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Guiding principles for the optimal use of data analytics by physicians at the point of care

https://policybase.cma.ca/en/permalink/policy11812
Last Reviewed
2020-02-29
Date
2016-02-27
Topics
Health information and e-health
  1 document  
Policy Type
Policy document
Last Reviewed
2020-02-29
Date
2016-02-27
Topics
Health information and e-health
Text
Electronic tools are now being used more widely in medicine than ever before. A majority of physicians in Canada have adopted electronic medical records (EMRs)-75% of physicians use EMRs to enter or retrieve clinical patient notes, and 80% use electronic tools to access laboratory/diagnostic test results. The increased use of point-of-care tools and information repositories has resulted in the mass digitization and storage of clinical information, which provides opportunities for the use of big data analytics. Big data analytics may come to be understood as the process of examining clinical data in EMRs cross-referenced with other administrative, demographic and behavioural data sources to reveal determinants of patient health and patterns in clinical practice. Its increased use may provide opportunities to develop and enhance clinical practice tools and to improve health outcomes at both point-of-care and population levels. However, given the nature of EMR use in Canada, these opportunities may be restricted to primary care practice at this time. Physicians play a central role in finding the right balance between leveraging the advantages of big data analytics and protecting patient privacy. Guiding Principles for the Optimal Use of Data Analytics by Physicians at the Point of Care outlines basic considerations for the use of big data analytics services and highlights key considerations when responding to requests for access to EMR data, including the following: * Why will data analytics be used? Will the safety and effectiveness of patient care be enhanced? Will the results be used to inform public health measures? * What are the responsibilities of physicians to respect and protect patient and physician information, provide appropriate information during consent conversations, and review data sharing agreements and consult with EMR vendors to understand how data will be used? As physicians will encounter big data analytics in a number of ways, this document also outlines the characteristics one should be looking for when assessing the safety and effectiveness of big data analytics services: * protection of privacy * clear and detailed data sharing agreement * physician-owned and -led data collaboratives * endorsement by a professional or recognized association, medical society or health care organization * scope of services and functionality/appropriateness of data While this guidance is not a standalone document-it should be used as a supplemental reference to provincial privacy legislation-it is hoped that it can aid physicians to identify suitable big data analytics services and derive benefits from them. Introduction This document outlines basic considerations for the use of big data analytics services at the point of care or for research approved by a research ethics board. This includes considerations when responding to requests for access to data in electronic medical records (EMRs). These guiding principles build on the policies of the Canadian Medical Association (CMA) on Data Sharing Agreements: Principles for Electronic Medical Records/Electronic Health Records,1 Principles Concerning Physician Information2 and Principles for the Protection of Patients' Personal Health Information,3 the 2011 clinical vignettes Disclosing Personal Health Information to Third Parties4 and Need to Know and Circle of Care,5 and the Canadian Medical Protective Association's The Impact of Big Data on Healthcare and Medical Practice.6 These guiding principles are for information and reference only and should not be construed as legal or financial advice, nor is this document a substitute for legal or other professional advice. Physicians must always comply with all legislation that applies to big data analytics, including privacy legislation. Big data analytics in the clinical context involves the collection, use and potential disclosure of patient and physician information, both of which could be considered sensitive personal information under privacy legislation. Big data analytics has the potential to improve health outcomes, both at the point of care and at a population level. Doctors have a key role to play in finding the right balance between leveraging the advantages of big data (enhanced care, service delivery and resource management) and protecting patient privacy.7 Background A majority of physicians in Canada have adopted EMRs in their practice. The percentage of physicians using EMRs to enter or retrieve clinical patient notes increased from 26% in 2007 to 75% in 2014. Eighty percent of physicians used electronic tools to access laboratory/diagnostic test results in 2014, up from 38% in 2010.8 The increasingly broad collection of information by physicians at the point of care, combined with the growth of information repositories developed by various governmental and intergovernmental bodies, has resulted in the mass digitization and storage of clinical information. Big data is the term for data sets so large and complex that it is difficult to process them using traditional relational database management systems, desktop statistics and visualization software. What is considered "big" depends on the infrastructure and capabilities of the organization managing the data.9 Analytics is the discovery and communication of meaningful patterns in data. Analytics relies on the simultaneous application of statistics, computer programming and operations research. Analytics often favours data visualization to communicate insight, and insights from data are used to guide decision-making.10 For physicians, big data analytics may come to be understood as the process of examining the clinical data in EMRs cross-referenced with other administrative, demographic and behavioural data sources to reveal determinants of patient health and patterns in clinical practice. This information can be used to assist clinical decision-making or for research approved by a research ethics board. There are four types of big data analytics physicians may encounter in the provision of patient care. They are generally performed in the following sequence, in a continuous cycle11,12,13,14: 1. Population health analytics: Health trends are identified in the aggregate within a community, a region or a national population. The data can be derived from biomedical and/or administrative data. 2. Risk-based cost analysis: Populations are segmented into groups according to the level of risk to the patient's health and/or cost to the health system. 3. Care management: Clinicians are enabled to manage patient care according to defined care pathways and clinical protocols informed by population health analytics and risk-based cost analysis. Care management includes the following: o Clinical decision support: Outcomes are predicted and/or alternative treatments are recommended to clinicians and patients at the point of care. o Personalized/precision care: Personalized data sets, such as genomic DNA sequences for at-risk patients, are leveraged to highlight best practice treatments for patients and practitioners. These solutions may offer early detection and diagnosis before a patient develops disease symptoms. o Clinical operations: Workflow management is performed, such as wait-times management, mining historical and unstructured data for patterns to predict events that may affect care. o Continuing education and professional development: Longitudinal performance data are combined across institutions, classes, cohorts or programs with correlating patient outcomes to assess models of education and/or develop new programs. 4. Performance analytics: Metrics for quality and efficiency of patient care are cross-referenced with clinical decision-making and performance data to assess clinical performance. This cycle is also sometimes understood as a component of "meaningful" or "enhanced" use of EMRs. How might physicians encounter big data analytics? Many EMRs run analytics both visibly (e.g., as a function that can be activated at appropriate junctures in the care pathway) and invisibly (e.g., as tools that run seamlessly in the background of an EMR). Physicians may or may not be aware when data are being collected, analyzed, tailored or presented by big data analytics services. However, many jurisdictions are strengthening their laws and standards, and best practices are gradually emerging.15 Physicians may have entered into a data sharing agreement with their EMR vendor when they procured an EMR for their practice. Such agreements may include provisions to share de-identified (i.e., anonymized) and/or aggregate data with the EMR vendor for specified or unspecified purposes. Physicians may also receive requests from third parties to share their EMR data. These requests may come from various sources: * provincial governments * intergovernmental agencies * national and provincial associations, including medical associations * non-profit organizations * independent researchers * EMR vendors, service providers and other private corporations National Physician Survey results indicate that in 2014, 10% of physicians had shared data from their EMRs for the purposes of research, 10% for chronic disease surveillance and 8% for care improvement. Family physicians were more likely than other specialists to share with public health agencies (22% v. 11%) and electronic record vendors (13% v. 2%). Specialists were more likely than family physicians to share with researchers (59% v. 37%), hospital departments (47% v. 20%) and university departments (28% v. 15%). There is significant variability across the provinces with regard to what proportion of physicians are sharing information from their EMRs, which is affected by the presence of research initiatives, research objectives defined by the approval of a research ethics board, the adoption rates of EMRs among physicians in the province and the functionality of those EMRs.16 For example, there are family practitioners across Canada who provide data to the Canadian Primary Care Sentinel Surveillance Network (CPCSSN). The CPCSSN is a multi-disease EMR surveillance and research system that allows family physicians, epidemiologists and researchers to understand and manage chronic care conditions for patients. Health information is collected from EMRs in the offices of participating family physicians, specifically information about Canadians suffering from chronic and mental health conditions and three neurologic conditions, including Alzheimer's and related dementias.17 In another example, the Canadian Partnership Against Cancer's Surgical Synoptic Reporting Initiative captures standardized information about surgery at the point of care and transmits the surgical report to other health care personnel. Surgeons can use the captured information, which gives them the ability to assess adherence to the clinical evidence and safety procedures embedded in the reporting templates, to track their own practices and those of their community.18 The concept of synoptic reporting-whereby a physician provides anonymized data about their practice in return for an aggregate report summarizing the practice of others -can be expanded to any area in which an appropriate number of physicians are willing to participate. Guiding principles for the use of big data analytics These guiding principles are designed to give physicians a starting point as they consider the use of big data analytics in their practices: * The objective of using big data analytics must be to enhance the safety and/or effectiveness of patient care or for the purpose of health promotion. * Should a physician use big data analytics, it is the responsibility of the physician to do so in a way that adheres to their legislative, regulatory and/or