Review question and objectives

We conducted a scoping review to generate a broad overview of this topic and summarize the available evidence. We conducted a preliminary search of PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews, and JBI Evidence Synthesis in 2021 and found no scoping or systematic reviews on this topic. This scoping review is part of a larger project on regulating virtual work that reviewed additional sources for professions outside health and presented policy case studies to provide a deeper dive into specific Canadian examples and contexts. The report for the full project is openly available on Athabasca University’s institutional repository [29], and the evidence brief is available on the website of the funding agency, the Social Sciences and Humanities Research Council [30].

The research question for this scoping review was: How is the public interest protected when regulating health professionals engaged in virtual care? The objectives of this scoping review were to examine how the public interest is protected when regulating health professionals providing virtual care, to discuss policy and practice implications related to professional regulation of virtual care, and to make recommendations for future research.

Inclusion criteria

We used the Population-Concept-Context approach recommended by the JBI scoping review methodology to define our inclusion criteria. Our population included any studies involving regulated health professionals, defined for the purposes of our review as those governed by professional regulators with the legal mandate to protect the public. Studies that discussed the concept of protecting the public interest (in the narrower sense of ensuring patient/client safety or the broader sense of acting in the interests of the public) when regulating health professionals providing virtual care were considered for inclusion. In searching for literature on virtual care, we included any form of health professional service delivery without in-person interaction. We considered studies from any jurisdictional context if regulatory activities relevant to professionals providing virtual care were discussed. Articles that did not discuss regulation by professional regulators with a public protection mandate (e.g., those focused on other aspects of health sector regulation such as pharmaceuticals, medical devices, or provider reimbursement; those focused on voluntary certification by professional associations or accredited registries) were excluded.

Types of sources

English-language academic literature incorporating any type of study design published between January 2015 and May 2021 was considered for inclusion. English-language grey literature in the public domain (such as government reports, documents from regulatory consortiums, and policy papers) that specifically discussed regulating health professionals providing virtual care was also considered for inclusion. Letters to the editors, textbook chapters, and conference abstracts were excluded. We also excluded practice guidance or standards from individual health profession regulators (given the volume of documents this would represent).

Search strategy

An initial limited search of the Scopus database was conducted to identify relevant articles on the topic. The words in the titles and abstracts of these articles, as well as the index terms, were used to develop a full search strategy (see S1 File). This search strategy was then adapted across the other databases in consultation with a research librarian.

The literature on health profession regulation of virtual practice is diverse, and we wanted to capture various disciplinary perspectives. Therefore, we searched six multidisciplinary academic databases (MEDLINE [Ovid], Embase [Ovid]), Sociological Abstracts [Proquest], Social Work Abstracts [EBSCO], Scopus and Google Scholar). Additionally, an iterative grey literature search was conducted, including grey literature databases (OpenGrey, Nexis Uni, ProQuest Dissertations and Theses Global), search engines (first 200 Google results), and relevant websites (e.g., OECD Regulatory Policy Division, GovInfo, and Government of Canada) based on keywords used for the academic databases and in consultation with the research team. Studies published in English from 1 January 2015 until 29 May 2021 (when the searches were conducted) were included. This date range was chosen for feasibility given the rapidly evolving nature of virtual care, particularly during the COVID-19 pandemic. Reference lists of articles selected for inclusion were screened for additional papers not captured in the database searches.

Study selection

Following the search, all identified records were collated and uploaded into the review management software Covidence and duplicates were removed. Two reviewers independently screened all titles and abstracts against the inclusion criteria for the review. Potentially relevant papers were retrieved in full; two reviewers assessed full-text studies and excluded those that did not meet the inclusion criteria. Reasons for exclusion at this stage are reported in the PRISMA diagram (see Fig 1). Any disagreements between reviewers were resolved through discussion or by a third reviewer to achieve consensus.

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Fig 1. Search results and study selection and inclusion process [34].

https://doi.org/10.1371/journal.pdig.0000163.g001

Data extraction and analysis

Data were extracted from included papers by one reviewer and verified by a second reviewer using a modification of the JBI data extraction tool developed for this scoping review by the research team (available as a supplementary file with our study protocol). Data extraction tools for academic and grey literature were pilot tested on 10 sources and revised to ensure that the most relevant information was captured appropriately. The data extracted included details about the population (e.g., the specific health profession), the concept of regulating health professionals providing virtual care, the context of regulatory activities in the public interest, type of article, geographic location, and key findings relevant to the review objectives and question. Analysis of included studies was conducted by summarizing these characteristics descriptively and synthesizing the extracted data according to key findings. Based on our review objectives, we have highlighted implications for regulatory policy and professional practice and knowledge gaps warranting further research.

