Providing care in the community, as opposed to a hospital, brings the business side of healthcare much closer to RT practice. The CRTO Standards of Practice states that “RTs must only engage in business practices that are transparent, ethical, and not misleading to the public.” Privacy and confidentiality, security of Personal Health Information (PHI) and ethical, evidenced-informed care are essential in all healthcare settings. However, providing RT services in the community may necessitate that other concerns such things as billing and advertising also be taken into consideration.  This section on business practices endeavors to clarify how these and other aspects need to be managed in community RT practice.

Federal and provincial legislation protects patients’ rights to privacy and confidentiality of their PHI. Therefore, RTs have a legal obligation, as well as a professional and ethical obligation, to ensure that their patients’ PHI remains secure and confidential. The following two agencies have been tasked with enforcing this legislation:

The term “circle of care” is not defined in PHIPA. However, the Information and Privacy Commissioner of Ontario states that it is “a term commonly used to describe the ability of certain health information custodians to assume an individual’s implied consent to collect, use or disclose personal health information for the purpose of providing health care, in circumstances defined in PHIPA”1. The circle of care includes the health care providers who require specific medical information in order to provide care to a particular patient. In most situations, these health care providers may rely on the implied consent of a client to share medical information within the circle of care.

Consent by a client to share information with providers in the circle of care is generally implied. Therefore, a client who accepts a referral to another health care provider implies consent for sharing relevant information.

If a client cannot provide consent, then a Substitute Decision-Maker (SDM) becomes part of the circle of care, and can provide consent on the client’s behalf to allow PHI to be shared within the circle of care.

Expressed consent is required to share information with non-custodians outside the circle of care (e.g., family members who are not a guardian or SDM, police, insurance, etc.).

Example… A physician orders home oxygen for a client and the client agrees with the physician’s plan of care. This means that the client has given implied consent for the RT(s) who will be providing their oxygen to be part of the circle of care. The RT(s) is, therefore, permitted to access the client’s PHI and share that information within the circle of care.

As outlined previously, RTs have a legal and professional obligation to maintain the confidentiality of a patient’s PHI. There are circumstances, however, where health care professionals are either required or permitted to report particular events or clinical conditions to the appropriate government or regulatory agency. In Canada, provincial, territorial and federal statutory requirements mandate that health care providers report to the appropriate agencies when certain conditions apply. RTs who work in the community, particularly those who have established an independent practice, need to be aware of the relevant mandatory reporting requirements. Some examples of circumstances where information either must or can be shared outside the circle of care include:

Unique challenges to the privacy and confidentiality of PHI can arise in a community care setting, particularly when PHI is being transported to and communicated in an unsecure location. The risk of information being lost or stolen is greater when it is being taken out of a more secure location (e.g., a home care company office) to an outpatient clinic or client’s home. In addition, sharing PHI in a less secure location runs a greater risk of disclosing sensitive information to individuals who are outside the circle of care (e.g., relatives, neighbours).

The specific legislation that applies to RTs depends, to some degree, on the practice setting and the nature of the RT services being provided. Relevant legislation to community RT practice may include the:

HICs are responsible for implementing and following information practices that comply with PHIPA.

Example… If an RT is working independently (e.g., is a sole practitioner; has established their own company), they are considered to be the HIC. This means that the RT is responsible for setting the privacy standards for handling and securing PHI in their organization and for making sure that any agents of the HIC working for them understand what is expected of them.

Example…If an RT is working as an employee for an organization (e.g., home care company, FHT), they are considered to be an “agent of the HIC”. This means that the RRT must comply with the PHIPA policies put in place by the HIC (their employer).

Retention of Electronic

Electronic Medical Records (EMR) must be backed-up on a routine basis and back-up copies stored in a physically secure environment separate from where the original data is normally stored. All PHI contained on an EMR, external storage media, or a mobile device must be strongly encrypted. Various enterprise solutions (e.g., patient portals) can provide encryption, and an increasing number of encryption applications are available for use on personal devices such as smartphones. RTs considering using unsecured or unencrypted email or text messaging should do so only for information that does not include identifiable personal health information (e.g., scheduling, reminders).

Under PHIPA, if a HIC is in the custody of a client’s PHI that is lost, stolen or used or disclosed without proper authority, the HIC must notify the individual at the first reasonable opportunity⁶.

If an RT ceases to practise or act in the capacity of a HIC, the PHI must be retained for the periods outlined above unless complete custody and control of the records are transferred to the custodian’s successor.