professional obligations. * Physicians are responsible for the privacy of their individual patients. Physicians may wish to refer to the CMA's policy on Principles for the Protection of Patients' Personal Health Information.19 * Physicians are responsible for respecting and protecting the privacy of other physicians' information. Physicians may wish to refer to the CMA's policy on Principles Concerning Physician Information.20 * When physicians enter into and document a broad consent discussion with their patient, which can include the electronic management of health information, this agreement should convey information to cover the elements common to big data analytics services. * Physicians may also wish to consider the potential for big data analytics to inform public health measures and enhance health system efficiency and take this into account when responding to requests for access to data in an EMR. * Many EMR vendors provide cloud-based storage to their clients, so information entered into an EMR may be available to the EMR vendor in a de-identified and/or aggregate state. Physicians should carefully read their data sharing agreement with their EMR vendor to understand how and why the data that is entered into an EMR is used, and/or they should refer to the CMA's policy on the matter, Data Sharing Agreements: Principles for Electronic Medical Records/Electronic Health Records.21 * Given the dynamic nature of this emerging tool, physicians are encouraged to share information about their experiences with big data analytics and its applications with colleagues. Characteristics of safe and effective big data analytics services 1. Protection of privacy Privacy and security concerns present a challenge in linking big data in EMRs. As data are linked, it becomes increasingly difficult to de-identify individual patients.22 As care is increasingly provided in interconnected, digital environments, physicians are having to take on the role of data stewardship. To that end, physicians may wish to employ conservative risk assessment practices-"should we" as opposed to "can we" when linking data sources-and obtain express patient consent, employing a "permission-based" approach to the collection and stewardship of data. 2. A clear and detailed data sharing agreement Physicians entering into a contract with an EMR vendor or other third party for provision of services should understand how and when they are contributing to the collection of data for the purposes of big data analytics services. There are template data sharing agreements available, which include the basic components of safe and effective data sharing, such as the model provided by the Information and Privacy Commissioner of Ontario.23 Data sharing agreements may include general use and project-specific use, both of which physicians should assess before entering into the agreement. When EMR access is being provided to a ministry of health and/or regional health authority, the data sharing agreement should distinguish between access to administrative data and access to clinical data. Physicians may wish to refer to the CMA's policy on Data Sharing Agreements: Principles for Electronic Medical Records/Electronic Health Records.24 3. Physician-owned and -led data collaboratives In some provinces there may exist opportunities to share clinical data in physician-owned and -led networks to reflect on and improve patient care. One example is the Physicians Data Collaborative in British Columbia, a not-for-profit organization open to divisions of family practice.25 Collaboratives such as this one are governed by physicians and driven by a desire to protect the privacy and safety of patients while producing meaningful results for physicians in daily practice. Participation in physician-owned data collaboratives may ensure that patient data continue to be managed by physicians, which may lead to an appropriate prioritization of physicians' obligations to balance patient-centred care and patient privacy. 4. Endorsement by a professional or other recognized association or medical society or health care organization When considering use of big data analytics services, it is best to select services created or endorsed by a professional or other recognized association or medical society. Some health care organizations, such as hospitals, may also develop or endorse services for use in their clinical environments. Without such endorsement, physicians are advised to proceed with additional caution. 5. Scope of services and functionality/appropriateness of data Physicians may wish to seek out information from EMR vendors and service providers about how big data analytics services complement the process of diagnosis and about the range of data sources from which these services draw. While big data analytics promises insight into population health and practice trends, if it is not drawing from an appropriate level of cross-referenced sources it may present a skewed picture of both.26 Ultimately, the physician must decide if the sources are appropriately diverse. Physicians should expect EMR vendors and service providers to make clear how and why they draw the information they do in the provision of analytics services. Ideally, analytics services should integrate population health analytics, risk-based cost analysis, care management services (such as point-of-care decision support tools) and performance analytics. Physicians should expect EMR vendors to allocate sufficient health informatics resources to information management, technical infrastructure, data protection and response to breaches in privacy, and data extraction and analysis.27,28 Physicians may also wish to consider the appropriateness of data analytics services in the context of their practices. Not all data will be useful for some medical specialties, such as those treating conditions that are relatively rare in the overall population. The potential for new or enhanced clinical practice tools informed by big data analytics may be restricted to primary care practice at this time.29 Finally, predictive analytics often make treatment recommendations that are designed to improve the health outcomes in a population, and these recommendations may conflict with physicians' ethical obligations to act in the best interests of individual patients and respect patients' autonomous decision-making).30 References 1 Canadian Medical Association. Data sharing agreements: principles for electronic medical records/electronic health records [CMA policy]. Ottawa: The Association; 2009. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD09-01.pdf 2 Canadian Medical Association. Principles concerning physician information [CMA policy]. CMAJ 2002 167(4):393-4. Available: http://policybase.cma.ca/dbtw-wpd/PolicyPDF/PD02-09.pdf 3 Canadian Medical Association. Principles for the protection of patients' personal health information [CMA policy]. Ottawa: The Association; 2010. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD11-03.pdf 4 Canadian Medical Association. Disclosing personal health information to third parties. Ottawa: The Association; 2011. Available: www.cma.ca/Assets/assets-library/document/en/advocacy/CMA_Disclosure_third_parties-e.pdf 5 Canadian Medical Association. Need to know and circle of care. Ottawa: The Association; 2011. Available: www.cma.ca/Assets/assets-library/document/en/advocacy/CMA_Need_to_know_circle_care-e.pdf 6 Canadian Medical Protective Association. The impact of big data on healthcare and medical practice. Ottawa: The Association; no date. Available: https://oplfrpd5.cmpa-acpm.ca/documents/10179/301372750/com_14_big_data_design-e.pdf 7 Kayyali B, Knott D, Van Kuiken S. The 'big data' revolution in US health care: accelerating value and innovation. New York: McKinsey & Company; 2013. p. 1. 8 College of Family Physicians of Canada, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada. National physician survey, 2014. National results by FP/GP or other specialist, sex, age and all physicians. Q7. Ottawa: The Colleges and Association; 2014. Available: http://nationalphysiciansurvey.ca/wp-content/uploads/2014/08/2014-National-EN-Q7.pdf 9 Anonymous. Data, data everywhere. The Economist 2010 Feb 27. Available: www.economist.com/node/15557443 10 Anonymous. Data, data everywhere. The Economist 2010 Feb 27. Available: www.economist.com/node/15557443 11 Canada Health Infoway. Big data analytics in health. Toronto: Canada Health Infoway; 2013. Available: www.infoway-inforoute.ca/index.php/resources/technical-documents/emerging-technology/doc_download/1419-big-data-analytics-in-health-white-paper-full-report (accessed 2014 May 16). 12 Ellaway RH, Pusic MV, Galbraith RM, Cameron T. 2014 Developing the role of big data and analytics in health professional education. Med Teach 2014;36(3):216-222. 13 Marino DJ. Using business intelligence to reduce the cost of care. Healthc Financ Manage 2014;68(3):42-44, 46. 14 Porter ME, Lee TH. The strategy that will fix health care. Harv Bus Rev 2013;91(10):50-70. 15 Baggaley C. Data protection in a world of big data: Canadian Medical Protective Association information session [presentation]. 2014 Aug 20. Available: https://oplfrpd5.cmpa-acpm.ca/documents/10179/301372750/com_2014_carmen_baggaley-e.pdf 16 College of Family Physicians of Canada, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada. National physician survey, 2014. National results by FP/GP or other specialist, sex, age and all physicians. Q10. Ottawa: The Colleges and Association; 2014. Available: http://nationalphysiciansurvey.ca/wp-content/uploads/2014/08/2014-National-EN-Q10.pdf 17 Canadian Primary Care Sentinel Surveillance Network. Available: http://cpcssn.ca/ (accessed 2014 Nov 15). 18 Canadian Partnership Against Cancer. Sustaining action toward a shared vision: 2012-2017 strategic plan. Toronto: The Partnership; no date. Available: www.partnershipagainstcancer.ca/wp-content/uploads/sites/5/2015/03/Sustaining-Action-Toward-a-Shared-Vision_accessible.pdf 19 Canadian Medical Association. Principles for the protection of patients' personal health information [CMA policy]. Ottawa: The Association; 2011. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD11-03.pdf 20 Canadian Medical Association. Principles for the protection of patients' personal health information [CMA policy]. Ottawa: The Association; 2011. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD11-03.pdf 21 Canadian Medical Association. Data sharing agreements: principles for electronic medical records/electronic health records [CMA policy]. Ottawa: The Association; 2009. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD09-01.pdf 22 Weber G, Mandl KD, Kohane IS. Finding the missing link for big biomedical data . JAMA 2014;311(24):2479-2480. doi:10.1001/jama.2014.4228. 23 Information and Privacy Commissioner of Ontario. Model data sharing agreement. Toronto: The Commissioner; 1995. Available: www.ipc.on.ca/images/Resources/model-data-ag.pdf 24 Canadian Medical Association. Data sharing agreements: principles for electronic medical records/electronic health records [CMA policy]. Ottawa: The Association; 2009. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD09-01.pdf 25 Physicians Data Collaborative. Overview. Available: www.divisionsbc.ca/datacollaborative/home 26 Cohen IG, Amarasingham R, Shah A, Xie B, Lo B. The legal and ethical concerns that arise from using complex predictive analytics in health care. Health Aff 2014;33(7):1139-1147. 27 Rhoads J, Ferrara L. Transforming healthcare through better use of data. Electron Healthc 2012;11(1):e27. 28 Canadian Medical Protective Association. The impact of big data and healthcare and medical practice. Ottawa: The Association; no date. Available: https://oplfrpd5.cmpa-acpm.ca/documents/10179/301372750/com_14_big_data_design-e.pdf 29 Genta RM, Sonnenberg A. Big data in gastroenterology research. Nat Rev Gastroenterol Hepatol 2014;11(6):386-390. 30 Cohen IG, Amarasingham R, Shah A, Xie B, Lo B. The legal and ethical concerns that arise from using complex predictive analytics in health care. Health Aff 2014;33(7):1139-1147.
Documents
Less detail