Characteristics of included articles

Academic literature included in this review consisted of the following types of papers: opinions/commentaries/perspectives/debates/expert reports (n = 24); reviews including meta-syntheses, narrative reviews, literature reviews and scoping reviews (n = 13); legal research notes/analyses/reviews (n = 4); descriptive/observational studies (n = 3); qualitative studies (n = 2); case reports/studies (n = 1), and other article types (n = 8).

Geographically, most papers focused on the United States (n = 44). The geographic contexts of the remaining articles were Canada (n = 2), India (n = 1), Hong Kong (n = 1), Brazil (n = 1), South East Asia (n = 1), as well as articles with a multi-country focus including Europe or the European Union (EU) (n = 7), the EU and Australia (n = 1), and Australia, Portugal, and Russia (n = 1).

Most articles focused on physicians (n = 34) and medical specialties or services, including radiology, psychiatry, surgery, dermatology/dermatopathology, and doctors providing abortions by virtual care. Professional populations highlighted in the remaining articles were nurses (registered nurses, nurse practitioners, advanced practice registered nurses); dentists, oral and maxillofacial radiologists, and allied dental providers (i.e., dental therapists); pharmacists and pharmacy technicians; allied health professionals (e.g., occupational therapists, physical and physiotherapists, speech-language pathologists), and mental health professionals (e.g., psychologists, social workers). A few articles discussed regulated health providers more generally.

Varying terminology used in the literature for virtual care

The literature contained varying terms and definitions to interpret aspects of virtual care, such as remote services, telehealth, and telemedicine. These terms and associated definitions varied based on a combination of profession or specialty, service(s) provided, technology and tools used to provide services, client population(s) served, location(s) of care, and proposed new specializations (i.e., medical virtualist). We have summarized the varying terms encountered in the literature in Table 1. Telemedicine and telehealth were most frequently used in the academic literature to discuss virtual care when regulating health professions. In this paper, we use the term virtual care in line with the recent movement by Canadian medical regulators to adopt this term in practice standards and other regulatory documents (see, e.g., the Federation of Medical Regulatory Authorities of Canada [FMRAC] Virtual Care Framework) [21].

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Table 1. Examples of terms used in the academic literature to describe practice encounters not involving in-person contact.

https://doi.org/10.1371/journal.pdig.0000163.t001

Key findings

We identified five key findings in our evidence synthesis of the academic and grey literature on this topic.

