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CMA PolicyBase

Policies that advocate for the medical profession and Canadians


170 records – page 1 of 9.

Promotion of healthy childhood

https://policybase.cma.ca/en/permalink/policy374
Last Reviewed
2020-02-29
Date
1999-08-25
Topics
Population health/ health equity/ public health
Resolution
GC99-42
That the Canadian Medical Association promote both medical and social interventions to ensure an optimal start to life and a physically, mentally and socially healthy childhood.
Policy Type
Policy resolution
Last Reviewed
2020-02-29
Date
1999-08-25
Topics
Population health/ health equity/ public health
Resolution
GC99-42
That the Canadian Medical Association promote both medical and social interventions to ensure an optimal start to life and a physically, mentally and socially healthy childhood.
Text
That the Canadian Medical Association promote both medical and social interventions to ensure an optimal start to life and a physically, mentally and socially healthy childhood.
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Access by the elderly to medical and supportive health care

https://policybase.cma.ca/en/permalink/policy377
Last Reviewed
2020-02-29
Date
1999-08-25
Topics
Population health/ health equity/ public health
Resolution
GC99-78
That the Canadian Medical Association adopt as policy the following principle: Access in old age. Older citizens in all parts of Canada should have timely access to medical and supportive health care services that are clinically appropriate. This includes: a) rapid access to primary medical care, b) access to a full range of medical, surgical, diagnostic, treatment and rehabilitative services, and c) access to specialized programs designed to address the physical and mental problems of old age. Access to clinically appropriate services should not be denied on the basis of age or disability.
Policy Type
Policy resolution
Last Reviewed
2020-02-29
Date
1999-08-25
Topics
Population health/ health equity/ public health
Resolution
GC99-78
That the Canadian Medical Association adopt as policy the following principle: Access in old age. Older citizens in all parts of Canada should have timely access to medical and supportive health care services that are clinically appropriate. This includes: a) rapid access to primary medical care, b) access to a full range of medical, surgical, diagnostic, treatment and rehabilitative services, and c) access to specialized programs designed to address the physical and mental problems of old age. Access to clinically appropriate services should not be denied on the basis of age or disability.
Text
That the Canadian Medical Association adopt as policy the following principle: Access in old age. Older citizens in all parts of Canada should have timely access to medical and supportive health care services that are clinically appropriate. This includes: a) rapid access to primary medical care, b) access to a full range of medical, surgical, diagnostic, treatment and rehabilitative services, and c) access to specialized programs designed to address the physical and mental problems of old age. Access to clinically appropriate services should not be denied on the basis of age or disability.
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Safety of genetically modified organisms

https://policybase.cma.ca/en/permalink/policy378
Last Reviewed
2020-02-29
Date
1999-08-25
Topics
Health care and patient safety
Resolution
GC99-80
That the Canadian Medical Association ask Health Canada to ensure it obtains sound evidence of the safety of genetically modified organisms before they are authorized by Agriculture and Agri-Food Canada.
Policy Type
Policy resolution
Last Reviewed
2020-02-29
Date
1999-08-25
Topics
Health care and patient safety
Resolution
GC99-80
That the Canadian Medical Association ask Health Canada to ensure it obtains sound evidence of the safety of genetically modified organisms before they are authorized by Agriculture and Agri-Food Canada.
Text
That the Canadian Medical Association ask Health Canada to ensure it obtains sound evidence of the safety of genetically modified organisms before they are authorized by Agriculture and Agri-Food Canada.
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Information program for Canadians on genetically modified organisms

https://policybase.cma.ca/en/permalink/policy379
Last Reviewed
2020-02-29
Date
1999-08-25
Topics
Health information and e-health
Resolution
GC99-81
That the Canadian Medical Association urge the federal government to create an information program for Canadians on genetically modified organisms.
Policy Type
Policy resolution
Last Reviewed
2020-02-29
Date
1999-08-25
Topics
Health information and e-health
Resolution
GC99-81
That the Canadian Medical Association urge the federal government to create an information program for Canadians on genetically modified organisms.
Text
That the Canadian Medical Association urge the federal government to create an information program for Canadians on genetically modified organisms.
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Regulations for genetically modified organisms

