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Streamlining patient flow from primary to specialty care: a critical requirement for improved access to specialty care

https://policybase.cma.ca/en/permalink/policy11299
Last Reviewed
2020-02-29
Date
2014-10-25
Topics
Health systems, system funding and performance
  1 document  
Policy Type
Policy document
Last Reviewed
2020-02-29
Date
2014-10-25
Topics
Health systems, system funding and performance
Text
When physicians believe their patients may require the expertise of another physician, effective, timely and informative communication between all physicians is essential to ensure appropriate use of specialty care services. The results of physician surveys indicate a lack of informative referral communication exists in Canada. Significant variation exists in referral request processes*. This is contributing to the poor access to specialty care that many patients are experiencing. Some of this variation is necessary, however, which means that a single, standardized solution to improve the entire referral and consultation process is not feasible. Nonetheless, while communication processes and information requirements for referral requests vary considerably, the communication and information needs in consultant responses is essentially the same for all referring physicians. Unfortunately, provision of this information is often lacking. This problem can be addressed through standard communication protocols because all referring physicians benefit from receiving the same types of information in response to referral requests; for example, acknowledgement of referral receipt or patient consult reports. Furthermore, when referrals are initiated, specific types of requests can benefit from standardization of communication methods and information requirements. Such activities are already underway in Canada in select areas. These successful initiatives, used together as complementary approaches to address the varying needs of referral requests, should be adopted throughout the country. Visit CMA's Referral and Consultation Process Toolbox1 for examples. Recognition, in the form of appropriate compensation, must also be given to the time spent preparing and analyzing referral requests as well as conducting consultations. Support for the use of information technology infrastructure, where available, will also facilitate efforts to streamline referral and consultation processes. It should be noted that, while the language of this policy statement has a focus on primary to specialty care referrals, the concepts and recommendations apply to referrals between all specialties. RECOMMENDATIONS * All stakeholders, especially physicians, but also, where appropriate, office assistants, nurses, other health care providers as well as patients, must be engaged in an early and meaningful way regarding any initiative that has a goal to improve referral or consultation processes. * There is no single best way to access specialist expertise; as a result, a combination of complementary initiatives (e.g., formal consultation systems, standardized referral processes with central intake systems and/or physician directories) should be implemented to reduce variation in the approaches that are used and to facilitate more timely access to specialty care for patients. * While acknowledging the referring physician's ability to interpret certain test results, the referral must be accompanied by appropriate information to allow the consulting specialist to fully assess the request, and the referring physician must be informed of what is "appropriate". * The referring physician (and family physician if different), as well as the patient, should be kept informed, in a timely fashion, of the status of the referral request, using standardized procedures, minimum information requirements and timelines. * Physician and/or physician practices should receive compensation and support in recognition of the time and effort undertaken to communicate appropriate information regarding referral requests as well as to conduct electronic or real-time consultations. Introduction When a physician decides that a patient requires the expertise of another specialist, the most appropriate next step can range from the specialist answering a question to assessing the need for a particular procedure or treatment. No matter how simple or complex the specialist's involvement may be, successful communication between all physicians is critical. Unfortunately, this does not occur as often as it should. In October 2012, a survey of physicians on the topic of referrals found that while over half of both family physicians (52%) and other specialists (69%) agree that referral communication is effective, two-thirds of family physicians noted that some kind of communication problem was a main source of frustration for them; for example not being informed about: referral receipt, the patient's appointment, a treatment plan, or that the specialist does not do the service requested. A similar proportion of specialists noted a lack of basic or supporting information (e.g., reason for referral or lab test results) as a main frustration with referral requests.2 The most appropriate method of communication differs depending on the degree of specialist involvement that is required. There are no standards about which method of communication is the most appropriate or effective, or what information is required, for each situation. Referral request processes† vary significantly; not only across specialties but among specialists within a particular specialty and even within a geographic region. Examples of this variation include: some consulting specialists will accept referrals only if the referring physician has used their specific referral form; others accept referrals using only one particular communication method (e.g., by fax); and others accept referrals on just one day each month. Such variation creates inefficiencies because referring physicians must familiarize themselves with each request process that is required by each consulting specialist. The range and quality of information provided in a referral request also varies considerably; for example, too little information (i.e. no reason for referral provided), insufficient information (i.e. out-of-date or a lack of lab or imaging tests), or to too much information (i.e. non-contributory family history). This lack of standardization is problematic. In this context, standardization means simplification rather than obligation. Standardized processes facilitate communications for referrals by removing ambiguities about which method is most appropriate for each situation. Communication methods and the types of information that are transferred between referring physicians and consulting specialists vary based on numerous factors, ranging from those beyond the control of physicians such as regulations and available technology, to those completely within their control such as their own individual preferences. An effective way to facilitate appropriate and timely access to specialty care that is within the control of the health care profession is to explore the rationale behind these varying communication and information preferences and address these variations by developing, with meaningful participation and approval from physicians and their administrative staff, standard processes for requesting a specialist referral and for communicating back to the referring physician. Some of the provincial Colleges of Physicians and Surgeons have guidelines or standards of practice specifically about referrals and consultations. The most comprehensive of these are the College of Physicians & Surgeons of Nova Scotia's (CPSNS) Guidelines for Physicians Regarding Referral and Consultation3 and the College of Physicians and Surgeons of Alberta's (CPSA) Standard for Practice on The Referral Consultation Process.4 In addition, the College of Family Physicians of Canada (CFPC) and the Royal College of Physicians and Surgeons of Canada (Royal College) developed collaboratively a guide to enhancing referrals and consultations between physicians.5 While these documents do not discuss which method of communication should be used for each referral request scenario, they do provide guidance in a number of areas, including: * minimum requirements for information that should be provided with all referral requests * information that should be conveyed to patients (e.g., why they are being referred, information about the specialist appointment, etc) as well as who should be providing this information * processes that should be followed for patients requiring ongoing care from the consulting physician While standardization of the minimum information requirements that should be included in communications between referring and consulting physicians is essential for finding efficiencies with referral processes, these efficiencies will not be fully realized without proper consideration of the information technology infrastructure that is used to convey this information. The way in which the information is provided should not require additional effort for either the sender or the receiver. Electronic referral systems, where all data necessary for an informative referral can be easily obtained by the appropriate physician from the patient's electronic health record, would be the best way to ensure that this occurs. However, until this becomes a reality, a suitable compromise can be found by allowing flexibility in the format in which the information is provided. Communication from Primary Care to Specialty Care When the extent of a specialist's involvement in patient care is simply providing a second opinion or advice about appropriate next steps, standardizing the process for this kind of communication is relatively straightforward. This is because the variation that exists in this situation is primarily due to the availability of the consulting specialist and the methods of communication that each referring physician can use to contact the specialist. Certain regions of the country have established consultation services whereby specialists participating in the program must respond to consult requests within a specified time frame. Examples of effective consultation systems include the telephone advice line known as Rapid Access to Consultative Expertise (RACE)6 in BC or the secure electronic consultation system known as Building Access to Specialist Care through e-Consultation (BASE)7 in the Champlain Local Health Integration Network (LHIN) in Ontario. Such services have proven quite effective at reducing the number of unnecessary referrals8,9; thereby ensuring more appropriate use of specialty care and helping to reduce wait times for this care. Through both of these systems, specialists ensure that they are available to respond to the consult question in a timely manner and each system uses only one form of communication. At the other end of the spectrum of specialist involvement in patient care, when the patient sees the specialist, there is a much greater degree of variation in what is required of the specialist - from one-time interventions such as surgical procedures, to chronic care. The best approach for streamlining the referral process in these more complex situations varies, depending on the type of specialist care that is required. Central Intake With central intake referral systems, the referring physician sends a referral request to one location. This central location can be organized in two ways; central triage or pooled referrals. With central triage, referrals are assigned to specialists based on their level of urgency. With pooled referrals, each referral is