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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
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Climate Change and Human Health

https://policybase.cma.ca/en/permalink/policy9809
Last Reviewed
2018-03-03
Date
2010-06-09
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2010-06-09
Topics
Population health/ health equity/ public health
Text
Climate Change and Human Health Background Climate change is increasingly recognized as a significant threat facing society and has the potential to be one of the greatest threats to human health in the 21st Century1. While the damage is being done now, many of the health effects may arise only decades in the future2. Possible impacts could include some or all of the following: * Increased mortality, disease and injuries from heat waves and other extreme weather events; * Continued change in the range of some infectious disease vectors (i.e. 260-320 million more cases of malaria predicted by 2080, with six billion more at risk for dengue fever); * Effects on food yields- increased malnutrition; * Increased flooding in some areas and increased droughts in others, along with other impacts on freshwater supply; * Increases in foodborne and waterborne illnesses; * Warming and rising sea levels adding to displacement and also impacting water supply through salination; * Impaired functioning of ecosystems; * Negative effects on air quality associated with ground level ozone, including increases in cardio-respiratory morbidity and mortality, asthma, and allergens; * Displacement of vulnerable populations (especially in coastal areas)1; and * Loss of livelihoods3. Most of the impacts of climate change will result from amplifying the existing health hazards found in populations4. How susceptible a population is to the effects of climate change is dependent on their existing vulnerabilities (i.e. disease burden, resources etc.) as well as their adaptive capacity5. The World Health Organization has projected that countries that have, and will likely continue to suffer the greatest effects, are those who have contributed the smallest amount to the causes of climate change.6 While the vast majority of climate change deaths will occur in developing countries with systemic vulnerabilities, a recent Health Canada report has noted that Canada is likely to experience higher rates of warming in this century than most other countries in the world. Climate change scenarios predict an increased risk of extreme weather and other climate events for all regions of Canada, with the exception of extreme cold7. Canadians most vulnerable to climate change include seniors, children and infants, socially disadvantaged individuals, and those with pre-existing medical conditions such as cardiovascular disease8. Those living in cities could be especially vulnerable due to the impact of the heat island effect. However, given their greater access to emergency, health, social, and financial resources, they might also have the greatest adaptive capacity9. The health consequences of climate change have the potential to be more severe in far northern regions. Populations in Canada's north including aboriginals have already begun to see differences in their hunting practices as a result of changing ice patterns10, and the melting of permanent snowpacks11. Changes in ice patterns have also led to increased injuries12. In some places in the North, climate changes have led to greater risks from avalanches, landslides and other hazards13. Further problems are related to the infrastructure in Northern Canada, with some communities already noticing degradation of structures due to the thawing of the permafrost14. Given that much of the Northern infrastructure is already in disrepair, this represents a considerable problem. Geographic isolation, and a lack of resources may further exacerbate the situation15. What CMA has done? Physicians have a critical role to play in advancing public understanding of the potential impact of climate change on health and promoting health protecting responses. The CMA has been working on the issue of climate change and human health for a number of years. CMA was supportive of Canada's ratification of the Kyoto Protocol, and urged the Government of Canada to commit to choosing a climate change strategy that satisfied Canada's international commitments while also maximizing the clean air co-benefits and smog-reduction potential of any greenhouse gas reduction initiatives. In 2007, a number of resolutions were passed at General Council calling on government to properly plan for the health impacts of climate change and put in place measures to mitigate the impact of climate change on vulnerable populations in Canada's north. In that same year, CMA and the Canadian Nurses Association updated a joint position statement first entered into in 1994 calling for environmentally responsible activity in the health-care sector. Most recently, the CMA has been an integral part of the drafting of the World Medical Association (WMA) policies on health and climate change. The WMA Declaration of Delhi on Health and Climate Change was adopted at its annual General Assembly in New Delhi, India in October 2009, The declaration calls for action in five main areas; advocacy to combat global warming; leadership-help people be healthy enough to adapt to climate change; education and capacity building; surveillance and research; and collaboration to prepare for climate emergencies. This policy is written to complement the WMA declaration. What needs to be done? Climate change may lead to significant impacts on human health. While it is unlikely that these outcomes can be avoided, there are some strategies that can be employed to help limit the negative consequences. Education and Capacity Building There is a need for greater public and health professional awareness and education about climate change in order to gain understanding of the health consequences and support for strategies to reduce green house gases and mitigate climate change effects. CMA recommends: 1. A national public awareness program on the importance of the environment and global climate change to personal health; 2. Encouraging health sciences schools to enhance their provision of educational programs on environmental health; and fostering the development of continuing education modules on environmental health and environmental health practices. Surveillance and Research There are important gaps in our knowledge on the health impacts of climate change as well as the effectiveness of various mitigation and adaptation strategies. Surveillance and reporting functions need to be strengthened to allow for greater accuracy in modeling of future impacts. CMA recommends: 3. That the federal government must address the gaps in research regarding climate change and health by undertaking studies to - quantify and model the burden of disease that will be caused by global climate change - identify the most vulnerable populations, the particular health impacts of climate change on vulnerable populations, and possible new protections for such populations; - increase the collection and accuracy of health data, particularly for vulnerable and underserved populations; - report diseases that emerge in conjunction with global climate change, and participate in field investigations, as with outbreaks of infectious diseases; and - develop and expand surveillance systems to include diseases caused by global climate change. Reducing the Burden of Disease to Mitigate Climate Change Impacts How susceptible a population is to the effects of climate change is dependent on their existing vulnerabilities. Therefore, work needs to be done to reduce the burden of diseases and improve upon the social determinants of health for vulnerable populations in Canada and globally. CMA recommends: 4. That the federal and provincial/territorial governments work together to improve the ability of the public to adapt to climate change and catastrophic weather events by - Encouraging behaviours that improve overall health, - Creating targeted programs designed to address specific exposures, - Providing health promotion information and education on self-management of the symptoms of climate-associated illness, - Ensuring physical infrastructure that allows for adaptation; 5. That the federal government develop concrete actions to reduce the health impact of climate-related emissions, in particular those initiatives which will also