When the obligation to retain medical records outlined above comes to an end, the PHI may be destroyed, provided that this occurs in a manner that is in keeping with the obligation of maintaining confidentiality and requirements of PHIPA.

Disposal of Electronic Medical Records (EMRs)

There are basically two ways to securely destroy digital information:

The best method to securely destroy personal information will vary depending on the type of media (e.g., hard drives, USB flash drives). Note that some devices, such as printers, fax machines, and smart phones, may contain multiple types of storage media, with each type requiring a different information destruction method⁷.

A privacy breach involves the improper or unauthorized collection, use, disclosure, retention or disposal of personal information. A privacy breach may occur within an institution or off-site and may be the result of inadvertent errors or malicious actions by employees, third parties, partners in information-sharing agreements or intruders.

Regardless of the nature of the breach, they must be reported by the HICs to the Information and Privacy Commissioner of Ontario. No actual harm has to have happened to the client as a result of the breach for reporting to be required. 

RTs are subject to prosecution for breaches of PHIPA. An RT found guilty of committing an offence under PHIPA can be liable for a fine of up to $50,000, while an organization/institution can be liable for a fine of up to $500,000⁸.

Privacy breeches can occur in a number of different ways.

* NOTE that the HIC does not need to notify the Commissioner if the stolen information was de-identified or properly encrypted.

The CRTO has processes in place to issue Certificates of Authorization for health profession corporations. RTs who independently practice Respiratory Therapy are not currently required by the CRTO to do so through a health profession corporation.

More information on Professional Incorporation can be found on the CRTO website in the section entitled Guide to an Application for a Certificate of Authorization for Health Professional Corporations.

Not all services or equipment that a client in the community requires may be covered by OHIP. As a result, RTs, or their employers, may have to deal with fees, billing and payment for care that is covered by the client directly, or a third-party payer such as the Assistive Devices Program (ADP) or private insurer. RTs should understand that money often changes individuals’ expectations regarding services being provided as they perceive themselves to be consumersⁱ. This shift alone can alter the power imbalance between health care provider and client, at least at the time money is changing hands. RTs have a professional obligation to ensure that their business practices are transparent, ethical and not misleading to the publicⁱⁱ.

Professional advertising relates to any material that is used to promote an RRT’s professional practice.

Regardless of the advertising method, there are some common considerations when advertising RT services.

An RTs professional advertising must not:

The RHPA grants regulatory Collegesthe authority to develop a regulation governing advertising. RTs in Ontario must adhere to all the advertising parameters set out in the CRTO Advertising Regulation. In addition, the performance requirements for RTsregarding advertising and marketing are articulated in the CRTO Standards of Practice (Standard 1 – Business Practice).

Example… If a client is asked for a testimonial, they may be concerned that refusing could negatively affect their relationship with the RT. This can also be true for former clients, who may feel uncomfortable in returning for treatment in the future.

The Regulated Health Professions Act identifies a number of specific activities as controlled acts; designated as such because they carry a higher degree of risk of harm associated with their performance. These controlled acts are subsequently authorized through profession specific legislation, such as the Respiratory Therapy Act.

There are a number of exceptions in the RHPA [s.29 (1)] that enable individuals to perform controlled acts that they do not have the legislative authority to perform. The two exceptions that are most relevant to community practice are as follows:

More information on the controlled acts authorized to RT’s and the exceptions to these can be found in the CRTO’s Interpretation of Authorized Acts Professional Practice Guideline.

RTs are authorized by the Prescribed Procedures regulation to perform an arterial puncture. This procedure can be performed by an RT in any employment setting (e.g., hospital, an outpatient clinic, a client’s home) provided it is permitted by their employer.

The 5th authorized act (“administrating a prescribed substance”) enables RRTs to independently administer oxygen. “Prescribed” in this context means prescribed in regulation¹⁰ and “independently” means the oxygen therapy can be provided without the requirement of an order.

This means that, in certain practice settings, RRTs can administer initiate, titrate or discontinue oxygen based solely on their own professional judgement. However, it is important to understand that there are other pieces of legislation and policies limiting where RTs can independently administer.