Community-based physician teachers

https://policybase.cma.ca/en/permalink/policy1887
Last Reviewed
2019-03-03
Date
2005-08-17
Topics
Physician practice/ compensation/ forms
Resolution
GC05-67
The Canadian Medical Association urges medical faculties to compensate and recognize community-based physician teachers appropriately to reflect the value of their contributions to medical education.
Policy Type
Policy resolution
Last Reviewed
2019-03-03
Date
2005-08-17
Topics
Physician practice/ compensation/ forms
Resolution
GC05-67
The Canadian Medical Association urges medical faculties to compensate and recognize community-based physician teachers appropriately to reflect the value of their contributions to medical education.
Text
The Canadian Medical Association urges medical faculties to compensate and recognize community-based physician teachers appropriately to reflect the value of their contributions to medical education.
Less detail

Capacity of the medical educational and training infrastructure

https://policybase.cma.ca/en/permalink/policy1888
Last Reviewed
2019-03-03
Date
2005-08-17
Topics
Health human resources
Health systems, system funding and performance
Resolution
GC05-68
The Canadian Medical Association calls on the federal government to commission an independent body to assess and report on the capacity of the educational and training infrastructure across Canada to expand enrolment in medicine and nursing programs.
Policy Type
Policy resolution
Last Reviewed
2019-03-03
Date
2005-08-17
Topics
Health human resources
Health systems, system funding and performance
Resolution
GC05-68
The Canadian Medical Association calls on the federal government to commission an independent body to assess and report on the capacity of the educational and training infrastructure across Canada to expand enrolment in medicine and nursing programs.
Text
The Canadian Medical Association calls on the federal government to commission an independent body to assess and report on the capacity of the educational and training infrastructure across Canada to expand enrolment in medicine and nursing programs.
Less detail

Primary care delivery models

https://policybase.cma.ca/en/permalink/policy1893
Last Reviewed
2019-03-03
Date
2005-08-17
Topics
Health systems, system funding and performance
Resolution
GC05-73
The Canadian Medical Association will conduct an economic evaluation of multidisciplinary and other primary care delivery models.
Policy Type
Policy resolution
Last Reviewed
2019-03-03
Date
2005-08-17
Topics
Health systems, system funding and performance
Resolution
GC05-73
The Canadian Medical Association will conduct an economic evaluation of multidisciplinary and other primary care delivery models.
Text
The Canadian Medical Association will conduct an economic evaluation of multidisciplinary and other primary care delivery models.
Less detail

Family medicine training

https://policybase.cma.ca/en/permalink/policy1895
Last Reviewed
2019-03-03
Date
2005-08-17
Topics
Health human resources
Resolution
GC05-75
The Canadian Medical Association will call on the Association of Faculties of Medicine of Canada and the College of Family Physicians of Canada to ensure that all medical students undergo a significant period of family medicine training in community settings that are representative of real-world general and family practice.
Policy Type
Policy resolution
Last Reviewed
2019-03-03
Date
2005-08-17
Topics
Health human resources
Resolution
GC05-75
The Canadian Medical Association will call on the Association of Faculties of Medicine of Canada and the College of Family Physicians of Canada to ensure that all medical students undergo a significant period of family medicine training in community settings that are representative of real-world general and family practice.
Text
The Canadian Medical Association will call on the Association of Faculties of Medicine of Canada and the College of Family Physicians of Canada to ensure that all medical students undergo a significant period of family medicine training in community settings that are representative of real-world general and family practice.
Less detail

Clinical faculty

https://policybase.cma.ca/en/permalink/policy1896
Last Reviewed
2019-03-03
Date
2005-08-17
Topics
Population health/ health equity/ public health
Resolution
GC05-76
The Canadian Medical Association calls upon the federal/provincial/territorial governments, in conjunction with practicing physicians, to immediately develop a joint comprehensive plan with practicing physicians for recruiting, retaining, and adequately compensating clinical faculty.
Policy Type
Policy resolution
Last Reviewed
2019-03-03
Date
2005-08-17
Topics
Population health/ health equity/ public health
Resolution
GC05-76
The Canadian Medical Association calls upon the federal/provincial/territorial governments, in conjunction with practicing physicians, to immediately develop a joint comprehensive plan with practicing physicians for recruiting, retaining, and adequately compensating clinical faculty.
Text
The Canadian Medical Association calls upon the federal/provincial/territorial governments, in conjunction with practicing physicians, to immediately develop a joint comprehensive plan with practicing physicians for recruiting, retaining, and adequately compensating clinical faculty.
Less detail

International medical students

https://policybase.cma.ca/en/permalink/policy1898
Last Reviewed
2019-03-03
Date
2005-08-17
Topics
Health human resources
Physician practice/ compensation/ forms
Resolution
GC05-78
The Canadian Medical Association will approach international medical associations to determine best practices for attracting medical students to family medicine and methods for securing a strong professional and adequately compensated future for general and family practitioners.
Policy Type
Policy resolution
Last Reviewed
2019-03-03
Date
2005-08-17
Topics
Health human resources
Physician practice/ compensation/ forms
Resolution
GC05-78
The Canadian Medical Association will approach international medical associations to determine best practices for attracting medical students to family medicine and methods for securing a strong professional and adequately compensated future for general and family practitioners.
Text
The Canadian Medical Association will approach international medical associations to determine best practices for attracting medical students to family medicine and methods for securing a strong professional and adequately compensated future for general and family practitioners.
Less detail

Physician workforce planning for under-serviced areas

https://policybase.cma.ca/en/permalink/policy1900
Last Reviewed
2019-03-03
Date
2005-08-17
Topics
Health human resources
Health systems, system funding and performance
Resolution
GC05-80
The Canadian Medical Association recommends that any definition of under-serviced areas for physician workforce planning and related purposes must also include and recognize the needs of inner-city communities and populations, and not be limited to rural and remote locations.
Policy Type
Policy resolution
Last Reviewed
2019-03-03
Date
2005-08-17
Topics
Health human resources
Health systems, system funding and performance
Resolution
GC05-80
The Canadian Medical Association recommends that any definition of under-serviced areas for physician workforce planning and related purposes must also include and recognize the needs of inner-city communities and populations, and not be limited to rural and remote locations.
Text
The Canadian Medical Association recommends that any definition of under-serviced areas for physician workforce planning and related purposes must also include and recognize the needs of inner-city communities and populations, and not be limited to rural and remote locations.
Less detail

Family medicine residency positions

https://policybase.cma.ca/en/permalink/policy1901
Last Reviewed
2019-03-03
Date
2005-08-17
Topics
Health human resources
Health systems, system funding and performance
Resolution
GC05-81
The Canadian Medical Association urges governments to assign targeted funding to increase the number of family medicine residency positions to meet recent increases in medical school enrolment and other demand factors.
Policy Type
Policy resolution
Last Reviewed
2019-03-03
Date
2005-08-17
Topics
Health human resources
Health systems, system funding and performance
Resolution
GC05-81
The Canadian Medical Association urges governments to assign targeted funding to increase the number of family medicine residency positions to meet recent increases in medical school enrolment and other demand factors.
Text
The Canadian Medical Association urges governments to assign targeted funding to increase the number of family medicine residency positions to meet recent increases in medical school enrolment and other demand factors.
Less detail

Re-entry training positions

https://policybase.cma.ca/en/permalink/policy1902
Last Reviewed
2019-03-03
Date
2005-08-17
Topics
Health human resources
Resolution
GC05-83
The Canadian Medical Association recommends to educational and licensing authorities, Provincial Governments and the Canadian Medical Forum a fourfold increase in re-entry training positions and elimination of associated return of service requirements.
Policy Type
Policy resolution
Last Reviewed
2019-03-03
Date
2005-08-17
Topics
Health human resources
Resolution
GC05-83
The Canadian Medical Association recommends to educational and licensing authorities, Provincial Governments and the Canadian Medical Forum a fourfold increase in re-entry training positions and elimination of associated return of service requirements.
Text
The Canadian Medical Association recommends to educational and licensing authorities, Provincial Governments and the Canadian Medical Forum a fourfold increase in re-entry training positions and elimination of associated return of service requirements.
Less detail

Pilot needle exchange program in prisons

https://policybase.cma.ca/en/permalink/policy1912
Last Reviewed
2019-03-03
Date
2005-08-17
Topics
Population health/ health equity/ public health
Resolution
GC05-39
The Canadian Medical Association recommends that Correctional Service of Canada develop, implement and evaluate a pilot needle exchange program in prison(s) under its jurisdiction.
Policy Type
Policy resolution
Last Reviewed
2019-03-03
Date
2005-08-17
Topics
Population health/ health equity/ public health
Resolution
GC05-39
The Canadian Medical Association recommends that Correctional Service of Canada develop, implement and evaluate a pilot needle exchange program in prison(s) under its jurisdiction.
Text
The Canadian Medical Association recommends that Correctional Service of Canada develop, implement and evaluate a pilot needle exchange program in prison(s) under its jurisdiction.
Less detail