allocated to the next available specialist, who then does the triaging. The differences in where the triaging occurs exist due to a number of factors; including the type of care the specialty provides as well as the number of specialists in the geographic region. However, for both types of central intake systems, the referring physician follows a standard process regardless of the specialist who assumes care of the patient. Regardless of the type of central intake method that is used, the option to choose a particular specialist must always be available. However, even with this option in place, a central intake system of any kind is not necessarily the most appropriate solution for all specialties. This is often the case when ongoing patient-specialist relationships are quite common. For example, a woman might prefer that the same obstetrician cares for her during all of her pregnancies, or patients with chronic conditions such as arthritis or diabetes and require continuous care throughout their lifetime. In these situations, coordinating a central intake program where a significant proportion of specialist appointments are repeat visits is difficult. Physician Directory A physician directory might be a more useful referral tool in situations where specialties do not have sufficient numbers of specialists in one geographic region or for those that have a high degree of sub-specialization. Such directories provide, at a minimum, details of the services each specialist provides and does not provide. Those that provide information regarding wait times, especially those with information on the wait for the first specialist visit, are extremely useful for referring physicians as it allows them to select a specialist with the most appropriate wait time for their patient and, where relevant, it also allows the referring physician to develop an appropriate care plan based on the time the patient must wait for specialty care. Despite the fact that the complexities with specialty referrals mean that there is no one solution that is appropriate for all types of specialties, the extreme variation in processes that currently exists is also unnecessary. Standard referral information requirements for specialty groups with similar needs, such as most surgical specialties, have been effectively established in some areas of the country. For example, in Calgary, Alberta, a major initiative known as Medical Access to Service10, has, among other things, successfully developed a standard referral form and process for central intake for multiple specialties. While most of these specialties also request additional information, each specialty has agreed on a standard set of minimum requirements. These standards were developed collaboratively with physicians and could be expanded nationwide, while taking regulatory and technological differences into account. When establishing the requirements for an informative referral, consulting specialists must acknowledge that the referring physician may not have the expertise necessary to appropriately interpret certain test results. In such cases it is the consulting specialists who should order these tests. Communication from Specialty Care to Primary Care What must not be overlooked is that referral communication is bilateral. Informative and timely communication from the consulting specialist to the referring physician is also critical for a successful referral. Such a referral can be defined as one where the patient receives appropriate and timely specialty care where all parties - patient, specialist(s), referring physician and family physician (when the referring physician is not the patient's family physician) - are aware of all of the patient's relevant interactions with the health care system as well as any follow-up care that may be required. To ensure this occurs, after the referral request is initiated, the referring physician (and family physician if different) should be informed, in a timely manner, of the status of the referral at all stages: * referral receipt * request for more information * referral acceptance/rejection (with explanation and suggested alternatives) * patient appointment has been scheduled * patient consult notes (including recommended treatment plan and follow-up) A definition of what is considered "timely" is required. Standards must be established based on what is considered to be an acceptable response time at each stage. The patient must also be promptly informed of the status of the referral request throughout the entire process. Examples of the types of information that should be conveyed include (where appropriate): * how the referral request will be processed; e.g., pooled referral or central triage * expected wait time or when the appointment has been scheduled * whether another specialist has been contacted * whether a repeat visit is required * whether the patient has been contacted about anything that is relevant to them; e.g., referred elsewhere, wait time, appointment(s) scheduled The information and communication that the referring physician requires from the consulting specialist for all referrals is much more homogeneous. In addition, there are no regulatory or technological barriers preventing the provision of this information at the appropriate stages of the referral process. This is one area where communication between physicians is within their control. Therefore, improved communication for responses to referral requests through standardized processes can be much more easily established. Unfortunately this is not the case, causing considerable effort to be undertaken by referring physicians and/or their office staff to track the status of referrals. Considerably less attention has been given to this part of the process; however, some activities described in the CMA's Referral and Consultation Process Toolbox1 do address problems regarding the referral response. Central Intake systems are an example. These often include standard response times for at least the first three stages noted above, as well as information about the specialist who has received the referral request. The previously cited guidelines developed by the CPSNS 3, the standard of practice by the CPSA4 and the guide to enhancing referrals and consultations between physicians developed by the CFPC and the Royal College5 also have recommendations for consulting specialist responses to referral requests (including information requirements and timelines). These resources can be used as a starting point for establishing referral communication standards in both directions and with patients. As an important example, the guidelines for both provincial colleges specifically indicate that the consulting specialist is responsible for arranging appointments with the patient and notifying the referring physician of the date(s). Compensation and Support Another aspect of the referral process that is not given sufficient consideration is the time and effort that is involved in preparing and responding to a referral request. Both preparing an informative referral request and responding to one is time-consuming; very little recognition is given towards this work. In some areas of the country, physicians receive compensation for participating in electronic or telephone consultation programs. This form of recognition has successfully helped avoid unnecessary referrals and should be expanded nation-wide; however, much more should be done to acknowledge this effort, especially when a specialist visit is necessary. The time referring physicians spend gathering the necessary data for a referral request, or the time consulting specialists spend analyzing this data, triaging the referrals accordingly and preparing patient consult notes, is almost never acknowledged as part of a physician compensation package. In most jurisdictions this work is considered to be just a component of a typical patient visit. Since many primary care group practices employ administrative staff who are "referral coordinators"; whose main role is to assist physicians in the data gathering and preparation that is required for an informative referral request, as well as following up on referral requests; the process of referring a patient to specialty care is much more than "just a component of a typical patient visit". Support for widespread implementation of effective information technology infrastructure can facilitate the preparation of appropriate referral requests and responses and can also encourage timely and informative communication between referring physicians and consulting specialists. Conclusion The high degree of variability in both the methods of communication and the information transferred between physicians is a significant barrier to timely access to specialty care for patients. Significant effort by physicians and their office staff is expended unnecessarily in the referral process, not only in initiating or responding to the request, but also in tracking and follow-up. While there is no single solution that will address all referral communication problems, several complementary solutions exist that can reduce this variability and wasted effort, thereby simplifying the process and facilitating appropriate, timely and informative communication between referring physicians and consulting specialists. Examples of such initiatives can be found in the CMA's Referral and Consultation Process Toolbox.1 * For the purposes of this policy statement, this term applies to all situations where another physician is contacted regarding patient care. † For the purposes of this policy statement, this term applies to all situations where another physician is contacted regarding patient care. References 1 Canadian Medical Association. Referral/Consultation Process. Available at: http://www.cma.ca/referrals. Accessed 29 Nov 2013. 2 Canadian Medical Association. Challenges with patient referrals - a survey of family physicians and other specialists; October 2012 (Unpublished). 3 College of Physicians and Surgeons of Nova Scotia. Guidelines for Physicians Regarding Referral and Consultation. Available at: http://www.cpsns.ns.ca/Portals/0/Guidelines-policies/guidelines-referral-consultation.pdf. Accessed 15 Nov 2013. 4 College of Physicians & Surgeons of Alberta. The Referral Consultation Process. Available at: http://www.cpsa.ab.ca/Libraries/standards-of-practice/the-referral-consultation-process.pdf?sfvrsn=0. Accessed 16 Sep 2014. 5 College of Family Physicians of Canada, Royal College of Physicians and Surgeons of Canada. Guide to enhancing referrals and consultations between physicians. Available at: http://www.cfpc.ca/ProjectAssets/Templates/Resource.aspx?id=3448. Accessed 27 Nov 2013. 6 Rapid Access to Specialist Expertise. Available at: www.raceconnect.ca. Accessed 27 Nov 2013. 7 Liddy C, Rowan MS, Afkham A, Maranger J, Keely E. Building access to specialist care through e-consultation. Open Med. 2013 Jan 8;7(1):e1-8. Available at: http://www.openmedicine.ca/article/view/551/492. Accessed 27 Nov 2013. 8 Wilson M. Rapid Access to Consultative Expertise: An innovative model for shared care. Available at: https://www.cma.ca/Assets/assets-library/document/en/advocacy/RACE-Overview-March-2014.pdf. Accessed 16 Sep 2014. 9Afkham A. Champlain BASE project: Building Access to Specialists Through e-Consultation. Available at: https://www.cma.ca/Assets/assets-library/document/en/advocacy/Champlain-BASE-Dec2013-e.pdf. Accessed 16 Sep 2014. 10 Alberta Health Services, University of Calgary Department of Medicine. Medical Access to Service (MAS). Available at: http://www.departmentofmedicine.com/MAS/ Accessed 15 Nov 2013.
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Medical assistance fund