The Public Hospitals Act[9] requires an order for every treatment or diagnostic procedure. Therefore, RRTs are only permitted to independently administer oxygen in practice settings where this legislation does not apply (e.g., in a patient’s home)

[9] Public Hospital Act, O. Reg. 965 s. 24 Public Hospitals Act, R.S.O. 1990, c. P.40 | ontario.ca

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Home and Community Care Support Service agencies across the province provide access to home and community care services for Ontario residents and co-ordinate admission to long-term care facilities. These HCCSSs coordinate access to a wide range of contracted services in the community, including Respiratory Therapy in some regions.

Terms, conditions and limitations (TCLs) are restrictions placed on the certificate of registration of certain classes of registration and on certain Members for specific reasons.

GRTs are only permitted to perform a controlled act that is authorized to the profession if it is performed under general supervision. This supervision can be provided by any regulated health care professional (e.g., RT, RN, MD) who is authorized to perform the controlled act and is competent to do so. General supervision requires that the supervising health care professional be available to be “present” by the RTs side within ten minutes, if necessary.

Care in the community, particularly home-based care, is fundamentally different than the episodic, targeted interventions of the acute care system. Service provided near or in a client’s home requires a uniquely holistic, self-directed and person-centered approach to care delivery. Home-based care presents opportunities to better integrate the plan of care into the client’s day-to-day environment, but also present some challenges as well, such as:

The primary goal of health care is to optimize the health of clients. This means that the interest of the client must always come first and not a financial interest. A conflict of interest arises when a secondary goal (e.g., personal gain for the health care provider) interferes or is perceived to interfere with the primary goal. The CRTO’s Conflict of Interest Professional Practice Guideline states that “a conflict of interest exists when an RRT is in a position where his/her duty to their client could be compromised, or could be perceived to be compromised, by a personal relationship or benefit”. The nature of community practice (i.e., long standing RT and patient/family interactions; financial compensation for services provided) has the potential to increase the risk of a conflict of interest situation developing. Any actual, potential or perceived conflict of interest must be properly identified, avoided and managed so as not to compromise the client’s best interests.

The first step is to recognize that a conflict of interest situation may exist. The Conflict of Interest Regulation (O. Reg. 596/94) outlines the situations in which an RRT might find themselves in an actual, potential or perceived conflict of interest [s. 3 (1)]. The likelihood of a conflict of interest increases when:

In situations where a conflict of interest situation exists, the RT must declare the nature of the relationship/benefit to the client in advance of services being provided. This should occur regardless of whether the conflict of interest is actual, potential or perceived.

For example… An RT who works for a hospital that is part of a hospital-home care company business relationship is making arrangements for an inpatient to be discharged with home oxygen. In addition to the home care company that is associated with the hospital, the RT should – if possible – provide the client with other appropriate service providers. Where applicable, the RT should advise the client that their selection of a supplier or a product or service will not adversely affect the assessment, care or treatment that they receive. This enables the client to exercise informed choice over the services provided to them. This includes allowing them to select a service provider, as well as the type of equipment/treatment received.

RTs practicing in the community typically work with a diverse group of health care providers; some of whom are Regulated Health Care Professionals (RHCPs) (e.g., RNs, MDs, RSLPs), as well as some who are Non-Regulated Health Care Providers (NRHCPs) (e.g., PSWs, Customer Service Technicians).

NRHCPs can include an array of paid care providers and unpaid family members. One of the key considerations for RTs when working with NRHCPs in the community is to determine which services the NRHCP can provide to the patient/client and which services are best provided by the RT.  Communication and collaboration with all members of the healthcare team and the patient/clients family is key to ensure that their needs are met.  If the RT has any concerns regarding the care their patient/client is receiving from any member of the healthcare team, the RT is expected to raise those concerns with the patient’s/client’s primary care physician/nurse practitioner.

In addition to assisting other members of the health care, the RT practicing in the community is expected to know when it is appropriate to seek assistance from others.

More information on NRHCPs can be found on the CRTO website in the section entitled Working With Non-Regulated Health Care Providers.

Due to the fact that community-based RTs interact with such a wide variety of care providers, it is essential to understand the difference between delegation and education, as well as which is required in certain circumstances. The  Delegation of Controlled Acts and the   Respiratory Therapists Providing Education  provides detailed information on these two processes.

Despite the convenience of many communication mediums, the use of electronic communications to transmit sensitive information can increase the risk of such information being disclosed to third parties. The eCommunication Checklist produced by the Canadian Medical Protective Association provides some essential elements to considered when using electronic communication to convey sensitive PHI.