Scientifically proven health programs

https://policybase.cma.ca/en/permalink/policy1915
Last Reviewed
2019-03-03
Date
2005-08-17
Topics
Health systems, system funding and performance
Resolution
GC05-42
The Canadian Medical Association calls on the federal government to support only scientifically proven health programs that are accepted by a broad consensus of the scientific community.
Policy Type
Policy resolution
Last Reviewed
2019-03-03
Date
2005-08-17
Topics
Health systems, system funding and performance
Resolution
GC05-42
The Canadian Medical Association calls on the federal government to support only scientifically proven health programs that are accepted by a broad consensus of the scientific community.
Text
The Canadian Medical Association calls on the federal government to support only scientifically proven health programs that are accepted by a broad consensus of the scientific community.
Less detail

Programs to achieve national health goals

https://policybase.cma.ca/en/permalink/policy1926
Last Reviewed
2019-03-03
Date
2005-08-17
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Resolution
GC05-09
The Canadian Medical Association calls on all levels of government to adequately resource, coordinate and assume accountability for programs to achieve national health goals.
Policy Type
Policy resolution
Last Reviewed
2019-03-03
Date
2005-08-17
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Resolution
GC05-09
The Canadian Medical Association calls on all levels of government to adequately resource, coordinate and assume accountability for programs to achieve national health goals.
Text
The Canadian Medical Association calls on all levels of government to adequately resource, coordinate and assume accountability for programs to achieve national health goals.
Less detail

Supporting the enactment of Bill C-14, Medical Assistance in Dying

https://policybase.cma.ca/en/permalink/policy13693
Last Reviewed
2019-03-03
Date
2016-05-02
Topics
Ethics and medical professionalism
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2019-03-03
Date
2016-05-02
Topics
Ethics and medical professionalism
Text
In this submission to the House of Commons Standing Committee on Justice and Human Rights, the CMA’s feedback is focused on three of the legislative objectives of Bill C-14, given their relevance to the CMA’s Principles-based Recommendations for a Canadian Approach to Assisted Dying. On behalf of its more than 83,000 members and the Canadian public, the CMA performs a wide variety of functions. Key functions include advocating for health promotion and disease/injury prevention policies and strategies, advocating for access to quality health care, facilitating change within the medical profession, and providing leadership and guidance to physicians to help them influence, manage and adapt to changes in health care delivery. i) Robust Safeguards First, the CMA supports the legislative objective of ensuring a system of robust safeguards to the provision of medical assistance in dying. The safeguards proposed by Bill C-14 include: patient eligibility criteria, process requirements to request medical assistance in dying, as well as monitoring and reporting requirements. The CMA is a voluntary professional organization representing the majority of Canada’s physicians and comprising 12 provincial and territorial divisions and over 60 national medical organizations. ii) Consistent, Pan-Canadian Framework Second, the CMA supports the legislative objective that a consistent framework for medical assistance in dying in Canada is desirable. In addition to robust safeguards, key measures proposed by Bill C-14 support the promulgation of a consistent framework across jurisdictions include legislating definitions for “medical assistance in dying” and “grievous and irremediable condition.” The CMA’s Principles-based Recommendations reflect on the subjective nature of what constitutes “enduring and intolerable suffering” and a “grievous and irremediable condition” as well as the physician’s role in making an eligibility determination. iii) End-of-Life Care Coordination System Thirdly, the CMA supports the objective to develop additional measures to support the provision of a full range of options for end-of-life care and to respect the personal convictions of health care providers. The fulfilment of these commitments with federal non-legislative measures will be integral to supporting the achievement of access to care, respecting the personal convictions of health care providers, and developing a consistent, pan-Canadian framework. The CMA encourages the federal government to rapidly advance its commitment to engage the provinces and territories in developing a pan-Canadian end-of-life care coordinating system. It will be essential for this system to be in place for June 6, 2016. At least one jurisdiction has made a system available to support connecting patients with willing providers. Until a pan-Canadian system is available, there will be a disparity of support for patients and practitioners across jurisdictions. iv) Respect Personal Convictions Finally, it is the CMA’s position that Bill C-14, to the extent constitutionally possible, must respect the personal convictions of health care providers. In the Carter decision, the Supreme Court of Canada emphasized that any regulatory or legislative response must seek to reconcile the Charter rights of patients wanting to access assisted dying and physicians who choose not to participate in medical assistance in dying on grounds of conscientious objection. The CMA’s Principles-based Recommendations achieves an appropriate balance between physicians’ freedom of conscience and the assurance of effective and timely patient access to a medical service. From the CMA’s significant consultation with our membership, it is clear that physicians who are comfortable providing referrals strongly believe it is necessary to ensure the system protects the conscience rights of physicians who are not. While the federal government has achieved this balance with Bill C-14, there is the potential for other regulatory bodies to implement approaches that may result in a patchwork system. The CMA’s position is that the federal government effectively mitigate this outcome by rapidly advancing the establishment of the pan-Canadian end-of-life care coordinating system. CMA Supports Cautious Approach for “Carter Plus” The CMA must emphasize the need for caution and careful study in consideration of “Carter Plus”, which includes: eligibility of mature minors, eligibility with respect to sole mental health conditions, and advance care directives. The CMA supports the federal government’s approach not to legislate these issues, rather to study them in greater detail. Word count: 750
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Medical professionalism (Update 2005)