https://policybase.cma.ca/en/permalink/policy11699
Last Reviewed
2019-03-03
Date
2014-08-20
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Resolution
GC14-85
The Canadian Medical Association recommends that the federal government establish a medical assistance fund to enable people residing in Canada who have no medical coverage to receive critical emergency medical care
Policy Type
Policy resolution
Last Reviewed
2019-03-03
Date
2014-08-20
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Resolution
GC14-85
The Canadian Medical Association recommends that the federal government establish a medical assistance fund to enable people residing in Canada who have no medical coverage to receive critical emergency medical care
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The Canadian Medical Association recommends that the federal government establish a medical assistance fund to enable people residing in Canada who have no medical coverage to receive critical emergency medical care
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Response to “Consultation Document – Disability Tax Credit Public Consultations” CMA Submission to Canada Revenue Agency

https://policybase.cma.ca/en/permalink/policy14025
Date
2014-12-19
Topics
Health systems, system funding and performance
Physician practice/ compensation/ forms
  1 document  
Policy Type
Parliamentary submission
Date
2014-12-19
Topics
Health systems, system funding and performance
Physician practice/ compensation/ forms
Text
The Canadian Medical Association (CMA) submits this response to the Canada Revenue Agency (CRA) as part of its public consultation on the Disability Tax Credit. The CMA has long-standing and significant concerns pertaining to the Disability Tax Credit. Most notable is the recent legislative development that resulted in physicians being captured in the definition of “promoter”. In light of the significant concern with physicians being captured in the definition of “promoter”, this submission will focus exclusively on the regulatory development following the enactment of the Disability Tax Credit Promoters Restrictions Act. However, the CMA will follow up at a later date with feedback and recommendations to CRA on how the Disability Tax Credit form and process can be improved. Prior to providing the CMA’s position for consideration as part of the regulatory consultation, relevant background respecting the CMA’s participation and recommendations during the legislative process is reviewed. 2. Background: CMA’s Recommendations during the Legislative Process The CMA actively monitored and participated in the consultation process during the legislative development of Bill C-462, Disability Tax Credit Promoters Restrictions Act. During its consideration by the House of Commons, the CMA appeared before the House of Commons Finance Committee and formally submitted its recommendations.1 The CMA’s submission to the Finance Committee is attached as an appendix for reference. Throughout this process, the CMA consistently raised its concern that the bill proposed to include physicians in the definition of “promoter”, to which the response was consistently that physicians would not be captured. The Member of Parliament sponsoring the bill conveyed this message at the second reading stage in the House of Commons: 1 Canada. Parliament. House of Commons. Standing Committee on Finance (2013). Evidence, May 7, 2013. 41st Parliament, 1st Session. Retrieved from www.parl.gc.ca/HousePublications/Publication.aspx?DocId=6138958&Language=E&Mode=1&Parl=41&Ses=1 “Mr. Massimo Pacetti: Mr. Speaker…[in] her bill, she says that the definition of a promoter means a person who directly or indirectly accepts or charges a fee in respect to a disability tax credit. Who is a promoter exactly? Is a doctor, or a lawyer or an accountant considered a promoter? Mrs. Cheryl Gallant: Mr. Speaker, that is an excellent question from my colleague opposite. We are looking at third party promoters quite apart from the regular tax preparers and accountants. It is a new cottage industry that sprung up once the 10- year retroactive provision was made. It recognizes that there are volunteer organizations and even constituency offices that do this type of work. They help constituents fill out applications for tax credits. There is a provision for exemptions so people who volunteer their time at no charge or doctors do not fall into this.”2 In contradiction to this statement, during the Senate National Finance Committee’s study of Bill C-462, CRA Assistant Commissioner Brian McCauley confirmed the CMA’s concerns, stating explicitly that physicians would be captured in the definition of “promoter” and explained “they have to be captured because, if they weren't, you leave a significant compliance loophole”.3 As will be explained further below in this submission, this statement reveals a lack of understanding of the implications of capturing physicians in the definition of “promoter”, in that it has established duplicative regulatory oversight of physicians, specific to the Disability Tax Credit form. 3. Priority Issue: Identify Physicians as an Exempt Profession in Regulation The CMA has been consistent in our opposition to the approach that resulted in physicians being included in the definition of “promoters”. The definition of “promoter” captures physicians who may charge a fee to complete the disability tax credit form, a typical practice 2 C. Gallant. (2013 Feb. 5) Parliament of Canada. Debates of House of Commons (Hansard). 41st Parliament, 1st Session. Retrieved at www.parl.gc.ca/HousePublications/Publication.aspx?Language=E&Mode=1&DocId=5962192#Int-7872066 3 Canada. Parliament. Senate. Standing Committee on National Finance (2014). Evidence, April 2, 2014. 41st Parliament, 2nd Session. Retrieved at www.parl.gc.ca/Content/SEN/Committee/412/nffn/09ev-51313-e.htm?Language=E&Parl=41&Ses=2&comm_id=13. for uninsured physician services. As indicated on page 4 of the CRA’s consultation document, the Disability Tax Credit Promoters Restrictions Act includes the authority to “identify the type of promoter, if any, who is exempt from the reporting requirements under the Act.” Two questions are included on page 7 of the consultation document in relation to this regulatory authority. It is the CMA’s recommendation in response to Question 12 (“Are there any groups or professions that should be exempt from the reporting requirements of the new Act?”) that physicians licensed to practice are identified in regulation as an exempt profession. Specifically, the CMA recommends that CRA include an exemption in the regulations for “a health care practitioner duly licensed under the applicable regulatory authority who provides health care and treatment” from the reporting requirements of the Disability Tax Credit Promoters Restrictions Act. As explained below, this exemption will not introduce a potential loophole that may be exploited by third party companies to circumvent the new restrictions and will mitigate the legislative development that has introduced duplicative regulatory oversight of physicians. 4. Exemption Required to Avoid Duplicative Regulatory Regime; Not a Loophole By capturing physicians in the definition of promoters, the Disability Tax Credit Promoters Restrictions Act has introduced a duplicative regulatory body for physicians: a development which the CMA has fundamentally opposed. As CMA understands it, the CRA’s key concern in capturing physicians in the definition of promoter is with respect to the possibility that third party companies may circumvent these limitations by employing a physician. As previously noted, this issue was raised by CRA’s Assistant Commissioner Brian McCauley in his appearance before the Senate National Finance Committee during its study of Bill C-462. A) CMA’s Recommendation Respects Existing Regulatory Oversight Regime of Physicians The CMA’s recommendation and regulatory proposal limits the exemption of physicians as a profession to those currently licensed under the regulatory authority of provincial/territorial medical regulatory colleges. In Canada, medical practice is the regulatory purview of provinces and territories. Charging a fee for the completion of a form is a typical practice for uninsured services – these are services that fall outside of provincial/territorial health insurance coverage. The practice of charging a fee for an uninsured service by a licensed physician is an activity that is part of medical practice. Such fees are subject to guidelines by provincial and territorial medical associations and oversight by provincial/territorial medical regulatory colleges. The regulatory oversight, including licensing, of physicians falls under the statutory authority of medical regulatory colleges, as legislated and regulated by provincial and territorial governments. For example, in the Province of Saskatchewan, the Medical Profession Act, 1981 establishes the regulatory authority of the College of Physicians and Surgeons of Saskatchewan. This regulatory authority is comprehensive and captures: medical licensure, governing standards of practice, professional oversight, disciplinary proceedings, and offences. In Ontario, this authority is established by the Regulated Health Professions Act, 1991; in British Columbia, by the Health Professions Act, 1996, and so on. B) CMA’s Recommendation Does Not Introduce a Loophole The exemption of physicians as a profession that is “duly licensed under the applicable regulatory authority who provides health care and treatment” would not constitute a loophole. Firstly, any concerns regarding the practices of a physician that is exempted based on this definition could be advanced to the applicable regulatory college for regulatory oversight and if appropriate, discipline. The CMA’s proposed regulatory exemption would not be applicable in the case of a physician not licensed to practice; in this case, the individual would not be under the regulatory authority of a medical regulatory college and would fall under the CRA’s regulatory purview, as established by the Disability Tax Credit Promoters Restrictions Act. With regard to the example raised by CRA’s Assistant Commissioner Brian McCauley in his remarks before the Senate Committee of a retired doctor hired by promoter, retired physicians can retain their licence. If this was the case for this particular physician, as noted above, when CRA had concerns regarding this physician’s actions, his or her regulatory college could have taken appropriate disciplinary action. If, on the other hand, this retired physician’s licence had lapsed, both the individual and the promoter who hired him or her would be potentially liable for fraud (assuming that the term “medical doctor” used in Form T2201 refers to an actively licensed physician) which would convey more serious consequences than those proposed by the Disability Tax Credit Promoters Restrictions Act. 5. Conclusion The CMA strongly encourages the CRA to identify physicians as a profession that is exempt from the reporting requirements of the Disability Tax Credit Promoters Restrictions Act. This exemption is critical to ensure that possible unintended consequences, specifically duplicative regulatory oversight of physicians, are avoided.
Documents
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Emergency funding for end-of-life care for uninsured people residing in Canada