The discussion and patient’s agreement should be documented in the medical record. In addition, the Information and Privacy Commissioner of Ontario has published a Fact Sheet on Communicating Personal Health Information by Email that addresses the risk of email communication and how those risks might be mitigated.

In keeping with the Standards of Practice, “Respiratory Therapists must act with honesty, integrity, and respect appropriate professional boundaries with patients/clients, healthcare team members, students, and others.”  While most RTs will reflect on “professional boundaries” in relatively limited terms, such as romantic or financial relationships, professional boundaries covers every aspect of communication and interaction between RTs and everyone with whom they come into contact in their roles. 

More information can be found regarding Professional Boundaries in the CRTO Respiratory Therapists Providing Education PPG and the Abuse Awareness and Prevention PPG

In 2016, the federal government passed legislation to amend Canada’s Criminal Code and established a framework for Medical Assistance in Dying (MAID) for individuals who meet pre-defined eligibility criteria. RTs in community practice may be required to provide information to clients seeking information about MAID or to assist a physician or NP in carrying out a request for a medically assisted death. Therefore, it is important that a community-based RT be knowledgeable about the following:

The above information, as well as addition resources can be found on the CRTO website in the section on the Medical Assistance in Dying.

In most circumstances, RTs in community practice are obligated to maintain a professional relationship with a client as long as the client requires services from the RT. However, situations may arise that require the RT to end the professional relationship prior to reaching the normal or expected conclusion of the client’s treatment. These situations generally fall into one of two categories where the RRT will no longer able to provide the services:

All reasonable efforts must be made to resolve the situation in the best interest of the patient, and only consider ending the professionalrelationship where those efforts have been unsuccessful.

Example… Most home care companies have a policy in place to deal with situations where there is unsafe use of oxygen in the home (e.g., oxygen in use while patient/family member is smoking). These processes generally include all of the following steps:

1. Inform the client (preferably in writing) of what will happen if they use oxygen in an unsafe manner (i.e., how many warning they will receive and how those warning will be documented);

2. Notify the client (preferably in writing) of the decision to discontinue their treatment;

3. Document in the client’s medical record the reasons for the discontinuation of services, as well as all steps undertaken to resolve the issues prior to discontinuation;

4. Clearly convey to the client that they should seek ongoing care (e.g., speak to their primary care physician; go to their local emergency department); and

5. Notify the healthcare provider(s) who ordered the oxygen that the therapy is no longer being provided to the patient. Also consider informing the funder of oxygen services (i.e. MOH Home Oxygen Program) and other members of the patient’s healthcare team, as appropriate.

The CRTO Documentation PPG and the CRTO Standards of Practice (Standard 7) outlines the principles and standards of documentation that must be maintained by all RTs in every practice setting. Documentation styles and documentation mediums vary from one organization to the next. RTs may utilize any documentation format that meets both the CRTO’s expectation regarding documentation and their employer’s requirements.

An essential foundational principle for all RT documentation is that every client contact must be documented. “Client contact” includes (but is not limited to):

The Regulated Health Professions Act requires all practicing regulated health professionals to carry PLI that meets specific criteria. The CRTO Professional Liability Insurance Policy   outlines those requirements, as well as the consequences of an RT not being covered by the requisite amount of PLI.

RTs who are “personally insured” by their employer’s PLI plan in the required amounts and coverage are not obliged to obtain additional liability insurance coverage. “Personally insured” means the employer’s insurance policy covers not just the organization, but the RRT as an individual. The policy does not have to list the RT by name but must specify that it covers the “employees” of the organization as “added insureds”.

Additional PLI is available for members of the provincial or national professional associations (i.e., the RTSO, CSRT).

There are a number of instances where an RT is required to report specific information to certain organizations/agencies. Some of these reporting requirements were covered in the section in this document entitled Sharing PHI Outside of the Circle of Care.   More information on other reporting requirements can be found in the CRTO’s Reporting Obligations webpage.

When an RT has reasonable grounds, obtained in the course of practicing the profession, to believe that another RT or regulated health professional has sexually abused a patient, the RT must file a report in writing with the Registrar of the College to which the alleged abuser belongs.

More information on the reporting of sexual abuse of patients can be found in the CRTO Abuse Awareness and Prevention PPG.

Although the majority of RTs who work in the community are employed by home care companies or community care clinics, RTs are able to set up their own independent practice. This requires the RT to establish processes for securing client’s health records, set fees for their services, ensure they have the required level of professional liability insurance and that they attain optimal business ethics.