https://policybase.cma.ca/en/permalink/policy380
Last Reviewed
2020-02-29
Date
1999-08-25
Topics
Health care and patient safety
Resolution
GC99-82
That the Canadian Medical Association urge the federal government to act quickly to adopt regulations controlling the development, testing and commercialization of genetically modified organisms.
Policy Type
Policy resolution
Last Reviewed
2020-02-29
Date
1999-08-25
Topics
Health care and patient safety
Resolution
GC99-82
That the Canadian Medical Association urge the federal government to act quickly to adopt regulations controlling the development, testing and commercialization of genetically modified organisms.
Text
That the Canadian Medical Association urge the federal government to act quickly to adopt regulations controlling the development, testing and commercialization of genetically modified organisms.
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Evaluating international medical graduates competencies

https://policybase.cma.ca/en/permalink/policy455
Last Reviewed
2020-02-29
Date
1999-08-25
Topics
Health human resources
Resolution
GC99-29
That the Canadian Medical Association support efforts to evaluate the competencies of international medical graduates prior to licensure in Canada by applying equivalent evaluation standards to international medical graduates as those used for graduates of Canadian medical schools so that the safety of the public is assured.
Policy Type
Policy resolution
Last Reviewed
2020-02-29
Date
1999-08-25
Topics
Health human resources
Resolution
GC99-29
That the Canadian Medical Association support efforts to evaluate the competencies of international medical graduates prior to licensure in Canada by applying equivalent evaluation standards to international medical graduates as those used for graduates of Canadian medical schools so that the safety of the public is assured.
Text
That the Canadian Medical Association support efforts to evaluate the competencies of international medical graduates prior to licensure in Canada by applying equivalent evaluation standards to international medical graduates as those used for graduates of Canadian medical schools so that the safety of the public is assured.
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Addressing professional issues of Canadian physicians and medical practice

https://policybase.cma.ca/en/permalink/policy465
Last Reviewed
2020-02-29
Date
1999-08-25
Topics
Physician practice/ compensation/ forms
Resolution
GC99-60
That the Canadian Medical Association be the national focus for enhancing organized medicine's effectiveness in addressing the variety of professional issues facing Canadian physicians and medical practice.
Policy Type
Policy resolution
Last Reviewed
2020-02-29
Date
1999-08-25
Topics
Physician practice/ compensation/ forms
Resolution
GC99-60
That the Canadian Medical Association be the national focus for enhancing organized medicine's effectiveness in addressing the variety of professional issues facing Canadian physicians and medical practice.
Text
That the Canadian Medical Association be the national focus for enhancing organized medicine's effectiveness in addressing the variety of professional issues facing Canadian physicians and medical practice.
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Streamlining patient flow from primary to specialty care: a critical requirement for improved access to specialty care