https://policybase.cma.ca/en/permalink/policy11221
Date
2014-08-20
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Ethics and medical professionalism
Resolution
GC14-26
The Canadian Medical Association supports in principle emergency funding for end-of-life care for uninsured people residing in Canada.
Policy Type
Policy resolution
Date
2014-08-20
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Ethics and medical professionalism
Resolution
GC14-26
The Canadian Medical Association supports in principle emergency funding for end-of-life care for uninsured people residing in Canada.
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The Canadian Medical Association supports in principle emergency funding for end-of-life care for uninsured people residing in Canada.
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Accessible, comprehensive and high-quality care for transgender patients

https://policybase.cma.ca/en/permalink/policy11227
Date
2014-08-20
Topics
Health systems, system funding and performance
Ethics and medical professionalism
Resolution
GC14-38
The Canadian Medical Association calls for accessible, comprehensive and high-quality care for transgender patients.
Policy Type
Policy resolution
Date
2014-08-20
Topics
Health systems, system funding and performance
Ethics and medical professionalism
Resolution
GC14-38
The Canadian Medical Association calls for accessible, comprehensive and high-quality care for transgender patients.
Text
The Canadian Medical Association calls for accessible, comprehensive and high-quality care for transgender patients.
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Early training in cultural awareness

https://policybase.cma.ca/en/permalink/policy11229
Date
2014-08-20
Topics
Ethics and medical professionalism
Health systems, system funding and performance
Resolution
GC14-49
The Canadian Medical Association encourages the directors of all medical trainee programs to provide early training in cultural awareness.
Policy Type
Policy resolution
Date
2014-08-20
Topics
Ethics and medical professionalism
Health systems, system funding and performance
Resolution
GC14-49
The Canadian Medical Association encourages the directors of all medical trainee programs to provide early training in cultural awareness.
Text
The Canadian Medical Association encourages the directors of all medical trainee programs to provide early training in cultural awareness.
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Secure modes of electronic communication between patients and health care providers

https://policybase.cma.ca/en/permalink/policy11230
Date
2014-08-20
Topics
Health information and e-health
Ethics and medical professionalism
Resolution
GC14-41
The Canadian Medical Association supports the creation and use of secure modes of electronic communication between patients and health care providers.
Policy Type
Policy resolution
Date
2014-08-20
Topics
Health information and e-health
Ethics and medical professionalism
Resolution
GC14-41
The Canadian Medical Association supports the creation and use of secure modes of electronic communication between patients and health care providers.
Text
The Canadian Medical Association supports the creation and use of secure modes of electronic communication between patients and health care providers.
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Canada Health Infoway engaging consultation with physicians

https://policybase.cma.ca/en/permalink/policy11238
Date
2014-08-20
Topics
Health systems, system funding and performance
Resolution
GC14-43
The Canadian Medical Association encourages Canada Health Infoway to engage in consultation with physicians.
Policy Type
Policy resolution
Date
2014-08-20
Topics
Health systems, system funding and performance
Resolution
GC14-43
The Canadian Medical Association encourages Canada Health Infoway to engage in consultation with physicians.
Text
The Canadian Medical Association encourages Canada Health Infoway to engage in consultation with physicians.
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Supports for women who must leave their home communities to give birth

https://policybase.cma.ca/en/permalink/policy11253
Date
2014-08-20
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
Resolution
GC14-53
The Canadian Medical Association calls for the development and implementation of supports for women who must leave their home communities to give birth.
Policy Type
Policy resolution
Date
2014-08-20
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
Resolution
GC14-53
The Canadian Medical Association calls for the development and implementation of supports for women who must leave their home communities to give birth.
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The Canadian Medical Association calls for the development and implementation of supports for women who must leave their home communities to give birth.
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Federal government’s preparedness for national health emergencies

https://policybase.cma.ca/en/permalink/policy11254
Date
2014-08-20
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
Resolution
GC14-54
The Canadian Medical Association will seek a current-state assessment of the federal government’s preparedness for national health emergencies with respect to mechanisms for providing timely knowledge translation of public health directives for clinicians and increased surveillance by physicians and health officials.
Policy Type
Policy resolution
Date
2014-08-20
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
Resolution
GC14-54
The Canadian Medical Association will seek a current-state assessment of the federal government’s preparedness for national health emergencies with respect to mechanisms for providing timely knowledge translation of public health directives for clinicians and increased surveillance by physicians and health officials.
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The Canadian Medical Association will seek a current-state assessment of the federal government’s preparedness for national health emergencies with respect to mechanisms for providing timely knowledge translation of public health directives for clinicians and increased surveillance by physicians and health officials.
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Big data and its negative impact on professionalism and the confidentiality of medical data

https://policybase.cma.ca/en/permalink/policy11263
Date
2014-08-20
Topics
Ethics and medical professionalism
Health information and e-health
Resolution
GC14-67
The Canadian Medical Association will propose guidelines to ensure optimal use of big data while limiting its negative impact on professionalism and the confidentiality of medical data.
Policy Type
Policy resolution
Date
2014-08-20
Topics
Ethics and medical professionalism
Health information and e-health
Resolution
GC14-67
The Canadian Medical Association will propose guidelines to ensure optimal use of big data while limiting its negative impact on professionalism and the confidentiality of medical data.
Text
The Canadian Medical Association will propose guidelines to ensure optimal use of big data while limiting its negative impact on professionalism and the confidentiality of medical data.
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Theory of constraints