https://policybase.cma.ca/en/permalink/policy1936
Last Reviewed
2018-03-03
Date
2005-12-03
Topics
Ethics and medical professionalism
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2005-12-03
Replaces
Medical professionalism (2002)
Topics
Ethics and medical professionalism
Text
Medical professionalism (Update 2005) The environment in which medicine is practised in Canada is undergoing rapid and profound change. There are now continued opportunities for the medical profession to provide leadership for our patients, our communities and our colleagues through strengthened professionalism. The Canadian Medical Association (CMA) is strongly committed to medical professionalism and has developed this policy both to inform physicians and others about its meaning and value and to promote its preservation and enhancement. This document outlines the major features of medical professionalism, the opportunities which exist in this area and the challenges which lie before us. Why Medical Professionalism? The medical profession is characterized by a strong commitment to the well-being of patients, high standards of ethical conduct, mastery of an ever-expanding body of knowledge and skills, and a high level of clinical independence. As individuals, physicians' personal values may vary, but as members of the medical profession they are expected to share and uphold those values that characterize the practice of medicine and the care of patients. Medical professionalism includes both the relationship between a physician and a patient and a social contract between physicians and society. Society grants the profession privileges, including exclusive or primary responsibility for the provision of certain services and a high degree of self-regulation. In return, the profession agrees to use these privileges primarily for the benefit of others and only secondarily for its own benefit. Three major features of medical professionalism - the ethic of care, clinical independence and self-regulation - benefit physicians, their patients and society: Ethic of care: This is characterized by the values of compassion, beneficence, nonmaleficence, respect for persons and justice (CMA's Code of Ethics). Society benefits from the ethic of care whereby, in the provision of medical services, physicians put the interests of others ahead of their own. Dedication and commitment to the well-being of others is clearly in the interests of patients, who are the primary beneficiaries. Clinical independence: Medicine is a highly complex art and science. Through lengthy training and experience, physicians become medical experts and healers. Whereas patients have the right to decide to a large extent which medical interventions they will undergo, they expect their physicians to be free to make clinically appropriate recommendations. Although physicians recognize that they are accountable to patients, funding agencies and their peers for their recommendations, unreasonable restraints on clinical autonomy imposed by governments and administrators, whether public or private, are not in the best interests of patients, not least because they can damage the trust that is an essential component of the patient-physician relationship. Conversely, physicians are not morally obliged to provide inappropriate medical services when requested by patients despite their respect for patient autonomy. Self-regulation: Physicians have traditionally been granted this privilege by society. It includes the control of entrance into the profession by establishing educational standards and setting examinations, the licensing of physicians, and the establishment and ongoing review of standards of medical practice. In return for this privilege, physicians are expected to hold each other accountable for their behaviour and for the outcomes they achieve on behalf of their patients. Self-regulation is exercised by many different professional organizations, from medical practice partnerships to the statutory provincial/territorial licensing bodies. It has evolved into a partnership with the public. Self-regulation benefits society by taking the best advantage of the professional expertise needed to appropriately set and maintain standards of training and practice, while providing suitable accountability in matters of professional behaviour. The profession's commitment to the maintenance of those standards is demonstrated by its willingness to participate in outcomes review at many levels, from institutional quality assurance activities to formal prospective peer review, and to actively support their statutory and legislated licensing authorities. Opportunities in Medical Professionalism Over the past few years much has been written about the issue of medical professionalism in both the lay and scientific media. The practice of medicine has changed considerably, and with these changes have come challenges but also opportunities. The medical profession continues to be a greatly respected one, and it is still generally seen as being distinct from many others because of the unique nature of the physician-patient relationship. There exists now an opportunity to reinforce the professional values and priorities that have sustained medicine for so long, and to embrace new approaches which will serve it well in the years to come. Medical professionals must recognize that patients have a wide variety of resources available for their health care needs, from traditional physician services to paramedical practitioners, to complementary medicine and to information obtained from the internet. While maintaining responsibility for care of the patient as a whole, physicians must be able to interact constructively with other health care providers within an interdisciplinary team setting, and must be able to interpret information for patients and direct them to appropriate and accurate resources. The relationship of physicians with their colleagues must be strengthened and reinforced. Patient care benefits when all health care practitioners work together towards a common goal, in an atmosphere of support and collegiality. Although there are some challenges to professionalism, as outlined below, the greatest opportunity before us may be to remind physicians of the reasons they chose a career in medicine to begin with - for many, it is a calling rather than a job. In spite of the numerous recent changes in the health care system and the practice of medicine, the primary reason most physicians entered the field remains the same - the sanctity of the fiduciary relationship between physicians and their patients. The renewal of medical professionalism must be led from within the profession itself, and the CMA and its members are in a unique position to take advantage of the many opportunities which exist and to respond to the challenges we face. Challenges to Medical Professionalism Medical professionalism is being challenged from within and without. These challenges arise from pressures that may serve to undermine the ethic of care, clinical independence and self-regulation and may result, for individual physicians and the medical profession, in diminished morale and changes in lifestyle and practice patterns. These changes may have a detrimental impact on the health of physicians, and also on the quality of patient care. Resource restraints: The CMA has identified scarcity of resources, whether human or material, as undermining the ability of physicians to maintain excellence in clinical care, research and teaching. Although much attention has been paid recently to the insufficient number of physicians in Canada, and although recent developments indicate some limited cause for optimism, much work remains to be done. Issues of access to continuing professional development, workforce sustainability, inadequate numbers of training positions for new doctors, the integration of foreign-trained physicians into the workforce and the apparent inability of governments to resolve inadequacies in health care funding continue to frustrate physicians' attempts to achieve their professional goals and care for their patients. These factors all have the potential for contributing to the decline of professional morale. Bureaucratic challenges: This refers to the introduction of layers of management and policy directives between the physician and the patient. It is a result of changes that have taken place in the organization and delivery of medical care, especially the involvement of governments in all aspects of health care. The traditional one-on-one relationship of physician and patient is now set within a context of government and corporate interests, in which the physician may sometimes assume the status of an employee, that pose considerable challenges to the exercise of the professional values of clinical autonomy and self-regulation. Moreover, while the responsibility for organizing the delivery of scarce resources has been increasingly transferred from physicians to managers, physicians are still ultimately responsible, both morally and legally, for providing quality care. Although the increasing complexity of health care delivery requires recourse to sophisticated management systems, there is a danger that as physicians become increasingly answerable to or constrained by third parties, their ability to fulfill their commitment to their individual patients can be seriously compromised. Unprofessional conduct: Some physicians do not uphold the values of the profession. A few put their interests or the interests of third parties ahead of the interests of their patients. The profession needs to meet this challenge by demonstrating its ability to uphold its values and its commitment to doing so. Supporting strong and transparent self-regulatory systems will be a key component of this endeavor. Commercialism: In recent years the market mentality has expanded its influence to many areas formerly outside its domain, including governments, universities and the professions. Health care has become a major industry, one in which physicians play a central role, and commercial interests, whether private or public, may pressure physicians to compromise their responsibilities to their patients, research subjects and society. The potential for physicians and medical associations to become drawn into conflict-of-interest situations is increasing. Commercialism may compromise both the ethic of care and clinical independence by its reinterpretation of medical care as a commodity and the patient-physician relationship as something less than a fiduciary relationship. There is an inherent opportunity for the profession to address the issue of conflict of interest and to re-affirm its primary obligation and dedication to the patients it cares for. Consumerism: Physicians strongly support the right of patients to make informed decisions about their medical care. However, the CMA's Code of Ethics requires physicians to recommend only those diagnostic and therapeutic procedures that they consider to be beneficial to the patient or to others. There is a proliferation of health information and advertising in the popular media and on the Internet that may be inaccurate or poorly understood. Taken to its extreme, consumerism can be detrimental not just to professionalism but to the well-being of patients and the interests of society. Industrialization: This refers to the increased division and specialization of labour in the delivery of health care, whereby the delivery of health care may become fragmented. There is increasing pressure within medicine to improve efficiency and optimize cost savings. While these may be important goals in the broader context of health care, we must ensure that they do not impact negatively on the doctor-patient relationship. Realizing Opportunities and Dealing with Challenges Individual physicians should protect, enhance and promote professionalism in medicine by reflecting the values of the medical profession in their practice and by contributing to the efforts of organized medicine to maintain and enhance the ethic of care, clinical autonomy and self-regulation. These efforts require action in 3 areas: policy, education and self-regulation. Policy: All those involved in health care - physicians, patients, other health care providers, administrators, governments and the general public (as taxpayers, potential patients, relatives of patients, etc.) - should be informed about the values of the medical profession and where it stands on issue related to accountability, clinical autonomy and self-regulation. Policies of medical associations should reflect these values and should speak clearly on topics such as conflict of interest. Policies should be reviewed frequently and updated when necessary, in order to take account of the rapidly changing environment in which medicine is practiced. The topic of professionalism should be granted increasing importance in policy discussions. Policies should be developed and updated in related areas, such as conflict of interest and physician-industry interactions. In order to be consistent and trustworthy, medical associations should adhere to the same high standards of behaviour that they require of individual physicians. The challenges posed by resource restraints, bureaucratization, unprofessional conduct, commercialism and consumerism are no less serious for associations than for individuals and require sound harmonized policies for both. The CMA has an opportunity for leadership in this regard. Education: However professional values and policies are established, they must be transmitted to current and future members of the profession in order to have any effect. Like most other aspects of medical education, the values of professionalism are both taught and modeled. Professionalism should be an essential component of the formal medical curriculum at the undergraduate and postgraduate training levels. Moreover, active demonstration of professionalism such as role modeling by physicians, and in the internal culture of the medical schools and hospitals where students receive their training, should be used to advantage and challenged when necessary. Likewise for physicians in practice, formal continuing professional development programs and role modeling by other physicians are important for the maintenance of professionalism. Physicians need to communicate and test their understanding of their professional role with others involved in patient care at numerous levels. Such initiatives, which would engage patients, other professionals and policy-makers, require further development. The CMA and other medical organizations have taken leadership roles in assisting patients and health care providers in making informed decisions by creating numerous continuing professional development opportunities and readily available clinical information for physicians, effective patient education materials, self-help books and validated Web sites, including www.cma.ca. These efforts need to continue and be strengthened. Self-regulation: In order to maintain self-regulation in an environment that is increasingly suspicious of such privileges, the medical profession has to demonstrate that self regulation benefits society in general. This requires, among other things, that the medical profession continue to demonstrate its commitment to the tasks required by self-regulation, including setting and enforcing high standards of behaviour for both individual physicians and medical associations. Conclusion Physicians continue to value medical professionalism highly. They believe that it benefits patients greatly and that it should be preserved and enhanced. Professionalism will continue to be based on the relationship of trust between patients and physicians, and the primacy of the physician-patient relationship. It encompasses the values of compassion, beneficence, nonmaleficence, respect for persons and justice. As professionals, physicians will strive to maintain high standards of ethics, clinical practice and education and demonstrate a capacity for social responsibility through self-regulation and accountability (see CMA Policy Statement The Future of Medicine). The CMA welcomes opportunities to engage in dialogue with others as to how professionalism in health care can be preserved and enhanced for the benefit of patients, physicians and society in general.
Documents
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Summary of federal legislation/regulations

https://policybase.cma.ca/en/permalink/policy11922
Last Reviewed
2018-03-03
Date
2016-08-24
Topics
Physician practice/ compensation/ forms
Resolution
GC16-46
The Canadian Medical Association will create an up-to-date summary of federal legislation/regulations that impacts physician practice.
Policy Type
Policy resolution
Last Reviewed
2018-03-03
Date
2016-08-24
Topics
Physician practice/ compensation/ forms
Resolution
GC16-46
The Canadian Medical Association will create an up-to-date summary of federal legislation/regulations that impacts physician practice.
Text
The Canadian Medical Association will create an up-to-date summary of federal legislation/regulations that impacts physician practice.
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Medical assistance in dying education

https://policybase.cma.ca/en/permalink/policy11941
Last Reviewed
2018-03-03
Date
2016-08-24
Topics
Ethics and medical professionalism
Resolution
GC16-48
The Canadian Medical Association supports the inclusion of education and the development of Canadian accreditation elements related to medical assistance in dying for all medical students and resident physicians.
Policy Type
Policy resolution
Last Reviewed
2018-03-03
Date
2016-08-24
Topics
Ethics and medical professionalism
Resolution
GC16-48
The Canadian Medical Association supports the inclusion of education and the development of Canadian accreditation elements related to medical assistance in dying for all medical students and resident physicians.
Text
The Canadian Medical Association supports the inclusion of education and the development of Canadian accreditation elements related to medical assistance in dying for all medical students and resident physicians.
Less detail
Last Reviewed
2017-03-04
Date
2005-05-31
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
Resolution
BD05-05-148
The Canadian Medical Association will work with the Canadian Council on Health Services Accreditation to introduce a standard of accreditation for hospitals/districts/ regions with respect to monitoring and reporting on wait times and outcomes of patients awaiting care.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
2005-05-31
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
Resolution
BD05-05-148
The Canadian Medical Association will work with the Canadian Council on Health Services Accreditation to introduce a standard of accreditation for hospitals/districts/ regions with respect to monitoring and reporting on wait times and outcomes of patients awaiting care.
Text
The Canadian Medical Association will work with the Canadian Council on Health Services Accreditation to introduce a standard of accreditation for hospitals/districts/ regions with respect to monitoring and reporting on wait times and outcomes of patients awaiting care.
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The Role of Physicians in Recognizing and Supporting Treatment of Gambling Addiction (Update 2005)

