and/or treatment/intervention, to clients, groups of clients, substitute decision-makers (SDM), and caregivers, using technology (such as telephone, videoconferencing or other electronic communication). Virtual care may also support collaboration with and between health care providers within the client’s circle of care.
 
Virtual care may improve health care accessibility and is often a practical option for clients who prefer not to attend appointments in-person or who cannot. Virtual care uses information technologies to facilitate or maximize the quality and effectiveness of client care across many practice areas (e.g., nutrition care, public health, private practice, etc.).

Virtual care can be synchronous (interacting with the client or substitute decision maker in real-time) or asynchronous (interaction not occurring at the same time). In general, practice obligations do not change, regardless of how care is provided. The dietitian must practise the same way they would if conducting an in-person session, recognizing no change to their professional obligations, including relevant legislation.

 

Standard Statements

Standard 1: Dietitians must take reasonable steps to ensure the appropriate use of virtual care and technology for each client.

A registered dietitian demonstrates the standard by:

  1. Assessing the appropriateness of virtual care for each client at all stages of the care process. Virtual care may not be appropriate for some clients and in some situations (e.g., a client requiring a physical assessment).
  2. Exercising professional judgment, which includes understanding the limitations of virtual care and how this impacts effective client interaction. Virtual care must align with your client’s culture, cognition, knowledge of technology, and others.
  3. Showing sensitivity, respect and understanding of client-specific factors for virtual care (e.g., client’s preference, accessibility, comfort, competence, history of use, hearing and visual abilities,language barriers/need for a translator,  access to devices/internet etc.).
  4. Ensuring that virtual care is in the client’s best interest, where the quality of care will be comparable to in-person care and potential benefits to the client outweigh any potential risks. 

Practice Guidelines

Dietitians are encouraged to:

  1. Collaborate with your clients to determine the best delivery option for care and consider client preferences and needs.
  2. Adapt assessment tools, approaches to care, resources, and communication to meet clients’ needs, be appropriate for the virtual platform, and consider clients’ progress and care plan, by keeping up with changes in virtual care technologies (advances, security features).
  3. Communicate necessary information to deliver safe, competent and ethical virtual care to clients (e.g., consent conversations, including details in your privacy policies, instructions for virtual care, software resources and support, policies for rescheduling appointments, refunds, etc.).
  4. Anticipate technical problems and disruptions and the need to change virtual care technologies. This may include but is not limited to technical issues or failures and client progress, and preferences, which may consist of a client declining virtual care.
Standard 2: Dietitians must ensure the confidentiality, privacy and security of clients’ Personal Health Information (PHI) when practising virtually.

A registered dietitian demonstrates the standard by:

  1. Taking all reasonable steps to ensure that the PHI in a dietitian’s custody or control is protected against theft, loss, unauthorized use, or disclosure, including the transmission, management, and storage of PHI securely and confidentially. 

Practice Guidelines
 

Dietitians are encouraged to:

  1. Be familiar with risks and benefits, evidence-informed and best practices around appropriate and secure technologies, privacy, virtual platforms, functions, security measures, employer requirements, and data collection.
  2. Complete a Privacy Impact Assessment (PIA) regarding collecting, using, and disclosing personal health information when deciding to use an app/platform. A PIA is a risk management tool and a process “to identify and manage privacy and information security risks associated with virtual health care.” See the Information and Privacy Commissioner of Ontario’s (IPC) Privacy Impact Assessment Guidelines for the Ontario Personal Health Information Protection Act and Planning for Success: Privacy Impact Assessment Guide.
  3. Identify administrative, technical, and physical safeguards to protect the security of PHI, and explain the functionality of virtual platforms before any virtual sessions, such as ensuring private space for both you and your client for the delivery of virtual sessions, sending client emails, and securing mobile devices when unattended. In individual and group settings, clarify with clients what PHI will be collected, used and/or disclosed. Dietitians should identify limitations (i.e., security risks) if clients disclose PHI in group settings and consider strategies for maintaining privacy and security as required. Refer to the Privacy of Personal Information Dietetic Practice Toolkit or organizational policies.
  4. Understand and address the risks of emails that include PHI — and have safeguards in place to allow for secure transmission of information.The IPC expects emails containing PHI from one health information custodian (HIC) to another will be encrypted, barring exceptional circumstances. Dietitians who are HICs or agents should use encrypted email with clients. If encryption is not feasible, dietitians should determine whether it is reasonable to communicate with clients through unencrypted email. Refer to the IPC fact sheet for details, or organizational policies.
  5. Use measures to ensure confidentiality, such as password protection, data encryption, two-factor authentication, and secure networks (e.g., encrypting a mobile device). Dietitians may wish to consult with the IPC or an information technology and/or privacy expert for up-to-date guidance and questions about technical support services, if warranted.
  6. Keep up-to-date with the requirements of the IPC and the Office of the Privacy Commissioner of Canada, including safeguards outlined in the Information and Privacy Commissioner’s Privacy and Security Considerations for Virtual Health Care Visits. 
  7. Implement a cyber security plan (e.g., security software, updates, security scans to identify and eliminate viruses, malware, spyware, etc.) and maintain good information technology practices.
  8. Work with their Health Information Custodian or Privacy Officer (as applicable) to ensure understanding and compliance with the IPC requirements. In private practice, dietitians can refer to the Privacy of Personal Information Dietetic Practice Toolkit.
  9. Ensure virtual practice policies are updated and current, and consider the risks, benefits, and limitations of virtual care and the virtual care technology (e.g., when dietitians will use technology, the technical requirements, how dietitians will keep information and any recordings secure, etc.). Dietitians should communicate policies with clients, as required (e.g., email communication issues, etc.).
Information and Privacy Commissioner of Ontario, Privacy and Security Considerations for Virtual Health Care Visits (2021).
Standard 3: Dietitians must meet informed consent and record-keeping standards when providing virtual care.