https://policybase.cma.ca/en/permalink/policy11269
Date
2014-08-20
Topics
Ethics and medical professionalism
Health systems, system funding and performance
Resolution
GC14-72
The Canadian Medical Association will study the potential health applications of the theory of constraints.
Policy Type
Policy resolution
Date
2014-08-20
Topics
Ethics and medical professionalism
Health systems, system funding and performance
Resolution
GC14-72
The Canadian Medical Association will study the potential health applications of the theory of constraints.
Text
The Canadian Medical Association will study the potential health applications of the theory of constraints.
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Criteria for identifying barriers to quality, efficiency and equity in emerging models of health care delivery

https://policybase.cma.ca/en/permalink/policy11271
Date
2014-08-20
Topics
Health systems, system funding and performance
Resolution
GC14-74
The Canadian Medical Association will develop policy tools that provide criteria for identifying barriers to quality, efficiency and equity in emerging models of health care delivery.
Policy Type
Policy resolution
Date
2014-08-20
Topics
Health systems, system funding and performance
Resolution
GC14-74
The Canadian Medical Association will develop policy tools that provide criteria for identifying barriers to quality, efficiency and equity in emerging models of health care delivery.
Text
The Canadian Medical Association will develop policy tools that provide criteria for identifying barriers to quality, efficiency and equity in emerging models of health care delivery.
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Shared health system leadership

https://policybase.cma.ca/en/permalink/policy11274
Date
2014-08-20
Topics
Health systems, system funding and performance
Resolution
GC14-78
The Canadian Medical Association supports the development of a framework for shared health system leadership involving physicians, hospital administrators and other stakeholders.
Policy Type
Policy resolution
Date
2014-08-20
Topics
Health systems, system funding and performance
Resolution
GC14-78
The Canadian Medical Association supports the development of a framework for shared health system leadership involving physicians, hospital administrators and other stakeholders.
Text
The Canadian Medical Association supports the development of a framework for shared health system leadership involving physicians, hospital administrators and other stakeholders.
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Insurance industry medical information requirements

https://policybase.cma.ca/en/permalink/policy11275
Date
2014-08-20
Topics
Health information and e-health
Health care and patient safety
Resolution
GC14-79
The Canadian Medical Association will work with the Canadian Life and Health Insurance Association to review insurance industry medical information requirements and ensure that the disclosure of personal health information is restricted to that which is reasonably necessary.
Policy Type
Policy resolution
Date
2014-08-20
Topics
Health information and e-health
Health care and patient safety
Resolution
GC14-79
The Canadian Medical Association will work with the Canadian Life and Health Insurance Association to review insurance industry medical information requirements and ensure that the disclosure of personal health information is restricted to that which is reasonably necessary.
Text
The Canadian Medical Association will work with the Canadian Life and Health Insurance Association to review insurance industry medical information requirements and ensure that the disclosure of personal health information is restricted to that which is reasonably necessary.
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Reneging on freely negotiated and signed agreements

https://policybase.cma.ca/en/permalink/policy11280
Date
2014-08-20
Topics
Health systems, system funding and performance
Ethics and medical professionalism
Resolution
GC14-84
The Canadian Medical Association insists on the necessity for governments not to renege on freely negotiated and signed agreements by using legislative measures.
Policy Type
Policy resolution
Date
2014-08-20
Topics
Health systems, system funding and performance
Ethics and medical professionalism
Resolution
GC14-84
The Canadian Medical Association insists on the necessity for governments not to renege on freely negotiated and signed agreements by using legislative measures.
Text
The Canadian Medical Association insists on the necessity for governments not to renege on freely negotiated and signed agreements by using legislative measures.
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Amendments to PIPEDA, Bill S-4