https://policybase.cma.ca/en/permalink/policy1934
Last Reviewed
2017-03-04
Date
2005-12-03
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2017-03-04
Date
2005-12-03
Replaces
Statement on the role of physicians in recognizing and supporting treatment of gambling addiction (2003)
Topics
Population health/ health equity/ public health
Text
The Role of Physicians in Recognizing and Supporting Treatment of Gambling Addiction (Update November 2005) Gambling is a common activity in our society. For a small percentage, this behaviour can become pathological, affecting the well-being of gamblers as well as their families and workplaces. This disorder has been described in the "Diagnostic and Statistical Manual of Mental Disorders" Fourth Edition, (DSM IV) and is recognized as an illness by physicians. Physicians have a role in identifying pathological gambling behaviour and being aware of the resources that exist to treat and support addicted individuals and their families. To assist them in performing this role, the CMA makes the following recommendations: * The CMA supports the development of core curricula in gambling disorders to be offered at undergraduate and post-graduate levels and through CME programs. These could include inter-professional or interdisciplinary curricula developed in partnership with other health professionals. * The CMA supports the development and dissemination of resources to help practising physicians screen patients to identify those with gambling addiction and to provide appropriate treatment. * Governments should ensure the timely availability of quality treatment services appropriate to the age, culture and background of client groups. * The CMA encourages research into gambling addiction, which could include: ­ identifying the biological basis for gambling; ­ identifying best-practice interventions to reduce the prevalence of problem gambling; ­ measuring the social and economic impacts of gambling on individuals and communities; and ­ dispelling the myths surrounding gambling addiction. * Governments and others should work together to implement educational and policy strategies to reduce the prevalence of problem gambling. These could include: ­ elementary school programs to help prevent pathological gambling disorders; ­ limiting the number of gambling establishments, particularly video lottery terminals (VLTs) and casinos; ­ placing age limits on accessibility to VLTs so that children and adolescents are restricted from their use; and ­ promoting lower risk gambling approaches for primary prevention and harm reduction such as gambling only with a predetermined loss limit and not gambling alone.
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The physician appointment and reappointment process 2016