improve the general health of the population; 6. That the federal government support the Millennium Development Goals and support the principles outlined in the WHO Commission on the Social Determinants of Health report; and Preparing for Climate Emergencies To deal with the future burden of climate change related health issues there is a need to ensure adequate health capacity and infrastructure. Rebuilding of public health capacity globally is seen as the most important, cost-effective, and urgently needed response to climate change16. Domestically, there is a need to ensure adequate surge capacity within the health care system to be prepared for an increase in illness related to climate change effects. There is also a need to strengthen not only the health systems, but the infrastructure (i.e. housing) for vulnerable populations including Aboriginals and those in the North. CMA recommends that the federal and provincial /territorial governments work together to: 7. Strengthen the public health system both domestically and internationally in order to improve the capacity of communities to adapt to climate change; 8. Ensure adequate surge capacity within Canada's health system to handle the increase in climate change related illness; 9. Ensure the health of vulnerable populations is adequate to handle climate change related situations; 10. Develop knowledge about the best ways to adapt to and mitigate the health effects of climate change; 11. Integrate health professionals into the emergency preparedness plans of government and public health authorities so that front-line providers are adequately informed and prepared to properly manage any health emergencies. Advocacy to Combat Climate Change Finally, there is a need to take action to reduce the damaging effects of climate change. The global community needs to come together to reduce the levels of green house gases being released in the atmosphere, and focus on safer more environmentally friendly energy sources. Investments in cuts to greenhouse gas emissions would greatly outweigh their costs, and could help to reduce the future burden of climate change related illness17. CMA recommends: 12. That the government of Canada become a global leader in promoting equitable, carbon neutral economic, industrial, and social policies, and practices that fight global warming and adopt specific green house gas reduction targets as determined by the evolving science of climate change. 13. That health care professionals act within their professional settings to reduce the environmental impact of medical activities and to develop environmentally sustainable professional settings; 14. That all Canadians act to minimize individual impacts on the environment, and encourage others to do so, as well. Conclusions The CMA believes that Canada must prepare now for the potential health threat that climate change poses to its population. While many of these effects will take decades to materialize, certain populations, such as those in Canada's north, or those in low lying coastal areas, are already starting to experience the impact of climate change. A focus on education and health promotion, as well as advocacy for improved public policy and primary health care resources will be a good start in dealing with this issue. Additionally, further research and data collection is necessary to improve our understanding of climate change and the effectiveness of adaptation and mitigation strategies. Finally, the global community needs to act together to address the health and environmental impacts of climate change. By working together, in an international response, strategies can be implemented to mitigate any negative health effects of climate change. Canada's physicians believe that: What is good for the environment is also good for human health. It is past time for those of us in the health sector in Canada to engage fully in the debate and discussions within our own house, as well as in the broader body politic to ensure that protecting human health is the bottom line of environmental and climate change strategies. Bibliography 1 Currently a third of the world's population lives within 60 miles of the shoreline and 13 of 20 biggest world cities located on the coast- more than a billion people could be displaced (Costello et.al., 2009) 1 Costello, Anthony et.al. "Managing the health effects of climate change.' The Lancet Volume 373 May 16, 2009. pp.1693-1733. 2 World Health Organization, World Meteorological Organization & United Nations Environment Programme (2003) Climate Change and Human Health- Risks and Responses, Summary. Available at: http://www.who.int/globalchange/climate/en/ccSCREEN.pdf 3 Confalonieri et.al., (2007) Human Health. Climate Change 2007: Impacts, Adaptation and Vulnerability. Contribution of Working Group II to the Fourth Assessment Report of the Intergovernmental Panel on Climate Change. Available at: http://www1.ipcc.ch/pdf/assessment-report/ar4/wg2/ar4-wg2-chapter8.pdf ; Epstein, Paul R. "Climate Change and Human Health." The New England Journal of Medicine 353 (14) October 6, 2005.; Friel, Sharon; Marmot, Michael; McMichael, Anthony J.; Kjellstrom, Tord & Denny Vagero. "Global health equity and climate stabilization: a common agenda." The Lancet Volume 372 November 8, 2008. pp.1677-1683. 4Confalonieri et.al., (2007) Human Health. Climate Change 2007: Impacts, Adaptation and Vulnerability. Contribution of Working Group II to the Fourth Assessment Report of the Intergovernmental Panel on Climate Change. Available at: http://www1.ipcc.ch/pdf/assessment-report/ar4/wg2/ar4-wg2-chapter8.pdf; World Health Organization (2009) Protecting Health From Climate Change: Global research priorities. Available at: http://whqlibdoc.who.int/publications/2009/9789241598187_eng.pdf 5 Health Canada (2001) Climate Change and Health & Well-being: A Policy Primer Available at: http://www.hc-sc.gc.ca/ewh-semt/pubs/climat/policy_primer-abecedaire_en_matiere/index-eng.php 6 Campbell-Lendrum, Diarmid; Corvalan, Carlos & Maria Neira "Global climate change: implications for international public health policy." Bulletin of the World Health Organization. March 2007, 85 (3) pp.235-237 7 Seguin, Jacinthe & Peter Berry (2008) "Human Health in a Changing Climate: A Canadian Assessment of Vulnerabilities and Adaptive Capacity, Synthesis Report." Health Canada Available at: http://www.nbhub.org/hubfiles/pdf/HealthinChangingClimate_Synthesis_english_low.pdf 8 Health Canada (2002) Climate Change And Health & Well-Being: A Policy Primer for Canada's North. Available at: http://dsp-psd.pwgsc.gc.ca/Collection/H46-2-02-290E.pdf 9 Seguin, Jacinthe & Peter Berry (2008) "Human Health in a Changing Climate: A Canadian Assessment of Vulnerabilities and Adaptive Capacity, Synthesis Report." Health Canada Available at: http://www.nbhub.org/hubfiles/pdf/HealthinChangingClimate_Synthesis_english_low.pdf 10 Ibid 11 Health Canada (2002) Climate Change And Health & Well-Being: A Policy Primer for Canada's North. Available at: http://dsp-psd.pwgsc.gc.ca/Collection/H46-2-02-290E.pdf 12 Epstein, Paul R. "Climate Change and Human Health." The New England Journal of Medicine 353 (14) October 6, 2005. 13 Seguin, Jacinthe & Peter Berry (2008) "Human Health in a Changing Climate: A Canadian Assessment of Vulnerabilities and Adaptive Capacity, Synthesis Report." Health Canada Available at: http://www.nbhub.org/hubfiles/pdf/HealthinChangingClimate_Synthesis_english_low.pdf 14 Field, Christopher B. et.al. (2007) North America. Climate Change 2007: Impacts, Adaptation and Vulnerability. Contribution of Working Group II to the Fourth Assessment Report of the Intergovernmental Panel on Climate Change. Available at: http://www1.ipcc.ch/pdf/assessment-report/ar4/wg2/ar4-wg2-chapter14.pdf 15 Health Canada (2002) Climate Change And Health & Well-Being: A Policy Primer for Canada's North. Available at: http://dsp-psd.pwgsc.gc.ca/Collection/H46-2-02-290E.pdf 16 World Health Organization, World Meteorological Organization & United Nations Environment Programme (2003) Climate Change and Human Health- Risks and Responses, Summary. Available at: http://www.who.int/globalchange/climate/en/ccSCREEN.pdf 17 Campbell-Lendrum, Diarmid; Corvalan, Carlos & Maria Neira "Global climate change: implications for international public health policy." Bulletin of the World Health Organization. March 2007, 85 (3) pp.235-237
Documents
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Lessons from the frontlines: A collaborative report on Pandemic H1N1