https://policybase.cma.ca/en/permalink/policy11194
Date
2014-06-09
Topics
Health information and e-health
Ethics and medical professionalism
  1 document  
Policy Type
Parliamentary submission
Date
2014-06-09
Topics
Health information and e-health
Ethics and medical professionalism
Text
The Canadian Medical Association (CMA) is pleased to make submissions on Bill S-4. CMA has followed the history of PIPEDA and participated in the studies of various Standing Committees, most notably and recently in 2007 to the House of Commons Standing Committee on Access to Information, Privacy and Ethics. CMA is pleased that amendments to PIPEDA are once again being considered. The Canadian Medical Association represents over 80,000 physicians in Canada. Privacy is an important value to physicians and the patients to whom they serve. This is reflected in our Code of Ethics and policies, in particular, Principles for the Protection of Patients' Personal Health Information and Statement of Principles: The Sale and Use of Data on Individual Physicians' Prescribing. Physicians are also required to abide by privacy and confidentiality standards of practice. Thus, the CMA has a strong interest and valuable insights into the topic of personal information and privacy with respect to health information. We thank the Standing Committee for the opportunity to comment on the proposed amendments to PIPEDA. Our key comments are outlined below: Issue 1: CMA supports the existing legislative framework on the collection, use and disclosure of personal information produced by an individual in the course of their employment, business or profession ("work product") and suggests further amendments focus on strengthening it further. CMA supports the current standing of work products, that work products are considered to be personal information. That is, we support the framework defining personal information as information about an identifiable individual and that there is no carved out definition or exemption for "work product". CMA supports the position of the Office of Privacy Commissioner's following its 2007 investigation on work products, that they should not be exempted for two main reasons: * The exemption is not needed, and it would be inconsistent with the balanced approach in the current definition of personal information. The current definition of personal information and the approach to deciding issues based on that definition have worked well. They have promoted a level of privacy protection that balances the right of privacy in personal information with the needs of organizations for the reasonable and appropriate collection, use and disclosure of personal information. ...Because the concept of "work product" is ambiguous, excluding it from the definition of personal information could have unpredictable consequences that would diminish privacy unnecessarily. * (http://www.priv.gc.ca/parl/2007/sub_070222_03_e.asp) It is the CMA's position that work products should be considered personal information and given the section 7 amendments, work products should only be collected, used or disclosed without consent only if it is consistent with the purposes for which the information was produced. In the case of physicians, a prime example of a physician's work product is prescribing information. Prescribing information is a synthesis of assessing patients - by probing into their health, familial, social and sometimes financial background - infused with medical knowledge, skill and competencies resulting in a diagnosis and treatment plan, which often includes prescribing a medication or test. Not only is the physician's prescribing information a product of physicians' work but would not exist but for a trusting physician-patient relationship wherein the patient's private and personal information are shared under circumstances of vulnerability and trust. The outcome is that this is personal information. Prescribing information is about an individual: it includes the name of the patient, the name of the prescribing physician, and the drug name, dosage, amount and frequency; giving major clues as to what the patient's health issue(s) are. For further clarity, however, CMA recommends that physician information, and physician work products, should be specifically recognized within the legislation as personal information. To this end, we would propose that the following addition be made to the definition section under personal health information: Section 2.(1) "personal health information", with respect to an individual, whether living or deceased, means .....(d) information that is collected or is the outcome of collecting information in the course of providing health services to the individual; CMA supports the amendments to subsections 7(1)-(3) of the Act that any subsequent collection, use and disclosure of work products without consent must be related to the original purpose (of collection, use and disclosure). This relationship reflects the government's understanding and faithfulness to privacy principles. This is particularly critical when dealing with health information, and is even more critical in today's world given the ease of linking information through advancements in technology. In the absence of a causal relationship, personal information should not be used for system performance, commercial enterprise, data brokering, research, assessment or other purposes. CMA recommends that the legislation should go further and allow persons who believe that protection cannot be afforded under the legislation that they have the authority to refuse to communicate the information. This is the conceptual approach taken in Quebec's Act Respecting the Protection of Personal Information in the Private Sector wherein persons have an opportunity to refuse that professional information (as defined therein) be used for commercial purposes. Physicians are constantly writing prescriptions and such information should only be used for other purposes in the interests of patients and the health care system, and not to serve commercial interests or marketing strategies. If physicians do not feel that such protection is afforded patients, then they should be permitted to refuse that such information be collected, used or disclosed. Patient privacy should be primary. And finally, addressing work products in legislation clears up past differences of interpretation by Privacy Commissioners thus, providing certainty and clarity to the public. Recommendation 1: That Section 2. (1) "personal health information", be amended to read as follows: "personal health information", with respect to an individual, whether living or deceased, means .....