https://policybase.cma.ca/en/permalink/policy13564
Date
2016-12-03
Topics
Health human resources
Physician practice/ compensation/ forms
  1 document  
Policy Type
Policy document
Date
2016-12-03
Topics
Health human resources
Physician practice/ compensation/ forms
Text
Beginning in the 1990s most jurisdictions established regional health authorities (RHAs) with consolidated medical staff structures and there has been a trend toward requiring all physicians practising in a region to hold an appointment with the RHA in order to access health resources such as diagnostic imaging and laboratory services, irrespective of whether they hold hospital privileges or not. Subsequent to the consolidation of medical staff governance there have been several developments over the past decade that have implications for where and how physicians can practise, and for their ability to advocate freely on behalf of their patients. These include: * the establishment of formal physician resource plans that link the appointment process to the ability to participate in the provincial/territorial medical insurance plan; * a greater focus on clinical governance that includes detailed attention on scope of practice and privileges; * a growing concern about the ability of physicians to advocate on behalf of their patients and the communities they serve; and * an increase in the number of physicians entering into employment or contractual arrangements. The Canadian Medical Association (CMA) puts forward the following recommendations for governments, regulatory authorities, RHAs and medical staff structures within RHAs and hospitals. Recommendations Where physician appointments are to be approved in relation to Physician Resource Plans, the CMA recommends that such plans must: * take into consideration both population need and projected physician supply; * include transparency in the provision of information about available practice opportunities and on the criteria and processes through which applications for appointments are approved; * be based on a documented methodology with results in the public domain; and * be based on a medium-term projection range, using the most current and reliable data available, and be regularly reviewed and updated. The CMA recommends that the application of standardized credential templates must take into consideration the quality of care being provided by the physician and local circumstances such as the complement of medical and hospital resources available locally and the timeliness of proximity to secondary and tertiary care. The CMA strongly supports the implementation of policy to safeguard physicians from fear of reprisal and retaliation when speaking out as advocates for their patients and communities, and the right and duty of medical officers of health to speak publicly to the citizens they serve. The CMA supports provincial/territorial amendments to public health legislation to protect the right and duty of medical officers of health to speak publicly to the citizens they serve without political interference or risk of adverse employment consequences. The CMA believes that medical staff bylaws should expressly extend to physicians under contract entitlement to the procedural protections set out in the hospital or health authority bylaws. The CMA recommends that the processes of granting appointments, reappointments and privileges and allocating resources respect the following principles: 1. All processes should be fair, equitable, documented and transparent and should protect confidentiality. 2. Criteria for reappointment should be clearly specified in medical staff bylaws and should be no more onerous than necessary to verify the ongoing provision of quality care by the medical staff. 3. A regular evaluation of appointed physicians should be conducted by the appropriate clinical chief. 4. The quality of a physician's care is the most important criterion to be considered at the time of appointment, reappointment and the granting of privileges. 5. The information required for the granting of appointments, reappointments or privileges or for the allocation of medical resources must be accurate, valid and appropriate. 6. The processes of granting appointments, reappointments and privileges and allocating resources should recognize and accommodate the changes in practice patterns that may occur over the medical career cycle. 7. Physicians with established community practices have a significant investment in their practice and the community; this investment should be considered at the time of reappointment or change in privileges. 8. A recommendation, without just cause, to withdraw an appointment, to restrict privileges or to significantly reduce resources available to a physician must include appropriate compensation based on individual circumstances. 9. The reporting of legal actions or disciplinary actions as part of the reappointment or reappointment process should be restricted to those matters in which a final determination has been rendered and in which there has been an adverse finding to the physician. Objective This policy outlines the principles that should be considered for the granting of physician appointments, reappointments, privileges and access to resources at the health care facility, district or RHA level. Key definitions Appointment: The process by which a physician joins the medical staff of a health region or health facility in order to access resources to care for patients. Credentialing: An approach to obtaining, verifying and assessing the qualifications of a health professional against consistent criteria for the purposes of licensing and/or granting privileges.1 Privileges: Permission from an authorized body to a health care provider to conduct a specific scope and content of patient care. Privileges are granted based upon an evaluation of the provider's training, experience and competence related to the service, and are specific to a defined practice setting.1 Clinical peer review: The process by which physician peers assess each other's performance. A peer is a physician with relevant clinical experience in similar health care environments who also has the competence to contribute to the review of other physicians' performance.2 Background Historically the formal appointment process applied to physicians wishing to practise in hospitals. Beginning in the 1990s most jurisdictions established RHAs with consolidated medical staff structures and there has been a trend toward requiring all physicians practising in a region to hold an appointment with the RHA in order to access health resources such as diagnostic imaging and laboratory services, irrespective of whether they hold hospital privileges or not. Since the CMA first adopted principles for the physician appointment and reappointment process in 1997 there have been several developments that are reviewed below: * the establishment of formal physician resource plans that link the appointment process to the ability to participate in the provincial/territorial medical insurance plan; * a greater focus on clinical governance that includes detailed attention on scope of practice and privileges; * a growing concern about the ability of physicians to advocate on behalf of their patients and the communities they serve; and * an increase in the number of physicians entering into employment or contractual arrangements. Physician Resource Plans (PRPs): New Brunswick was the first province to require physicians to have privileges with an RHA in order to obtain a billing number.3 More recently jurisdictions such as Nova Scotia (N.S.) have introduced medium to longer range PRPs that are to be used when approving new appointments. In 2012 N.S. released a PRP for 2012-2021, which has since been updated to 2013-2022.4 Under the terms of the Nova Scotia Health Authority Medical Staff Bylaws, the RHA CEO or their designate will assess applications for new appointments in relation to need and availability of resources. The assessment is to be completed within 60 days and there is no right of review or appeal of the CEO's decision.5 Manitoba's medical staff bylaws make a similar provision.6 While Ontario has not regionalized to the same extent as other jurisdictions, legislation has been introduced that proposes to make the 14 Local Health Integration Networks (LHINs) responsible for primary care planning and performance management.7 Moreover the Bill will amend the Health Insurance Act to authorize the health minister to delegate non-fee-for-service physician compensation to the LHIN. Recommendation Where physician appointments are to be approved in relation to PRPs, the CMA recommends that such plans must: * take into consideration both population need and projected physician supply; * include transparency in the provision of information about available practice opportunities and on the criteria and processes through which applications for appointments are approved; * be based on a documented methodology with results in the public domain; and * be based on a medium-term projection range, using the most current and reliable data available, and be regularly reviewed and updated. Other physician resource planning considerations are set out in the CMA's comprehensive policy on PRPs.8 Clinical governance: Since the late 1990s there has been a great deal of attention paid to the concept of clinical governance, which may be defined as the structures, processes and culture needed to ensure that health care organizations and all individuals within them can assure the quality of the care they provide and are continuously seeking to improve it. During the past decade several provinces have carried out inquiries related to problems with pathology and radiology. In British Columbia (B.C.) the Chair of the BC Patient Safety & Quality Council conducted a review of the medical imaging credentialing and quality assurance that reported in 2011. In his final report, Dr. Douglas Cochrane set out 35 recommendations that called for much more rigorous and uniform oversight of medical practice in B.C.9 The recommendations included a call for: * the creation of a single medical staff administration to serve all health authorities and affiliated organizations; * the development of standardized processes for medical staff appointment, and credentialing and privileging, including common definitions; and * the development of performance assessment and review process for all physicians.9 The Cochrane report has resulted in the British Columbia Medical Quality Initiative (BC MQI). BC MQI is implementing an online Provincial Practitioner Credentialing and Privileging System (CACTUS Software) that will be used by all of B.C.'s RHAs to manage these processes for physicians, midwives, dentists and nurse practitioners.10 BC MQI has developed 62 privileging dictionaries for medical directors and department heads to use with their colleagues during initial and renewal privileging processes. The dictionaries recommend the required current experience to perform a certain activity in the form of numbers where applicable and also recommend the requirements for renewal of privileges and the requirements for return to practice. These recommendations are meant to take into account the individual's own experience and the context of the local site in which they work. They are meant to begin a conversation as needed with the department head, colleagues and others. The Society of Rural Physicians of Canada (SRPC) has raised concerns about the potential impact of volume-based credentialing on rural medical practice. For example, the dictionary for Family Practice with Enhanced Surgical Skills recommends that for operative delivery, a volume of at least five caesarean section deliveries be performed per year averaged over 24 months.11The SRPC has put forward recommendations that emphasize the need for appropriate peer review and consideration of geographic diversity and the range of medical practice, and that credential revalidation should be based on the actual quality of care provided by the physician, the continuing medical education completed by the physician and should also consider the impact of changes in delivery on the health outcomes in the community.12 It seems likely that other jurisdictions will be watching the CACTUS program with interest. Recommendation The CMA recommends that the application of standardized credential templates must take into consideration the quality of care being provided by the physician and local circumstances such as the complement of medical and hospital resources available locally and the timeliness of proximity to secondary and tertiary care. Advocacy: Advocacy has been identified as one of seven core roles of every physician by the Royal College of Physicians and Surgeons of Canada13 and the College of Family Physicians of Canada.14 This role entails physicians using their expertise and influence in the interests of their individual patients and the communities and populations they serve. Over the past decade there have been several instances where physicians have either expressed concern about their ability to advocate or have had disciplinary action taken against them, likely as a result of their advocacy activities. As a result of an inquiry carried out by the Health Quality Council of Alberta, the Alberta Medical Association, Alberta Health Services and the College of Physicians and Surgeons of Alberta have adopted a joint policy statement that sets out guidelines for physician advocacy.15 Eastern Health in Newfoundland and Labrador has a privacy/confidentiality oath or affirmation for physicians that acknowledges that they may have professional standards for disclosure and advocacy regarding patient safety, but stipulates the expectation that such concerns be first addressed through Eastern Health as an initial step.16 The CMA's policy on the evolving professional relationship between physicians and the health care system sets out nine factors for physicians to consider before undertaking advocacy.17 As predominantly employees of some level of government, and with a responsibility to sound an alert on population health risks, public health physicians are at greater risk of being disciplined for advocacy. There have been two high profile cases of public health physicians who have been dismissed for advocacy-related activities since 2000. Thus far only B.C. has enacted public health legislation to protect medical officers of health from political interference and adverse employment consequences. B.C.'s Public Health Act stipulates that the provincial health officer (PHO) has a duty to advise on provincial public health issues, which includes public reporting where the PHO believes it will best serve the public interest. Similarly sub-provincial medical health officers must advise on local public health issues and publicly report on them after consultation with the PHO. B.C.'s legislation also provides health officers with immunity from legal proceedings for actions done in good faith in the performance of their duties and for reports they are required to make. In addition the legislation protects health officers from "adverse actions", defined as an action that would either affect or threaten "the personal, financial or other interests of a person, or a relative, dependent, friend or business or other close association of that person" as a result of performing their duties in good faith.18 Recommendations The CMA strongly supports the implementation of policy to safeguard physicians from fear of reprisal and retaliation when speaking out as advocates for their patients and communities, and the right and duty of medical officers of health to speak publicly to the citizens they serve. The CMA supports provincial/territorial amendments to public health legislation to protect the right and duty of medical officers of health to speak publicly to the citizens they serve without political interference or risk of adverse employment consequences. Growing employment/contractual relationships: The move to RHAs, consolidation in the hospital sector and changing delivery models have had significant implications for the relationships between physicians and hospitals. The Canadian Medical Protective Association (CMPA) has identified several areas of concern, including patient advocacy, reporting of physicians, responding to adverse events, collection and use of physician information, practice arrangements and liability provision.19 One issue that the CMPA has highlighted in particular is the increasing trend in some jurisdictions for physicians to be engaged on a contracted employee basis rather than as independent contractors appointed with privileges.20 This is seen among facility-based physicians such as hospitalists, clinical and surgical assistants and laboratory physicians. The CMPA has cautioned that physicians engaged on a contractual basis may not have the same procedural rights on termination of contracts as those engaged under the privileging