A registered dietitian demonstrates the standard by:

  1. Complying with the Professional Practice Standard for Consent to Treatment and the Collection, Use and Disclosure of Personal Health Information when practising dietetics virtually.
  2. Respecting client decisions. If a client does not consent to virtual care services, dietitians must not discontinue services that are needed, unless alternate services are arranged, or the client is given notice to arrange alternative services.
  3. Ensure that methods of obtaining consent are  appropriate for virtual care and your client (e.g. electronic signatures, verbal consent, etc.)
  4. Complying with the Record Keeping Standard by keeping records in the same manner as in-person practice. 

Practice Guidelines
 

Dietitians are encouraged to:

  1. Plan for client safety and potential emergencies by verifying the client’s identity and developing a safety plan in case of emergency or service interruption. Be familiar with emergency and crisis resources and know how to access them.
  2. Document how the dietetic service was provided (e.g., via telephone or video conferencing), including billing records and invoices provided to clients.
  3. Develop processes and/or policies for a system of retention to secure client health records (e.g., clarify health record custody and retention requirements, particularly when working in multiple sites with numerous dietitians and interprofessional colleagues working together).
  4. When using electronic records, plan a reliable backup system. Refer to the Record Keeping Standards, and the Privacy of Personal Information Dietetic Practice Toolkit for Registered Dietitians in Ontario.
Professional Misconduct Regulation, O Reg 680/93, s 9-10.
Standard 4: Dietitians must know and comply with all the applicable legislation, Standards, and ethical expectations when providing virtual care, regardless of the dietitian or client’s geographic location.

A registered dietitian demonstrates the standard by:

  1. Applying the Code of Ethics principles to guide evidence-informed dietetic practice: beneficence (to do good), non-maleficence (not harm), respect for persons/justice, and autonomy. 
  2. If registered to practise dietetics in another province or country (“jurisdiction”), to report concurrent registration with another jurisdiction to the College of Dietitians of Ontario within 30 days.
  3. Ensuring and confirming that their liability insurance provides coverage for virtual care visits, particularly for dietitians who have insurance coverage through their employer and/or practise across borders.
  4. Complying with all applicable laws and College guidance regarding cross-border (interjurisdictional) practice when providing virtual care. 

Practice Guidelines
 

Dietitians are encouraged to:

  1. Contact the regulatory body in the jurisdiction where the client is located prior to providing virtual care across borders. This ensures you know any applicable licensing or practice requirements before care.
  2. Be clear and transparent with non-Ontario clients that registration to practise dietetics is held in Ontario.

For externally registered dietitians 

Externally licensed dietitians, not registered with the College of Dietitians of Ontario, who use the title dietitian and/or provide dietetic services to clients in Ontario must be aware of the College’s Position Statement: Registration Requirement for Inter-Jurisdictional Practice.

 
Resources

College of Dietitians of Ontario – Jurisprudence and Professional Practice Resources

 Legislation

Information and Privacy Commissioner of Ontario

Other

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