(d) information that is collected or is the outcome of collecting information in the course of providing health services to the individual; Issue 2: CMA is pleased to see a section on breaches of security safeguards and recommends greater specificity. As noted above, physicians have responsibilities as data stewards and custodians of health information. As such, CMA supports breach notification measures that would enhance and protect patient privacy. In principle, we support the proposed amendments of breach disclosures to the Privacy Commissioner, to individuals and to organizations. However, CMA is concerned that meeting the requirements may be confusing. For example, in the health care context, it is easy to surmise that all health information is "sensitive". A far more difficult matter is determining whether the risk reaches the threshold of "significant harm" and the "probability" that the information "will be misused". The result being that incidental disclosures will be reported causing unnecessary concern and confusion in the patient population. Further specificity is recommended and we suggest something akin to Ontario's Personal Health Information Protection Act, 2004 (PHIPA). The PHIPA is an act specifically dealing with personal health information. One of its purposes is "to establish rules for the collection, use and disclosure of personal health information about individuals that protect the confidentiality of that information and the privacy of individuals with respect to that information, while facilitating the effective provision of health care" (section 1a ). The PHIPA notification provision states that the individual shall be notified "...at the first reasonable opportunity if the information is stolen, lost or accessed by unauthorized persons", [section 12(2)]. CMA is unaware of any concerns with this approach. The language of PIPIEDA is one of reasonable belief of real risk of significant harm to an individual. The issue is the test for required notification of patients for incidental inadvertent breaches and decreasing "notification fatigue". To illustrate the issue, if physicians were told today that patient data could be retrieved from the drums of discarded photocopiers and printers, it would be inappropriate for legislation to suggest that the entire patient population during the life of the photocopier or printer be notified. To this end, we recommend that there be acknowledgement that in some circumstances notification may not be required. The probability of misuse under PIPEDA is more ambiguous than the PHIPA test. Under PHIPA, the approach is more objective in that the data must be stolen, lost or accessed by unauthorized persons. To our knowledge, the Ontario model has been in place for almost a decade with no significant issues and thus we submit is one that works. In other jurisdictions (eg., Newfoundland and Labrador, Nova Scotia, New Brunswick) with health privacy legislation, there is acknowledgement of trying to balance notification and those breaches unlikely to result in harm by directly indicating when notification is not required. Recommendation 2: CMA recommends that the statute move towards a more objective test and acknowledge that there are situations when notice is not required. Issue 3: CMA supports disclosure without consent under limited circumstances, but finds the current list of disclosures overly inclusive. Health information is considered highly sensitive information and is initially collected for the purpose of individual patient health care. It should only be disclosed with consent and in only some exceptions without consent. The PIPEDA amendments for disclosure without consent have been broadened. Privacy, confidentiality and trust are the foundations of the patient-physician relationship. Without these fundamental values in play, open and honest communications cannot occur and patients would not receive the care they require. Both the patient and the physician have significant investment in the relationship. CMA respects the requirements to disclose information without consent under certain premises, such as required by court order or statute. However, any kind of activity requiring physicians to disclose patient's information without consent for the purposes of advancing a government or institution's goal could jeopardize the relationship. Both the patient's consent and the physician's consent should be required if there is potential to disturb this relationship. The physician is fiduciary of the relationship and is appropriately situated to assess and determine whether disclosure will disturb the relationship. While CMA acknowledges that certain situations may require that disclosure occur without consent (eg. purposes of investigating fraud, national security, abuse or as legally required), disclosure for less malicious activities (e.g., breaches of an agreement, insurance claims) ought to require a court order or warrant. For example, under the proposed section 7(3)(d.1) if a physician were in default of a contract with a technology company supplying electronic medical record software or app to his/her clinic, the company could disclose health information without consent for the "purposes of investigating a breach of an agreement". While we appreciate that there is a caveat that disclosure without advising the patient can only occur if there is a reasonable expectation that the disclosure would compromise the investigation, we submit that leaving the determination of what is "reasonable" to an interested party to the breach is unfair to all. Another example, if a physician is a witness to a dispute between an employer and union representing an employee for denial of long term disability by an insurance company, and has filed a witness statement which includes a medical report he/she wrote to the employer's insurance company, under the proposed section 7(3)(e.1) disclosure of health information without consent is permitted in order to assess, process or settle an insurance claim. CMA is concerned that the disclosure amendments are overly broad and do not differentiate sufficiently between highly time sensitive or grossly malicious situations, and those where it is merely expedient or an administrative encumbrance to seek consent. In addition, the disclosure requirements are framed in permissive (ie., may) and not mandatory language (ie., shall). This is very problematic when the "organization" is a physicians' clinic unless the physician's own consent is made as a pre-condition. CMA believes this suggestion is a progressive one in keeping with the broadened disclosure amendments. Physicians are in a relationship of trust and take seriously the protection of patient privacy and confidentiality, for which they are trained and are ethically and legally required to protect. To place physicians in a position which might entail breaching this trust may impact the confidence of the physician and the patient in the patient-physician relationship which is required to properly formulate appropriate treatment plans; thus, negatively impacting the health of Canadians. Recommendation 3: That disclosures of health information without consent require a warrant or subpoena or court order. Furthermore, disclosures of health information require the physician's consent that in his/her opinion the disclosure does not harm the patient-physician relationship. And, finally any broadened disclosure situations be restricted to criminal activity or that impacting national security. Conclusion Once again, CMA appreciates the opportunity to provide comment as part of the committee's study of Bill S-4. CMA is prepared to work with Parliament, governments, health professionals and the public in ensuring legislative frameworks for the collection, usage and disclosure of personal information for legitimate and reasonable purposes.
Documents
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Bill C-422 An Act respecting a National Lyme Disease Strategy