1. The public interest when regulating health professionals providing virtual care was only implicitly considered in most of the literature
   The expansion of virtual service provision raises many challenges for regulators. The literature we reviewed, however, did not always specifically articulate public interest concerns in regulating virtual care. In some sources, public interest considerations were implied by the regulatory activities discussed, such as the public health impacts of relaxed prescribing rules and preventing incompetent or unethical practice when services are provided virtually [35–42]. The literature highlighted several virtual care concerns that impact the public interest created by current regulatory structures. Articles also used terms such as protecting (or enhancing) public safety, health, and welfare in the context of regulating professional practice.
   The literature primarily discussed licensure as a regulatory activity when discussing virtual practice (n = 45). Other regulatory activities described in the literature included certification, credentialing and privileging; the issuance of emergency orders and waivers during the COVID-19 pandemic; scope of practice; practice standards (including ethics and continuing competence); standards of care; duty to care; and guidance around issues such as requirements to consult with other providers and how to ensure privacy, security, and confidentiality when providing virtual care. Some articles identified that regulators needed to clarify specific aspects of virtual care for health professionals, including clarifying the expected standards for virtual care, determining when a practitioner-client relationship is established, and managing ethical issues [43–51]. Recognizing this need, umbrella regulatory consortiums have offered guidance, model codes, and support for memoranda or agreements for virtual care practice standards. In Canada, the Canadian Alliance of Physiotherapy Regulators established a cross-border physiotherapy memorandum of understanding to facilitate access to telerehabilitation [52]. The Federation of Medical Regulatory Authorities of Canada, at the time of this review, was exploring the potential for a license specific to virtual care, a short-duration license for portability, or a fast-tracked license agreement for physicians already licensed in another Canadian jurisdiction [53]. In the United States, regulatory umbrella organizations such as the National Council of State Boards of Nursing and the Federation of State Medical Boards have been instrumental in the proliferation of interstate licensure compacts for their respective professions. These compacts overcome the barrier of needing multiple licenses to provide services across state borders by allowing providers to practice in other compact states where they do not hold a license as long as they hold a license in good standing in a home state that is a compact member [54,55]. While not explicitly or specifically stated in the reviewed literature, the above examples suggest implicit discussion of the public interest as central to regulatory functions, activities, and decisions around virtual care, in line with jurisdictionally-specific and socially-influenced constructions of the public interest.
2. The dimension of access was emphasized when regulating health professionals providing virtual care
   When the public interest in virtual care was discussed in the literature, the dimension of access to affordable services was given the most weight. Indeed, virtual care has traditionally been used to facilitate more equitable access to healthcare in rural and remote areas to help address health disparities and health workforce shortages [56,57]. Increasing healthcare access in underserviced areas is thought to improve public health and welfare [57]. As virtual care continues to be commonplace in pandemic recovery and the post-pandemic world, a challenge for professional regulators will be to continue to adapt as virtual care evolves to ensure patient access to safe and competent care provision. There is also a growing public expectation of access to virtual care. The Organization for Economic Co-operation and Development has noted that societies across the globe are adopting digital technologies, and consumers are increasingly expecting the same level of responsiveness and ease of use in healthcare as in other digital technologies in other areas of life [58].
   The extent to which professional regulation is fulfilling its mandate to act in the public interest as it pertains to virtual care was questioned in the literature. In the American context, legal and regulatory mechanisms were criticized as impeding healthcare access by potentially restricting some providers from delivering medically necessary services [40]. For example, current Interstate Medical Licensure Compact standards may exclude approximately 20% of physicians from being eligible for compact licensure [43]. This is partly attributable to restrictive eligibility requirements (e.g., primary residence and at least 25% of medical practice must occur in a declared state of principal license) and individual practitioner self-determinations of eligibility to apply to participate in the compact [59].
   One somewhat opposing concern raised in the literature was the potential for increased access to addictive or illegal drugs because of relaxed teleprescribing for controlled substances that did not require conducting an in-person examination [35]. Several articles highlighted court cases and resulting legislation (Ryan Haight Online Pharmacy Consumer Protection Act, 2008; Hageseth v Superior Court, 2007) regarding online prescribing of controlled substances or other medications without an initial in-person exam [37,47,60,61]. Before the COVID-19 pandemic, Australia, South Africa, Spain, and the UK had uniform rules for in-person and teleprescribing. While restrictions on teleprescribing in many jurisdictions were relaxed during the pandemic to increase service access, there were still restrictions on prescribing medications via telepsychiatry in some jurisdictions [62]. While regulators understandably have quality and safety concerns for controlled drug prescriptions and psychiatric care delivered by virtual care, evidence regarding the extent to which these concerns are founded is mixed. Some articles we reviewed emphasized the mixed evidence around whether overprescribing occurred when clinical encounters did not involve in-person contact [49,63].
3. Criticism focused on social ideologies driving regulation that may inhibit more widespread use of virtual care
   The reviewed literature questioned whether regulatory decisions are in the public interest and identified criticisms about current regulatory structures that could inhibit more widespread use of virtual care. These criticisms around virtual care regulatory policy fell into two broad categories: that these policies potentially limited competition and created economic inefficiencies (i.e., health as a competitive business), and that they were driven by politics rather than sound evidence on the appropriateness of virtual care (i.e., ideological views on ‘controversial care’).
   Requiring patients or clients to travel for services that can be safely provided virtually could be viewed as acting in the interests of professionals to reduce competition for local providers. Many states limit virtual care provision by requiring health providers to be licensed in the state where the client resides [49,64]. Practice limitations like this may be subject to federal antitrust (competition law) challenges. The papers we reviewed highlighted two antitrust cases in the United States that involved health profession regulators. In Teladoc v Texas Board of Medicine, a national virtual care platform sued the Texas Board of Medicine for mandating that consultations be conducted face-to-face. Teladoc dropped its antitrust lawsuit after the Texas Board of Medicine enacted new regulations allowing virtual care without a prior face-to-face interaction, paving the way for increased virtual care provision and potentially driving competition for local in-person practitioners [65,66]. In North Carolina State Board of Dental Examiners v Federal Trade Commission, the Supreme Court of the United States determined that licensing boards could only claim to be immune from federal antitrust actions if those boards were under active state supervision. In short, while licensing boards must protect the public interest, they need to do so in a way that balances public safety with promoting a robust, competitive economy [67]. Competition and politics in health have a different meaning in the American context and may not be similarly prioritized in other countries, particularly given the framing of health as a predominantly private good in the United States.