https://policybase.cma.ca/en/permalink/policy9840
Last Reviewed
2018-03-03
Date
2010-08-26
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2010-08-26
Topics
Population health/ health equity/ public health
Text
Lessons from the frontlines: A report on Pandemic H1N1 from Canadian Medical Association, The College of Family Physicians of Canada, National Specialty Society for Community Medicine One year ago, a novel influenza virus claimed its first victim in Mexico, and soon the world was plunged into its first influenza pandemic in 40 years. Although pandemic H1N1 (pH1N1) swept across the globe, we were fortunate this time as the virus was far less virulent than first feared. Now that pH1N1 has peaked and faded, it is time to look at what we learned and how it will help us plan for the next national public health emergency. The College of Family Physicians of Canada, the National Specialty Society for Community Medicine and the Canadian Medical Association have joined together to present a picture of lessons learned from the front lines of the pandemic. Together we represent over 80,000 physicians, of whom almost 50,000 are family physicians, engaged in all aspects of Canada's health care and public health systems. Canada's experience with SARS in 2003 was a "wake-up call"; much changed in its aftermath. The creation of the Public Health Agency of Canada led by a chief public health officer and the Pan-Canadian Public Health Network increased Canada's ability to respond to a public health emergency like pH1N1. The Canadian Pandemic Influenza Plan for the Health Sector, as well as complementary provincial and territorial plans, provides a framework and approach to responding to a pandemic. In many ways, this planning paid off. Canada mobilized quickly in response to the pH1N1 threat. Morbidity and mortality were lower than feared, and 45% of the population was vaccinated. But this response can also be seen as a "dress rehearsal" for a more severe influenza pandemic or some other national public health emergency: a test of our plans and an opportunity to learn from experience, with the time to incorporate these lessons into our strategic planning. Those on the front lines of response understand how health emergencies test our entire system - public health, acute and primary care and the community-based family physician. The success of our response depends on planning and practice, the effectiveness of public health and clinical countermeasures, our health human resources, the surge capacity within our health care and public health systems and our ability to reach the public. One of our greatest challenges in Canada is also to establish a coherent national and provincial/territorial strategy that can be implemented at a local level. Although we believe that Canada's overall response to pH1N1 produced many success stories, there were circumstances that challenged us as health professionals. Both health care and public health need further strengthening, and their separate infrastructures and the interdependence between these structures need attention and bolstering. The following comments focus on two overarching areas that influenced our ability to respond to the pandemic: communications and health system integration. Communications Communication was a consistent source of concern. Channels of communication among the various levels of public health providers were stronger than those for primary care providers, especially family physicians. On 9 Aug. 2009, following the first wave of pH1N1, our leaders wrote to chief public health officer of Canada Dr. David Butler-Jones on behalf of our members to share their thoughts and recommendations on how to improve communications with physicians. Family physicians in particular, but also other front-line health care providers, needed communication that was tailored to the practice setting, resources that were easy to access, and clear messages written in a manner that allowed rapid implementation into clinical practice during health emergencies because the timing of clinical response was critical. We recommended that front-line clinical practitioners be involved in the development of guidelines and the strategies for their dissemination, so that the content could be linked directly to the clinical setting. Family physicians are part of our first line of defence during infectious disease outbreaks. To ensure optimum patient care, they need clinical guidance quickly. Many physicians felt that the urgent need to provide consistent, clinically relevant information was not well recognized by the Public Health Agency of Canada (PHAC), the Public Health Network and, in some cases, provincial, territorial, regional or local levels. It took three months after recognition of the emerging pandemic to publish Interim Guidance for Ambulatory Care of Influenza-like Illness in the Context of H1N1. The current Public Health Network process of federal/provincial/territorial (FPT) consultation and consensus building seemed ill-suited to the acute national need for clinical information on issues such as the use and prescription of anti-viral medications. As provincial authorities and professional medical organizations moved to fill the void, different approaches and recommendations arose independent from one another. Better integration of primary care response by a national organization such as PHAC and the provincial/territorial health ministries could address the needs of clinical practitioners in concert with public health responses. This would also ensure that care directives are translated into user-friendly formats appropriate to clinical settings. We were pleased to be able to work with PHAC in fall 2009 to produce Pandemic H1N1: Fast Facts for Front-line Clinicians. This resource was highly valued by many of our members, and the collaboration demonstrated how health organizations can work effectively with government to contribute their expertise to the development and distribution of appropriate, clinically relevant information. Nevertheless, our critics declared that it was too little, too late. In situations where scientific evidence is rapidly changing, the processes used to distribute information to both front-line public health and clinical professionals must be designed to avoid confusion. Coordinated, unified communication strategies are needed at the national, provincial/territorial and local levels. Regardless of the official source, the information must be consistent. During the pandemic, many physicians and public health workers complained that multiple levels of government provided similar, but not the same advice. The differences led to skepticism, and the inundation of messages led to overload. The bottom line is that clinically relevant and trustworthy information should be provided on a timely basis, even if levels of certainty are fluctuating. Jurisdictions with effective communication to the primary care sector were characterized by cooperation and consultation between the medical community and the provincial, territorial and regional health authorities, both before and during the crisis. We recommend: 1. That the Public Health Agency of Canada, with the provinces and territories, evaluate the effectiveness of pH1N1 communications between public health and physicians and other front-line primary health care providers, and use the finding of this evaluation to research options for future response to a public health crisis. 2. That federal, provincial/territorial public health authorities and health care professionals and their associations work together in the inter-pandemic period to develop a pan-Canadian communication strategy to be used during health emergencies. 