https://policybase.cma.ca/en/permalink/policy11140
Date
2014-06-02
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2014-06-02
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Text
The Canadian Medical Association is pleased to present this submission to the House of Commons Standing Committee on Health regarding Bill C-422, National Lyme disease strategy. The Canadian Medical Association (CMA) is the national organization representing over 80,000 physicians in Canada; its mission is to serve and unite the physicians of Canada and to be the national advocate, in partnership with the people of Canada, for the highest standards of health and health care. Lyme disease is a growing problem in Canada. According to the Public Health Agency of Canada (PHAC) there were 315 cases of Lyme disease reported in Canada in 2012 -two and one-half times more cases than the 128 reported in 2009, the year that it became a reportable disease. In the Ottawa area, cases have increased almost 8 fold from 6 in 2009 to 47 in 2013. The PHAC surveillance indicates that established populations of blacklegged ticks are spreading their geographic scope, and are increasing in number, in much of southern Canada. In 2013 the US Center for Disease Control and Prevention released new estimates of Lyme disease that was 10 times higher than the previous yearly reported number of 30,000 reported cases.1 This highlights the difficulty in establishing the true burden of illness from Lyme disease. Why this matters to Canada's physicians The Canadian Medical Association supports the implementation of a national strategy that can address the breath of public health and medical issues surrounding the spread of Lyme disease in Canada. As with any new infectious disease threat, Canada needs to ensure that we are prepared to address the impact of Lyme disease on Canadians. CMA's policy on climate change and human health notes that changes in the range of some infectious disease vectors such as blacklegged ticks, are a possible consequence of climate change in Canada. Research has suggested that the tick vector of Lyme disease has been expanding into southeastern Canada which can lead to increased disease risk for those living in areas with tick populations.2 In this policy, CMA recommends that the federal government report diseases that emerge in relation to global climate change, and participate in field investigations, as with outbreaks of infectious diseases like Lyme disease, and develop and expand surveillance systems to include diseases caused by global climate change. The World Medical Association Declaration of Delhi on Health and Climate Change urges colleges and universities to develop locally appropriate continuing medical and public health education on the clinical signs, diagnosis and treatment of new diseases that are introduced into communities as a result of climate change. Diagnosis of Lyme disease can be difficult, as signs and symptoms can be non-specific and found in other conditions. 3 If Lyme disease is not recognized during the early stages, patients may suffer seriously debilitating disease, which may be more difficult to treat.4 Given the increasing incidence of Lyme disease in Canada, continuing education for health care and public health professionals and a national standard of care would improve identification, treatment and management of Lyme disease. Greater awareness of where blacklegged ticks are endemic in Canada, as well as information on the disease and prevention measures, can help Canadians protect themselves from infection. Recommendation The CMA supports a national Lyme disease strategy which includes the federal, provincial and territorial governments and the medical and patient communities. This strategy must address concerns around research, surveillance, diagnosis, treatment and management of the disease and public health prevention measures will advance our current knowledge base, and improve the care and treatment of those suffering from Lyme disease. Conclusion Once again, CMA is pleased to provide this brief to the Standing Committee on Health as part of its study on this important issue. Canada's physicians recognize the importance of monitoring all emerging infectious diseases in Canada. In addition, Canada's physicians recognize the importance of developing strategies to treat, manage, and prevent Lyme disease in Canada. 1 CDC provides estimate of Americans diagnosed with Lyme disease each year, media release August 19, 2013 Accessed at http://www.cdc.gov/media/releases/2013/p0819-lyme-disease.html on Feb 21, 2014. 2 Ogden, N., L. Lindsay, and P. Leighton. 2013. Predicting the rate of invasion of the agent of Lyme disease Borrelia burgdorferi. Journal of Applied Ecology. April, 2013. 50(2):510-518. 3 Mayo Clinic, accessed at http://www.mayoclinic.org/diseases-conditions/lyme-disease/basics/tests-diagnosis/con-20019701 on Feb 21, 2014. 4 Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment, treatment, and prevention of Lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2006;43: 1089-134.
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