   Similarly, while registration or licensing fees are required to support regulatory programs and activities, requiring professionals to pay licensing fees in multiple jurisdictions potentially creates undue time and financial burdens to provide telemedicine services. Obtaining and maintaining licenses for multiple jurisdictions is costly and time-consuming for providers [68,69] and arguably raises costs for consumers, thereby impacting equitable access to care [70].
   Restrictions on politically controversial services such as abortion via virtual care were criticized as being motivated by politics rather than science, thus resulting in questionable policies promulgated by medical boards [71]. The example most commonly discussed in the literature we reviewed was a practice standard instituted by the Iowa Board of Medicine prohibiting abortion by virtual care. In a legal challenge brought by Planned Parenthood, the Iowa Supreme Court found that the medical board had singled out medical abortion despite evidence that the number of abortions and adverse outcomes do not increase when this service is provided by virtual care [72]. In Canada, there have not been similar assertions of regulatory restrictions on politically controversial services by virtual care. A protocol released early in the pandemic by the Society of Obstetricians and Gynecologists of Canada provided guidance on telemedicine abortion in Canada and did not suggest any in-person visit requirements [73]. Again, this may relate to the framing of health services in Canada, where universal health coverage exists, compared to the United States. Note that our review was conducted before the 2022 United States Supreme Court decision in Dobbs v. Jackson Women’s Health Organization (discussed below).
4. Subnational occupational licensure was viewed as a barrier to virtual care
   Critical to regulating virtual practice is the issue of cross-jurisdictional practice in federated jurisdictions such as the United States and Canada where health profession regulation initially emerged at the subnational (state/provincial/territorial) level to govern services provided locally, address regional concerns, and reflect local circumstances. However, technologies now facilitate cross-regional practice and the highly variable geographic approach to licensure and registration has become increasingly problematic and difficult to defend. The literature identified regulation at the subnational level in Canada and the United States as a barrier to equitable access to professional services, particularly during the COVID-19 pandemic. This was the most consistent point raised across the included articles and reflects the dominance of these countries in the literature we reviewed. Cross-jurisdictional virtual care is much less of a concern in countries where regulation occurs nationally (e.g., New Zealand), though an argument could be made about the need to regulate virtual care more globally, particularly for future conflict or crisis emergency situations.
   In Canada, where the constitutional division of powers has provided provinces and territories authority to regulate most professions, calls have been made to address the variability in the approach to professional regulation across provincial and territorial borders [74,75]. 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 practice [53]. A pilot for inter-jurisdictional registration for nurses in two Canadian provinces was just beginning at the time of our review [76].
   In the United States, the state-based system of occupational licensure has created a confusing web of virtual care requirements across health professions. For example, the Federation of State Medical Boards regularly updates its information on states that have modified their licensure requirements to support virtual care in response to the pandemic. At the time of our review, their document on this topic included 22 pages of detailed information on the regulatory variations between states [19]. A requirement that health professionals follow the standards of care of multiple states to provide virtual care out-of-state raises liability risks and potentially stifles broader use [51]. In the United States, like in Canada, this variability has been the subject of debate and calls for national regulation of virtual care standards of practice (justified through federal powers over commerce and spending). Several papers identified and discussed the development of national licensure systems and licenses as a possible solution to the barriers and inefficiencies imposed by a state licensure system [65,66,77,78]. Achieving this would require the successful navigation of many potential political and legal difficulties [66,79]. However, some exceptions to state jurisdiction over licensure currently exist. Some federal health programs permit out-of-state clinicians to provide virtual care services within the Veterans Affairs system [65], perhaps due to the salaried nature of Veterans Affairs health providers. While not the focus of our review, the varying models of reimbursement for health services across state borders and internationally, particularly the common fee-for-service model, complicate moves to standardize virtual care, another potential barrier to broader implementation.
   The literature demonstrated the value of policy harmonization and cooperation in the global digital economy. Canada and the United States can look to other countries and regions to see how they have adapted their occupational licensure systems and embraced new technologies for professional practice in the 21st century. For example, Australia has a national agency responsible for the regulation and accreditation of 15 health professions [80]. The European Economic Community recognizes sectoral professions including medicine, dentistry, nursing, pharmacy, and midwifery of member states to facilitate labour mobility, and the EU has a system of regulation which automatically recognizes professional qualifications, thereby allowing credentialed professionals to lawfully practice in any member state [81].
5. The demand for virtual care during COVID-19 catalyzed licensure and scope of practice changes
   The expansion of virtual care is anticipated to be an enduring legacy of COVID-19 in a pandemic recovery and post-pandemic world [43]. Regulatory reforms proliferated during the COVID-19 pandemic as regulatory bodies sought to ensure access to professional services while maintaining public protection. Grey literature reports described the rapid regulatory changes and waivers used to enable cross-border practice for virtual care, and the value of flexible rather than directive legislation to promote these types of regulatory responses [82–84]. For example, World Physiotherapy noted the various regulatory changes needed by physiotherapy regulators in different global jurisdictions to facilitate cross-border practice and provide guidance to registrants on standards for telerehabilitation services [84]. In the United States, executive orders from state governors temporarily lifted licensing requirements to solve workforce shortages related to an emergency. According to the National Conference of State Legislatures, before the start of the COVID-19 pandemic in 2020, only three governors had used executive orders for this purpose [67]. During the pandemic, all states took some sort of action to ease licensing requirements and meet workforce needs caused by the pandemic (most acutely seen in health and emergency response occupations). During the pandemic, legislation was also used to permit pharmacists, among other credentialed providers, to provide broader virtual care services to clients with fewer restrictions [85]. There was also a stronger push for states to join licensure compacts. A bill was introduced in the United States Congress in November 2020 that proposed penalizing states that did not join the IMLC and blocking state medical regulators from receiving specific federal grants if they did not have a public awareness campaign encouraging specialist physicians to practice virtual care [86].