model and it has issued guidance on issues to consider with individual contracts, including CMPA assistance, indemnification clauses, liability provisions, confidentiality, termination of contract, dispute resolution and governing law.21 Recommendation The CMA believes that medical staff bylaws should expressly extend to physicians under contract entitlement to the procedural protections set out in the hospital or health authority bylaws. Principles Physicians must take a leadership role and be active participants in the development of appointment, reappointment and related processes; medical communities must therefore be aware of the basic principles that should be reflected in these processes. Once a physician has obtained a licence to practice, the process of appointment approval is the next step in obtaining permission to practise medicine in a health care facility, district or region. The next step is the granting of privileges. This bestows the right to perform specific medical acts within the health care facility, district or region. The final step is the provision of the necessary resources so that the physician is able to provide appropriate medical services for patient care. A medical committee with a clear structure and mandate to deal with appointments, reappointments and privileges must be maintained in all health care facilities, districts and regions so that physician input may be given during the appointment, reappointment and related processes. Clinical peer review must be foundational to these processes. Time, training and resources must be sufficient to support consistent peer review processes. The principles proposed below apply to all of the following processes: the appointment and reappointment processes, the granting of privileges and the allocation of health care facility, district or regional resources. Principles for the processes of granting appointments, reappointments and privileges and allocating resources 1. All processes should be fair, equitable, documented and transparent and should protect confidentiality. They should be completed in a timely manner and follow the rules of natural justice. At a minimum, the rules of natural justice give the physician the right to notice and the right to be heard before, and provided with reasons by, an impartial adjudicator. Given the nature of the physician's interests in the appointment, reappointment and other related processes, the following principles should also be included: * the right to be heard, either in person and (or) by representation; * the right to full disclosure of the information being considered by the committee that makes recommendations on appointments, reappointments and privileges; * the right to present evidence; * the right to a hearing free from bias, either real or perceived; * the right to a record of the proceedings; * a decision within a reasonable period; * the right to receive written reasons for the decision; and * the right to an appeal process by an independent and impartial body other than the board of the health care facility, district or region. It is important that all processes, including any review processes, follow the principles of natural justice. These processes should be part of the medical staff bylaws that guide the operation of the health care facility, district or region and should be known to all appointed physicians. 2. Criteria for reappointment should be clearly specified in medical staff bylaws and should be no more onerous than necessary to verify the ongoing provision of quality care by the medical staff. Medical staff appointments are typically for a one-year term. Criteria for reappointment vary across Canada, ranging from the provision of evidence of renewed licensure and liability coverage with a discretionary in-depth performance evaluation to the foregoing plus a mandated in-depth performance evaluation and reporting on continuing professional development activity. 3. A regular evaluation of appointed physicians should be conducted by the appropriate clinical chief. It should consist of a fair, documented process with explicit, agreed-upon criteria for the review of the physician's qualifications and credentials and the quality of care provided. If there is demonstrated inappropriate behaviour or a quality-of-care issue, a program for remediation should be established with regular follow-up over a period deemed appropriate by the physician's peers. As in other jobs, the objective of regular performance evaluations for a physician is to improve the physician's performance and the focus should be on opportunities for learning and improvement. The appraisal should entail a standardized peer evaluation process, in addition to self-assessment. The self-assessment process should include the recognition of satisfactory existing skills and the identification of new skills to be learned. In some situations remediation may be justified, for example when there is a need to upgrade skills, when interpersonal and communication skills are unacceptable, and when there is alcohol or drug abuse. Physician evaluations conducted by RHAs should take into account requirements already asked of the physician by their certifying and/or licensing body or other speciality organization in order to avoid duplication of effort. Looking ahead, with the increasing focus on team-based collaborative care, performance of team function and its impact on overall performance to meet health service requirements and quality of care is expected to become increasingly relevant. Conflict resolution mechanisms, scopes of practice and shared roles and responsibilities will need to be considered in order to assess individual and team performance. 4. The quality of a physician's care is the most important criterion to be considered at the time of appointment, reappointment and the granting of privileges. Quality care may be defined as the provision of service that satisfies the needs of the patient and meets the standards set out by recognized bodies of the profession, such as licensing bodies, national clinical societies and others. The essential components of quality include competence, accessibility, acceptability, effectiveness, appropriateness, efficiency, affordability and safety. The cost of a physician's care should not be the primary criterion considered during appointment, reappointment and related processes. Practice patterns, resulting in differences in cost of care, will differ for numerous reasons, including severity of illness, patient mix and patient choices. If there is a local, regional or district physician resource plan, then the need for a particular physician skill base as identified in the plan is an important criterion for appointment or reappointment to institutions within the plan. Physicians must be involved in the development of such a plan, and the plan must be supported by physicians at the local, district or regional level. If a practice and remuneration plan is introduced for a facility, hospital or academic health sciences centre, then participation in such a plan should not be a criterion for reappointment. 5. The information required for the granting of appointments, reappointments or privileges or for the allocation of medical resources must be accurate, valid and appropriate. The information required for these purposes should generally be limited to that which is reasonably necessary to determine the physician's ability to provide safe care. Physician's privacy should only be violated if it is determined that a medical condition or other disability poses an unacceptable risk to patients. The physician's credentials, skills, expertise and quality of care, as judged by peer assessment, should be considered during the appointment or reappointment process. Utilization data and associated indicators are being used more frequently as criteria for appointment and reappointment. Therefore, physicians must be involved in the development of such indicators, and there must be agreement by all parties on the type and quality of data or indicators to be used. In addition, before appointment or reappointment, physicians must be made aware of the data or indicators that will be used to evaluate them and the criteria by which these indicators will be applied. 6. The processes of granting appointments, reappointments and privileges and allocating resources should recognize and accommodate the changes in practice patterns that may occur over the medical career cycle. These processes should be flexible and reasonable concerning other issues such as on-call responsibilities or time needed to fulfil research and teaching commitments. It is important to recognize that a physician's practice pattern may change during his or her medical career. These changes may reflect the desire to no longer take call, the narrowing of the physician's practice to achieve a higher level of expertise in a specific area or the desire to pursue academic interests or responsibilities. Pregnancy, parental leave and the wish to practice part-time must also be considered. The quality of a physician's personal life and other special needs should be viewed as important and should be considered by those making decisions in these areas. 7. Physicians with established community practices have a significant investment in their practice and the community; this investment should be considered at the time of reappointment or change in privileges. An established physician may face financial loss if he or she is not reappointed or if there is a recommendation to substantially change his or her privileges. This possibility should be considered at the time of reappointment or change in privileges. 8. A recommendation, without just cause, to withdraw an appointment, to restrict privileges or to significantly reduce resources available to a physician must include appropriate compensation based on individual circumstances. Appropriate compensation includes financial restitution, retraining, relocation assistance and counselling assistance as required. Sufficient notice and other elements of due process should also be components of this recommendation. Generally, physicians are not employees of a health care facility, district or regional authority. Nonetheless, there are often extensive restrictions on physician mobility and limited opportunities to practice both inside and outside a province or territory. Age may also be a factor in the ability to find placement elsewhere, particularly if the physician is nearing retirement age. For these reasons, an interruption or cessation of a physician's career caused by withdrawal of an appointment, restriction of privileges or reduction in the resources available to the physician justifies appropriate compensation and due notice; this is in keeping with good human resource practices. Appropriate notice should be provided to physicians so that there is minimal impact on patient care. What constitutes timely and appropriate notice may in some cases be several months and will differ depending on the impact of the decision. Examples of decisions that could have a significant impact on physicians include: * temporary or permanent closure of operating rooms or other facilities; * strategic redirection of the hospital that may adversely affect a particular medical service or department, such as regionalization of laboratory testing or provincial centralization of a specialized service; and * implementation of a retirement policy. 9. The reporting of legal actions or disciplinary actions as part of the reappointment or reappointment process should be restricted to those matters in which a final determination has been rendered and in which there has been an adverse finding to the physician. References 1 Accreditation Canada. Qmentum Standards. Governance. Ottawa: Accreditation Canada; 2016. 2 Australian Commission on Safety and Quality in Healthcare. Review by peers: a guide for professional, clinical and administrative processes. Sydney: Australian Commission on Safety and Quality in Health Care; July 2010. Available: http://www.safetyandquality.gov.au/wp-content/uploads/2012/01/37358-Review-by-Peers.pdf (accessed 2016 May 02). 3 New Brunswick Department of Health. Registration requirements. Fredericton: New Brunswick Department of Health; 2016. Available: http://www.gnb.ca/0394/prw/RegistrationRequirements-e.asp (accessed 2016 May 02). 4 Nova Scotia Department of Health and Wellness. Shaping our Physician Workforce. Updates. Halifax: Nova Scotia Department of Health and Wellness; 2016. Available: http://novascotia.ca/dhw/shapingPhysicianWorkforce/updates.asp (accessed 2016 May 02). 5 Province of Nova Scotia. Nova Scotia Health Authority Medical Staff Bylaws. Halifax: Province of Nova Scotia; April 2015. Available: https://www.novascotia.ca/just/regulations/regs/hamedstaff.htm (accessed 2016 May 02). 6 Winnipeg Regional Health Authority. WRHA Board By-Law No.3 Medical Staff. Winnipeg: Winnipeg Regional Health Authority; March 2014. Available: http://www.wrha.mb.ca/extranet/medicalstaff/files/MedByLaw.pdf (accessed 2016 May 02). 7 Bill 41. An Act to amend various Acts in the interests of patient-centred care. 2nd Sess, 41st Leg, Ontario; 2016. Available: http://www.ontla.on.ca/bills/bills-files/41_Parliament/Session2/b041.pdf (accessed 2016 Nov 07). 8 Canadian Medical Association. Physician resource planning. Updated 2015. Ottawa: The Association; 2015. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD15-07.pdf (accessed 2016 May 02). 9 Cochrane DD. Investigation into medical imaging, credentialing and quality assurance. Phase 2 report. Vancouver: BC Patient Safety & Quality Council; Aug 2011. Available: http://www.health.gov.bc.ca/library/publications/year/2011/cochrane-phase2-report.pdf (accessed 2016 May 02). 10 British Columbia Medical Quality Initiative. Briefing note: BC MQI - Provincial Practitioner Credentialing and Privileging System (CACTUS Software) Implementation. Vancouver: British Columbia Medical Quality Initiative; January 2016. Available: http://bcmqi.ca/wp-content/uploads/Briefing-Note_ProvincialPractitionerCPSystemImplementation.pdf (accessed 2016 May 02). 11 British Columbia Medical Quality Initiative. Family Practice with Enhanced Surgical Skills Clinical Privileges. Vancouver: British Columbia Medical Quality Initiative; March 2015. Available: http://www.srpc.ca/ess2016/summit/FamilyPracticeEnhancedSurgicalSkills.pdf (accessed 2016 Nov 06). 12 Soles H, Larsen Soles T. SRPC position statement on minimum-volume credentialing. Can J Rural Med. 2016;21(4):107-11. 13 Royal College of Physicians and Surgeons of Canada. CanMEDS 2015. Physician competency framework. Ottawa: Royal College of Physicians and Surgeons of Canada; 2015. Available: http://canmeds.royalcollege.ca/uploads/en/framework/CanMEDS%202015%20Framework_EN_Reduced.pdf (accessed 2016 May 02). 14 College of Family Physicians of Canada. CanMEDS-Family Medicine. Working Group on Curriculum Review. Mississauga: College of Family Physicians of Canada; October 2009. Available: http://www.cfpc.ca/uploadedFiles/Education/CanMeds%20FM%20Eng.pdf (accessed 2016 May 02). 15 Alberta Medical Association, Alberta Health Services, College of Physicians and Surgeons of Alberta. Advocacy Policy Statement. Edmonton: Alberta Medical Association; 2015. Available: https://www.albertadoctors.org/Advocacy/Policy_Statement.pdf (accessed 2016 May 02). 16 Eastern Health. Privacy and confidentiality. ADM-030. St. John's, NL: Eastern Health; 2015. Available: http://www.easternhealth.ca/OurServices.aspx?d=2&id=743&p=740 (accessed 2016 Jun 23). 17 Canadian Medical Association. The evolving professional relationship between Canadian physicians and our evolving health care system: where do we stand? Ottawa: The Association; 2012. Available: https://www.cma.ca/Assets/assets-library/document/en/advocacy/policy-research/CMA_Policy_The_evolving_professional_relationship_between_Canadian_physicians_and_our_health_care_system_PD12-04-e.pdf (accessed 2016 May 02). 18 Public Health Act. SBC 2008, Chapter 28. Available: http://www.bclaws.ca/civix/document/id/complete/statreg/08028_01 (accessed 2016 Nov 07). 19 Canadian Medical Protective Association. Changing physician-hospital relationships: Managing the medico-legal implications of change. Ottawa: The Association; 2011. Available: https://www.cmpa-acpm.ca/-/changing-physician-hospital-relationships (accessed 2016 Nov 07). 20 Canadian Medical Protective Association. The changing practice of medicine: employment contracts and medical liability. Ottawa: The Association; 2012. Available: https://www.cmpa-acpm.ca/-/the-changing-practice-of-medicine-employment-contracts-and-medical-liability (accessed 2016 Nov 07). 21 Canadian Medical Protective Association. Medical-legal issues to consider with individual contracts. Ottawa: The Association; 2016. Available: https://www.cmpa-acpm.ca/-/medico-legal-issues-to-consider-with-individual-contracts (accessed 2016 Nov 07).
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