3. The establishment of a pan-Canadian centre within the Public Health Agency of Canada - similar to the Centre for Effective Practice - to undertake timely knowledge translation of clinical management guidelines for clinicians during public health crises. Surveillance and electronic communications The national response to infectious disease would have been greatly facilitated if system-wide communicable disease surveillance had been in place to support the sharing of data between public health and the rest of the health care system, particularly at the regional and local levels of pandemic response. Clinicians' practices are highly influenced by illness patterns that develop regionally and locally within their practice populations; thus, surveillance data are useful in determining appropriate treatment. Real-time data were not available to most physicians and when data did become available, they were already several weeks old. Delayed clinical guidelines were not a suitable substitute for timely surveillance information. Expansion of the use of electronic medical records (EMRs) in primary care, with bi-directional links to public health electronic health records (EHRs), could have facilitated surveillance and communications. Family practice clinics with EMRs were able to quickly identify high-risk patients, communicate with them to schedule vaccination appointments and collect the required data for public health. The varied levels of success of public pH1N1 vaccination clinics were further proof of the need to move to standard use of EMRs and EHRs in the health system. Communications can be enhanced through the sharing of data between the public health and primary care systems. EMRs may help resolve the challenge of collecting data from primary care sites. Collaboration among the PHAC, the Canadian Medical Association and the Information Technology Association of Canada's Health Division led to development of a pilot project to demonstrate the use of primary care EMRs as real-time sentinel surveillance tools for public health action to supplement existing surveillance mechanisms. In addition, after a successful two-year pilot project, the College of Family Physicians of Canada is working with the PHAC, in association with the Canadian Institute for Health Information, to conduct surveillance for five chronic diseases using EMRs, local networks across Canada and a national central repository for standardized data. These studies represent the increasingly important role of electronic information in surveillance and the value of collaboration between public health and primary care. We recommend: 4. That the federal and provincial/territorial governments provide EMR funding to enable clinical care and public health authorities to build interconnectedness and allow real-time information collection and analysis. System issues FPT responsibilities The division of responsibility between federal and provincial/territorial authorities for health care and emergency response influences how we respond to public health emergencies. Provincial/territorial governments have a primary role to play in regulating health matters within their boundaries. At the same time, the federal government has responsibilities related to national public safety and health protection. There can be no disputing the legitimacy of federal involvement in public health matters of an interprovincial/territorial nature. Under International Health Regulations, the federal government also has a responsibility to report and monitor public health emergencies of potential harm to other countries. Since Canada's SARS experience, there has been much progress in building FPT cooperation and increasing consultation on public health matters. However, the division of responsibility has led us to a situation where public health and clinical guidance in each province and territory was similar, yet different. Although the Pandemic Influenza Committee and the Special FPT Advisory Committee on H1N1 Influenza strove for consensus at the national level, individual provinces and territories were under no obligation to implement the guidance agreed to at the FPT level. Consultative and collaborative processes at the FPT level created delays in decision-making and directly interfered with the capacity of front-line professionals to respond to the urgent health needs of their patients. This led to a sense of confusion in the media and a loss of trust among the public and health professionals regarding Canada's capacity to respond to pH1N1. System capacity Canada's health system lacks surge capacity and can be sorely tested during a public health emergency, such as the recent experience with pH1N1. The underdeveloped public health infrastructure also means that it is a challenge to handle more than one national crisis at a time. To mount a response to pH1N1, public health units pulled human resources from other programs and many critical ones were delayed, suspended or cancelled altogether. During the first wave of pH1N1, Manitoba experienced a severe outbreak that stretched the resources of its critical care infrastructure to its limits. Front-line health care providers were inundated with telephone calls from the worried well and an increase in visits from those with flu symptoms. If pH1N1 had been the severe pandemic that was expected and for which Canada had been preparing, our health system would have been brought to its knees. In 2008, the Canadian Coalition for Public Health in the 21st Century noted that Canada remains vulnerable to the risks presented by epidemics and pandemics. This vulnerability remains today, and a long-range plan to build our public health capacity and workforce and to address the lack of surge capacity in our health system must become a priority if we are to be prepared for the next emergency. We recommend: 5. That the federal government increase infrastructure funding to provinces/territories to assist local health emergency preparedness planning and response, to reduce variation across the country and to integrate clinical care structures into public health structures at the local level. 6. That the Public Health Agency of Canada review the recommendations of the 2003 report of the National Advisory Committee on SARS and Public Health (Naylor report) in light of the pH1N1 experience and develop a national action plan to address the persistent gaps. Public health/primary care partnership Family physicians, in particular, understand that primary health care happens at the local level. In fact, so does all public health. During times of public health crisis, it is crucial for public health and primary care to work together, each respecting, supporting and bolstering the efforts of the other. Strengthening local public health and primary care structures and the interface between them would have resulted in improved, shared understanding of each sector's roles and responsibilities during the pH1N1 epidemic, better communications, improved data sharing and, most important, better served populations. Public health measures are directed toward the mitigation of disease through surveillance, research and outbreak management activities, while physicians provide information, education and clinical treatment to their patients. A commitment from both sectors at the local and provincial levels - and the professionals within each sector - to work together in the inter-pandemic period to build on processes that allow sharing of perspectives and information is essential. It is crucial that local public health authorities receive financial resources to increase their ability to collaborate effectively with family physicians, specialist physicians and other front-line providers. A number of the challenges faced by front-line public health workers and front-line physicians during the pH1N1 outbreak could have been lessened if there had been stronger links within the health system. We recommend: 7. That the Public Health Agency of Canada develop a focus on improving the interrelationship between primary care and public health to support collaboration during public health crises. Vaccination A key measure to combat pandemic influenza is mass vaccination. On the whole, Canada mounted an effective campaign: 45% of Canadians were vaccinated, and the proportion was even higher in First Nations communities - a first in Canadian history. Canada was one of the first countries with sufficient vaccine for the population and, with one domestic vaccine supplier, Canada avoided the confusion of multiple formulations as seen in the United States. The outcome was positive, but many public health units were stretched as expectations exceeded the pre-existing constrained resources. Although we recognize that the provinces and territories have quite different approaches to the delivery of their routine immunization programs, there is agreement that the pandemic immunization process did not adequately engage physicians in planning and delivery. A number of difficulties, such as the impact of bulk packaging, manufacturing delays that affected the agreed "sequencing" of patients and the logistics of inventory management, led to friction between front-line public health practitioners and family physicians. These could have been avoided with strengthened interdependence and mutual understanding before this crisis. The great variation in mass vaccination programs between provinces/territories, and even between local public health units, led to public confusion. Recognition of the diversity of primary care settings in which physicians work and bilateral planning in advance of the event is essential, because it is simply not feasible to tailor responses to myriad settings in the heat of the moment. Television broadcasts of long lines of people waiting to be vaccinated contributed to a loss of confidence in the system at a time when public confidence was sorely needed to encourage vaccination. Nationally promulgated clinical practice guidelines had great potential to create consistent clinical responses across the country. Instead, the variation and lack of coordination in providing important clinical information during this crisis eroded the public's confidence in the federal, provincial and territorial response. Ensuring future consistency in clinical approaches will require examination of ethical principles for the allocation of resources, such as anti-virals, vaccines and hospital treatment. Public engagement in the discussion of ethical principles is essential and, as much as possible, the consultative process should be transparent and undertaken in advance. We recommend: 8. That the Public Health Network seek advanced pan-Canadian commitment to a harmonized and singular national response to clinical practice guidelines, including mass vaccination programs, during times of potential public health crisis. Conclusion In 2003, in its submission to the National Advisory Committee on SARS, the Canadian Medical Association noted that the uptake of new information is influenced by many qualitative factors, and that research is needed to determine how best to communicate with individual physicians and other health care providers in emergency situations. Communication processes should be based on sound research and build on existing communication networks and relationships. The College of Family Physicians of Canada has recommended that information networks be strengthened to promote the sharing of the most relevant information among family physicians, other primary care providers and public health at the local level. We believe that PHAC is well positioned to undertake research on how health professionals can best receive information and to catalogue existing communication networks to build them into a well-coordinated national emergency response communication system. We must work together to translate pandemic information into practical messages relevant to front-line providers and employ trusted channels to deliver key messages to our patients and the public. Broad consensus is developing that our experience with the pH1N1 outbreak has shown that one of our greatest needs in preparing for the next public health emergency is for a national communications strategy that involves all levels of government, targets all sectors of our health system and uses the channels with which these targets are most familiar. An effective response to infectious disease outbreaks depends on effective surveillance, data collection and sharing and tracking of clinical interventions. The absence of a national communicable disease/immunization monitoring system is an ongoing problem. In 2003, the report of the National Advisory Committee on SARS and Public Health recommended that "the [Public Health] Agency [of Canada] should facilitate the long term development of a comprehensive and national public health surveillance system that will collect, analyze, and disseminate laboratory and health care facility data on infectious diseases... to relevant stakeholders." In 2010, Canada still does not have a comprehensive national surveillance and epidemiological system. A pan-Canadian electronic health information system is urgently needed and must become a priority during the inter-pandemic phase, with adequate federal funding and provincial/territorial collaboration. Greater adoption of the EMR in primary care and better public health EHRs with the ability to link systems will augment existing surveillance capacity and should be considered essential to a pan-Canadian system. Many of the challenges front-line health practitioners faced during the pH1N1 were also challenges during the SARS outbreak in 2003. The Naylor report proposed a number of measures to improve Canada's readiness and strengthen public health. Although a great deal of work and effort has gone into building links with and between provinces/territories and the federal government within the public health and the health emergency management system, little has trickled down to the front lines. This is not to devalue the much-improved spirit of FPT cooperation and the important achievements that have been made. Rather it is to suggest that, as the roof is no longer leaking, it is time to focus attention on the foundation - the response at the local level. Embedding primary care expertise in public health planning within the PHAC and at provincial/territorial and local levels will help circumvent problems and improve the effectiveness of our health system to respond to public health emergencies. A dialogue between primary care and the emergency management structures will help the response team understand and value the capabilities within primary care and build them into their planning and response systems. At the end of the day, we need to nurture collaborative relations between public health and primary care. Our shared objective is protecting the health of Canadians, recognizing that, in reality, neither system can be successful in isolation. It is essential that we trust each other's professionalism and expertise and work together to ensure that a strong foundation is in place to protect Canadians from future health threats. We have the will and expertise. We need the resources and a firm commitment to move forward. We have had two "wake-up calls" - SARS and pH1N1. Let's not wait for a third to find that we are not yet prepared. Recommendations 1. That the Public Health Agency of Canada, with the provinces and territories, evaluate the effectiveness of pH1N1 communications between public health and physicians and other front-line primary health care providers, and use the finding of this evaluation to research options for future response to a public health crisis. 2. That federal, provincial/territorial public health authorities and health care professionals and their associations work together in the inter-pandemic period to develop a pan-Canadian communication strategy to be used during health emergencies. 3. The establishment of a pan-Canadian centre within the Public Health Agency of Canada - similar to the Centre for Effective Practice - to undertake timely knowledge translation of clinical management guidelines for clinicians during public health crises. 4. That the federal and provincial/territorial governments provide EMR funding to enable clinical care and public health authorities to build interconnectedness and allow real-time information collection and analysis. 5. That the federal government increase infrastructure funding to provinces/territories to assist local health emergency preparedness planning and response, to reduce variation across the country and to integrate clinical care structures into public health structures at the local level. 6. That the Public Health Agency of Canada review the recommendations of the 2003 report of the National Advisory Committee on SARS and Public Health (Naylor report) in light of the pH1N1 experience and develop a national action plan to address the persistent gaps. 7. That the Public Health Agency of Canada develop a focus on improving the interrelationship between primary care and public health to support collaboration during public health crises. 8. That the Public Health Network seek advanced pan-Canadian commitment to a harmonized and singular national response to clinical practice guidelines, including mass vaccination programs, during times of potential public health crisis.
Documents
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Patient-focused funding