Limitations

Much of the literature involved descriptive case examples, critical commentaries, or legal analysis and predominantly focused on licensure in high-income Anglophone countries and the historically dominant medical profession. It is likely that virtual care in the statutorily regulated health professions in these jurisdictions is more frequently highlighted in the literature. More publications from low- and middle- income countries, occupations outside medicine, and evidence published in other languages may have informed this review had they been included. Also, as most included academic literature was set in the American context, the findings may have differed if more articles from countries with universal health coverage had been included, limiting the generalizability of the findings. We only included sources since 2015 and did not include guidelines or documents from individual regulators. The search was conducted almost two years ago and there could be new evidence not included in this review.

Despite these limitations, this scoping review has provided a foundational base for conceptualizing the public interest when regulating health professionals providing virtual care. While the focus of a scoping review is to provide breadth rather than depth, insights from this review may be applied to inform regulatory approaches for health professional virtual care in steady state and in response to future emergencies.

Future research

This scoping review has highlighted knowledge gaps in how health profession regulators can act in the public interest when regulating practitioners who provide virtual or digitally-enabled services. As most of the articles available were reviews or commentaries, there appears to be little empirical evidence on which to base these regulatory activities or to understand the impact of regulation on equitable access to and affordability of virtual care. Future research focused on outcomes is needed, as well as studies on low- and middle-income countries and health practitioners that are not regulated by statute (including the assistant, support, and allied health workforces).

The literature did not always touch on the public interest explicitly; hence there is a need for more research on the public interest in regulating virtual care in the health professions. There is also a need to understand how the public can best be engaged in the regulatory process, particularly around understanding the public interest when receiving virtual care and how this should translate into regulatory policies and practices. Reforms in recent years have included more inclusive and expansive participation of the public in regulation [4,105]. Public engagement with regulation for particular technologies may influence regulators to understand what initial assumptions about impact, harm, and risk may not be substantiated and allow for continual evaluation, adjustment and improvement [22]. Future work could partner with regulators, policymakers, health practitioners, and the public to enrich findings.

Many articles focused on the regulatory changes necessitated by the COVID-19 pandemic. It is imperative to continue to monitor and evaluate professional regulation through research to determine the value of these changes in the post-pandemic world. Future research should assess the outcomes of these regulatory initiatives, with a specific lens on accessibility and equity aspects of the public interest.