https://policybase.cma.ca/en/permalink/policy9845
Last Reviewed
2017-03-04
Date
2010-08-25
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Resolution
GC10-13
The Canadian Medical Association will work with provincial/territorial medical associations and governments to ensure that patient-focused funding supports the timeliness, safety and quality of patient care.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
2010-08-25
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Resolution
GC10-13
The Canadian Medical Association will work with provincial/territorial medical associations and governments to ensure that patient-focused funding supports the timeliness, safety and quality of patient care.
Text
The Canadian Medical Association will work with provincial/territorial medical associations and governments to ensure that patient-focused funding supports the timeliness, safety and quality of patient care.
Less detail

Charter for Patient-centred Care

https://policybase.cma.ca/en/permalink/policy9847
Last Reviewed
2017-03-04
Date
2010-08-25
Topics
Ethics and medical professionalism
Population health/ health equity/ public health
Resolution
GC10-15
The Canadian Medical Association will work with provincial/territorial medical associations, patient advocacy groups and other medical and health organizations to further develop the elements of the Charter for Patient-centred Care.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
2010-08-25
Topics
Ethics and medical professionalism
Population health/ health equity/ public health
Resolution
GC10-15
The Canadian Medical Association will work with provincial/territorial medical associations, patient advocacy groups and other medical and health organizations to further develop the elements of the Charter for Patient-centred Care.
Text
The Canadian Medical Association will work with provincial/territorial medical associations, patient advocacy groups and other medical and health organizations to further develop the elements of the Charter for Patient-centred Care.
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Lifetime clinical prevention schedule

https://policybase.cma.ca/en/permalink/policy9855
Last Reviewed
2017-03-04
Date
2010-08-25
Topics
Health systems, system funding and performance
Physician practice/ compensation/ forms
Population health/ health equity/ public health
Resolution
GC10-24
The Canadian Medical Association, in collaboration with provincial/territorial medical associations, urges governments to support the development and implementation of a lifetime clinical prevention schedule based on scientific evidence and coordinated by primary care physicians.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
2010-08-25
Topics
Health systems, system funding and performance
Physician practice/ compensation/ forms
Population health/ health equity/ public health
Resolution
GC10-24
The Canadian Medical Association, in collaboration with provincial/territorial medical associations, urges governments to support the development and implementation of a lifetime clinical prevention schedule based on scientific evidence and coordinated by primary care physicians.
Text
The Canadian Medical Association, in collaboration with provincial/territorial medical associations, urges governments to support the development and implementation of a lifetime clinical prevention schedule based on scientific evidence and coordinated by primary care physicians.
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Healthy lifestyles

https://policybase.cma.ca/en/permalink/policy9860
Last Reviewed
2017-03-04
Date
2010-08-25
Topics
Population health/ health equity/ public health
Resolution
GC10-30
The Canadian Medical Association will review and assess the international use of patient-focused incentives and disincentives to promote healthy lifestyles.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
2010-08-25
Topics
Population health/ health equity/ public health
Resolution
GC10-30
The Canadian Medical Association will review and assess the international use of patient-focused incentives and disincentives to promote healthy lifestyles.
Text
The Canadian Medical Association will review and assess the international use of patient-focused incentives and disincentives to promote healthy lifestyles.
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Renegotiation of the 2004 First Ministers’ Health Accord

https://policybase.cma.ca/en/permalink/policy9865
Last Reviewed
2017-03-04
Date
2010-08-25
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Resolution
GC10-36
The Canadian Medical Association urges the federal government to begin discussions with provincial and territorial governments, in consultation with health care stakeholders, on the renegotiation of the 2004 First Ministers’ Health Accord that is set to expire March 31, 2014.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
2010-08-25
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Resolution
GC10-36
The Canadian Medical Association urges the federal government to begin discussions with provincial and territorial governments, in consultation with health care stakeholders, on the renegotiation of the 2004 First Ministers’ Health Accord that is set to expire March 31, 2014.
Text
The Canadian Medical Association urges the federal government to begin discussions with provincial and territorial governments, in consultation with health care stakeholders, on the renegotiation of the 2004 First Ministers’ Health Accord that is set to expire March 31, 2014.
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Social determinants of health

https://policybase.cma.ca/en/permalink/policy9878
Last Reviewed
2017-03-04
Date
2010-08-25
Topics
Population health/ health equity/ public health
Ethics and medical professionalism
Resolution
GC10-61
The Canadian Medical Association recognizes the importance of the social determinants of health and will incorporate them into its continued work to support a healthy population.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
2010-08-25
Topics
Population health/ health equity/ public health
Ethics and medical professionalism
Resolution
GC10-61
The Canadian Medical Association recognizes the importance of the social determinants of health and will incorporate them into its continued work to support a healthy population.
Text
The Canadian Medical Association recognizes the importance of the social determinants of health and will incorporate them into its continued work to support a healthy population.
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Comprehensive pregnancy care

https://policybase.cma.ca/en/permalink/policy9882
Last Reviewed
2017-03-04
Date
2010-08-25
Topics
Population health/ health equity/ public health
Health care and patient safety
Resolution
GC10-84
The Canadian Medical Association will work with provincial/territorial medical associations, affiliate and associate organizations, and other stakeholders to further develop educational materials for primary care providers and women on the importance of pre-pregnancy and early-pregnancy health, and early access to comprehensive pregnancy care.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
2010-08-25
Topics
Population health/ health equity/ public health
Health care and patient safety
Resolution
GC10-84
The Canadian Medical Association will work with provincial/territorial medical associations, affiliate and associate organizations, and other stakeholders to further develop educational materials for primary care providers and women on the importance of pre-pregnancy and early-pregnancy health, and early access to comprehensive pregnancy care.
Text
The Canadian Medical Association will work with provincial/territorial medical associations, affiliate and associate organizations, and other stakeholders to further develop educational materials for primary care providers and women on the importance of pre-pregnancy and early-pregnancy health, and early access to comprehensive pregnancy care.
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Allocation of resources

https://policybase.cma.ca/en/permalink/policy9886
Last Reviewed
2017-03-04
Date
2010-08-25
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Resolution
GC10-63
The Canadian Medical Association, in collaboration with provincial/territorial medical associations, strongly urges governments that decisions regarding the allocation of resources for new and existing health care treatments, programs, policies and products be consistent with the best available scientific evidence.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
2010-08-25
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Resolution
GC10-63
The Canadian Medical Association, in collaboration with provincial/territorial medical associations, strongly urges governments that decisions regarding the allocation of resources for new and existing health care treatments, programs, policies and products be consistent with the best available scientific evidence.
Text
The Canadian Medical Association, in collaboration with provincial/territorial medical associations, strongly urges governments that decisions regarding the allocation of resources for new and existing health care treatments, programs, policies and products be consistent with the best available scientific evidence.
Less detail
Last Reviewed
2017-03-04
Date
2010-08-25
Topics
Population health/ health equity/ public health
Resolution
GC10-67
The Canadian Medical Association, in collaboration with provincial/territorial medical associations, affiliates and associate organizations, calls on governments to add chronic pain to the list of recognized chronic diseases.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
2010-08-25
Topics
Population health/ health equity/ public health
Resolution
GC10-67
The Canadian Medical Association, in collaboration with provincial/territorial medical associations, affiliates and associate organizations, calls on governments to add chronic pain to the list of recognized chronic diseases.
Text
The Canadian Medical Association, in collaboration with provincial/territorial medical associations, affiliates and associate organizations, calls on governments to add chronic pain to the list of recognized chronic diseases.
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Online continuing medical education

https://policybase.cma.ca/en/permalink/policy9892
Last Reviewed
2017-03-04
Date
2010-08-25
Topics
Population health/ health equity/ public health
Ethics and medical professionalism
Health information and e-health
Resolution
GC10-69
The Canadian Medical Association, in collaboration with provincial/territorial medical associations, calls on governments to ensure that the necessary technology is in place to guarantee that physicians in rural and remote locations have access to accredited online continuing medical education/continuing professional development.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
2010-08-25
Topics
Population health/ health equity/ public health
Ethics and medical professionalism
Health information and e-health
Resolution
GC10-69
The Canadian Medical Association, in collaboration with provincial/territorial medical associations, calls on governments to ensure that the necessary technology is in place to guarantee that physicians in rural and remote locations have access to accredited online continuing medical education/continuing professional development.
Text
The Canadian Medical Association, in collaboration with provincial/territorial medical associations, calls on governments to ensure that the necessary technology is in place to guarantee that physicians in rural and remote locations have access to accredited online continuing medical education/continuing professional development.
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Antibiotic resistant organisms in humans

https://policybase.cma.ca/en/permalink/policy9902
Last Reviewed
2017-03-04
Date
2010-08-25
Topics
Population health/ health equity/ public health
Ethics and medical professionalism
Health care and patient safety
Resolution
GC10-79
The Canadian Medical Association, in collaboration with provincial/territorial medical associations, will work with Health Canada and the Public Health Agency of Canada to investigate the agriculture-related release of antibiotic resistant organisms and residual antibiotics into earth and water ecosystems, as well as the role they play in the emergence of antibiotic resistant organisms in humans.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
2010-08-25
Topics
Population health/ health equity/ public health
Ethics and medical professionalism
Health care and patient safety
Resolution
GC10-79
The Canadian Medical Association, in collaboration with provincial/territorial medical associations, will work with Health Canada and the Public Health Agency of Canada to investigate the agriculture-related release of antibiotic resistant organisms and residual antibiotics into earth and water ecosystems, as well as the role they play in the emergence of antibiotic resistant organisms in humans.
Text
The Canadian Medical Association, in collaboration with provincial/territorial medical associations, will work with Health Canada and the Public Health Agency of Canada to investigate the agriculture-related release of antibiotic resistant organisms and residual antibiotics into earth and water ecosystems, as well as the role they play in the emergence of antibiotic resistant organisms in humans.
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E-health strategies

https://policybase.cma.ca/en/permalink/policy9908
Last Reviewed
2017-03-04
Date
2010-08-25
Topics
Health information and e-health
Health systems, system funding and performance
Resolution
GC10-90
The Canadian Medical Association will work with provincial/territorial medical associations to ensure investments made by the Canada Health Infoway are aligned with, and respect e-health strategies that are currently being implemented or developed within various jurisdictions.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
2010-08-25
Topics
Health information and e-health
Health systems, system funding and performance
Resolution
GC10-90
The Canadian Medical Association will work with provincial/territorial medical associations to ensure investments made by the Canada Health Infoway are aligned with, and respect e-health strategies that are currently being implemented or developed within various jurisdictions.
Text
The Canadian Medical Association will work with provincial/territorial medical associations to ensure investments made by the Canada Health Infoway are aligned with, and respect e-health strategies that are currently being implemented or developed within various jurisdictions.
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Last Reviewed
2017-03-04
Date
2010-08-25
Topics
Health information and e-health
Population health/ health equity/ public health
Physician practice/ compensation/ forms
Resolution
GC10-93
The Canadian Medical Association supports and will expedite research into the expansion of telemedicine and the utilization of emerging technologies, to directly link health care providers and patients.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
2010-08-25
Topics
Health information and e-health
Population health/ health equity/ public health
Physician practice/ compensation/ forms
Resolution
GC10-93
The Canadian Medical Association supports and will expedite research into the expansion of telemedicine and the utilization of emerging technologies, to directly link health care providers and patients.
Text
The Canadian Medical Association supports and will expedite research into the expansion of telemedicine and the utilization of emerging technologies, to directly link health care providers and patients.
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Medical records

https://policybase.cma.ca/en/permalink/policy9923
Last Reviewed
2017-03-04
Date
2010-08-25
Topics
Ethics and medical professionalism
Health care and patient safety
Health information and e-health
Resolution
GC10-106
The Canadian Medical Association will work with provincial/territorial medical associations and other stakeholders including patients to develop a national strategy for the long-term retention, retrieval and disposal of medical records.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
2010-08-25
Topics
Ethics and medical professionalism
Health care and patient safety
Health information and e-health
Resolution
GC10-106
The Canadian Medical Association will work with provincial/territorial medical associations and other stakeholders including patients to develop a national strategy for the long-term retention, retrieval and disposal of medical records.
Text
The Canadian Medical Association will work with provincial/territorial medical associations and other stakeholders including patients to develop a national strategy for the long-term retention, retrieval and disposal of medical records.
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Preventive practices of health professionals

https://policybase.cma.ca/en/permalink/policy747
Last Reviewed
2017-03-04
Date
1991-10-19
Topics
Population health/ health equity/ public health
Resolution
BD92-03-34
That the Canadian Medical Association approve in principle the concept of enhancing preventive practices of health professionals.
Policy Type
Policy resolution
Last Reviewed
2017-03-04
Date
1991-10-19
Topics
Population health/ health equity/ public health
Resolution
BD92-03-34
That the Canadian Medical Association approve in principle the concept of enhancing preventive practices of health professionals.
Text
That the Canadian Medical Association approve in principle the concept of enhancing preventive practices of health professionals.
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Statement to the House of Commons Committee on Health addressing the opioid crisis in Canada

https://policybase.cma.ca/en/permalink/policy13936
Date
2016-10-18
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Population health/ health equity/ public health
Health care and patient safety
  1 document  
Policy Type
Parliamentary submission
Date
2016-10-18
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Population health/ health equity/ public health
Health care and patient safety
Text
Thank you Mr. Chair. I am Dr. Jeff Blackmer, the Vice-President of Medical Professionalism for the Canadian Medical Association. On behalf of the CMA, let me first commend the committee for initiating an emergency study on this public health crisis in Canada. As the national organization representing over 83,000 Canadian physicians, the CMA has an instrumental role in collaborating with other health stakeholders, governments and patient organizations in addressing the opioid crisis in Canada. On behalf of Canada’s doctors, the CMA is deeply concerned with the escalating public health crisis related to problematic opioid and fentanyl use. Physicians are on the front lines in many respects. Doctors are responsible for supporting patients with the management of acute and chronic pain. Policy makers must recognize that prescription opioids are an essential tool in the alleviation of pain and suffering, particularly in palliative and cancer care. The CMA has long been concerned with the harms associated with opioid use. In fact, we appeared before this committee as part of its 2013 study on the government’s role in addressing prescription drug abuse. At that time, we made a number of recommendations on the government’s role – some of which I will reiterate today. Since then, the CMA has taken numerous actions to contribute to Canada’s response to the opioid crisis. These actions have included advancing the physician perspective in all active government consultations. In addition to the 2013 study by the health committee, we have also participated in the 2014 ministerial roundtable and recent regulatory consultations led by Health Canada — specifically, on tamper resistant technology for drugs and delisting of naloxone for the prevention of overdose deaths in the community. 3 Our other actions have included: · Undertaking physician polling to better understand physician experiences with prescribing opioids; · Developing and disseminating new policy on addressing the harms associated with opioids; · Supporting the development of continuing medical education resources and tools for physicians; · Supporting the national prescription drug drop off days; and, · Hosting a physician education session as part of our annual meeting in 2015. Further, I’m pleased to report that the CMA has recently joined the Executive Council of the First Do No Harm strategy, coordinated by the Canadian Centre on Substance Abuse. In addition, we have joined 7 leading stakeholders as part of a consortium formed this year to collaborate on addressing the issue from a medical standpoint. I will now turn to the CMA’s recommendations for the committee’s consideration. These are grouped in four major theme areas. 1) Harm Reduction The first of them is harm reduction. Addiction should be recognized and treated as a serious, chronic and relapsing medical condition for which there are effective treatments. Despite the fact that there is broad recognition that we are in a public health crisis, the focus of the federal National Anti-Drug Strategy is heavily skewed towards a criminal justice approach rather than a public health approach. In its current form, this strategy does not significantly address the determinants of drug use, treat addictions, or reduce the harms associated with drug use. The CMA strongly recommends that the federal government review the National Anti-Drug Strategy to reinstate harm reduction as a core pillar. Supervised consumption sites are an important part of a harm reduction program that must be considered in an overall strategy to address harms from opioids. The availability of supervised consumption sites is still highly limited in Canada. The CMA maintains its concerns that the new criteria established by the Respect for Communities Act are overly burdensome and deter the establishment of new sites. 4 As such, the CMA continues to recommend that the act be repealed or at the least, significantly amended. 2) Expanding Pain Management and Addiction Treatment The second theme area I will raise is the need to expand treatment options and services. Treatment options and services for both addiction as well as pain management are woefully under-resourced in Canada. This includes substitution treatments such as buprenorphine-naloxone as well as services that help patients taper off opioids or counsel them with cognitive behavioural therapy. Availability and access of these critical resources varies by jurisdiction and region. The federal government should prioritize the expansion of these services. The CMA recommends that the federal government deliver additional funding on an emergency basis to significantly expand the availability and access to addiction treatment and pain management services. 3) Investing in Prescriber and Patient Education The third theme I will raise for the committee’s consideration is the need for greater investment in both prescriber as well as patient education resources. For prescribers, this includes continuing education modules as well as training curricula. We need to ensure the availability of unbiased and evidenced-based educational programs in opioid prescribing, pain management and in the management of addictions. Further, support for the development of educational tools and resources based on the new clinical guidelines to be released in early 2017 will have an important role. Finally, patient and public education on the harms associated with opioid usage is critical. As such, the CMA recommends that the federal government deliver new funding to support the availability and provision of education and training resources for prescribers, patients and the public. 4) Establishing a Real-time Prescription Monitoring Program Finally, to support optimal prescribing, it is critical that prescribers be provided with access to a real-time prescription monitoring program. 5 Such a program would allow physicians to review a patient’s prescription history from multiple health services prior to prescribing. Real-time prescription monitoring is currently only available in two jurisdictions in Canada. Before closing, I must emphasize that the negative impacts associated with prescription opioids represent a complex issue that will require a multi-faceted, multi-stakeholder response. A key challenge for public policy makers and prescribers is to mitigate the harms associated with prescription opioid use, without negatively affecting patient access to the appropriate treatment for their clinical conditions. To quote a past CMA president: “the unfortunate reality is that there is no silver bullet solution and no one group or government can address this issue alone”. The CMA is committed to being part of the solution. Thank you.
Documents
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Education on the prescription of physical activity and exercise

https://policybase.cma.ca/en/permalink/policy11892
Date
2016-08-24
Topics
Population health/ health equity/ public health
Resolution
GC16-22
The Canadian Medical Association supports national curriculum development within Canada's medical schools that ensures education on the prescription of physical activity and exercise
Policy Type
Policy resolution
Date
2016-08-24
Topics
Population health/ health equity/ public health
Resolution
GC16-22
The Canadian Medical Association supports national curriculum development within Canada's medical schools that ensures education on the prescription of physical activity and exercise
Text
The Canadian Medical Association supports national curriculum development within Canada's medical schools that ensures education on the prescription of physical activity and exercise
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