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

https://policybase.cma.ca/en/permalink/policy11476
Last Reviewed
2020-02-29
Date
2014-12-06
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2020-02-29
Date
2014-12-06
Topics
Population health/ health equity/ public health
Text
Adult health is pre-determined in many ways in early childhood and even by events occurring before birth. The years between conception and the start of school are the time when crucial developments in physical, social, cognitive, emotional and language domains take place. Disruptions during this period can lead to weakened physiological responses, influence brain architecture, and influence how the neuroendocrine, cardiovascular and other systems are developed.1,2 Experiences in early life can even 'get under the skin', changing the ways that certain genes are expressed.3,4 Negative experiences such as poverty or family or parental violence can have significant impacts on this important period of development. Even for those children who don't encounter these types of barriers, there can be problems in the early years. Evidence suggests that adult diseases should be viewed as developmental disorders that begin in early life.5 Just as children are susceptible to negative influences in early life, the period of rapid development means that effective interventions can minimize or eliminate these outcomes. Intervening in the early years has been shown to have the potential to impact developmental trajectories and protect children from risk factors that are present in their daily environments.6 At the government and national level there are four main areas of action: Early childhood learning and care; Support for parents; Poverty reduction; and Data collection for early childhood development. The CMA Recommends that: 1. The federal government, in collaboration with the provinces and territories, implement a national early learning and care program that ensures all children have equal access to high quality child care and early learning. 2. The federal government commit to increasing funding for early childhood development to 1% of GDP to bring Canada in line with other OECD countries. 3. Programs such as early childhood home visiting be made available to all vulnerable families in Canada. 4. Governments support the expansion of community resources for parents which provide parenting programs and family supports. 5. A national strategy to decrease family violence and the maltreatment of children, including appropriate community resources, be developed and implemented in all provinces and territories. 6. The federal government work with provinces and territories to adopt a national strategy to eradicate child poverty in Canada with clear accountability and measurable targets. 7. Provinces and territories implement comprehensive poverty reduction strategies with clear accountability and measurable targets. 8. The federal government work with the provinces and territories to create a robust and unified reporting system on early childhood to ensure that proper monitoring of trends and interventions can take place. 9. The federal government work with the provinces and territories to continue to implement the early development index in all jurisdictions. In addition, work should be supported on similar tools for 18 months and middle childhood. 10. The federal government support the development of a pan-Canadian platform that can share evidence and best practice, and focus research questions around the early years. While most of what is necessary for early childhood development will be done by governments and stakeholders outside of the health care system, there are opportunities for physicians to influence this important social determinant both through medical education, and clinical practice. The CMA Recommends that: 11. Curriculum on early brain, biological development and early learning be incorporated into all Canadian medical schools. 12. Continuing CME on early brain, biological development and early learning be available to all primary-care providers who are responsible for the health care of children. 13. All provinces and territories implement an enhanced 18 month well-baby visit with appropriate compensation and community supports. 14. Physicians and other primary care providers integrate the enhanced 18 month visit into their regular clinical practice. 15. Comprehensive resources be developed for primary-care providers to identify community supports and services to facilitate referral for parents and children. 16. Efforts be made to ensure timely access to resources and programs for children who have identified developmental needs. 17. Physicians serve as advocates on issues related to early childhood development. They should use their knowledge, expertise and influence to speak out on the need and importance of healthy development in the early years. 18. Physicians continue to include literacy promotion in routine clinical encounters with children of all ages. 19. National Medical Associations work with governments and the non-profit sector to explore the development of a clinically based child literacy program for Canada. Background Adult health is pre-determined in many ways in early childhood and even by events occurring before birth. The years between conception and the start of school are the time when crucial developments in physical, social, cognitive, emotional and language domains take place. The early childhood period is the most important development period in life.7 Disruptions during this period can lead to weakened physiological responses, influence brain architecture, and influence how the neuroendocrine, cardiovascular and other systems are developed.8,9 Experiences in early life can even 'get under the skin', changing the ways that certain genes are expressed.10,11 According to research done by the Centers for Disease Control and Prevention in the adverse childhood event (ACE)a study, child maltreatment, neglect, and exposure to violence can significantly impact childhood development. The study involved a retrospective look at the early childhood experiences of 17,000 US adults and the impact of these events on later life and behaviour issues. An increased number of ACEs was linked to increases in risky behaviour in childhood and adolescence12 and to a number of adult health conditions including alcoholism, drug abuse, depression, diabetes, hypertension, stroke, obesity, heart disease, and some forms of cancer.13,14 The greater the number of adverse experiences in childhood the greater the likelihood of health problems in adulthood.15 A high level of ACEs was linked to language, cognitive and emotional impairment; factors which impact on school success and adult functioning.16 Finally, the study found a correlation between experiencing ACEs, suicide, and being the victim of or perpetrating intimate partner violence.17 Poverty is a significant barrier to healthy child development. Children who grow up in poor families or disadvantaged communities are especially susceptible to the physiological and biological changes associated with disease risk.18 Poverty is associated with a number of risk factors for healthy development including: unsupportive parenting, inadequate nutrition and education, high levels of traumatic and stressful events19, including higher rates of traumatic injuries20, poorer housing, lack of services, and limited access to physical activity.21 Children from low-income families score lower than children from high-income families on various measures of school readiness, cognitive development and school achievement22,23, and this gap increases over time with children of low-income families being less likely to attend post-secondary education and gain meaningful employment.24 Children who grow up in poverty are more likely to be poor as adults25,26 and to pass this disadvantage on to their own children.27,28 Children living in poverty have more problem behaviours such as drug abuse, early pregnancy, and increased criminal behaviour.29 Finally, economic hardship in childhood has been linked to premature mortality and chronic disease in adulthood.30 Early adverse events and poverty are serious impediments to healthy development, however, it is not just disadvantaged children that need attention. The early years are critical for all children regardless of socio-economic status. Evidence suggests that adult diseases should be viewed as developmental disorders that begin in early life.31 By 2030, 90% of morbidity in high income countries will be related to chronic diseases.32 These diseases are due in large part to risk factors such as smoking, poor nutrition, alcohol and drug abuse, and inadequate physical activity.33 These risk factors can be heavily influenced by the environment in which people live and can be increased by poor early childhood experiences.34,35 Health promotion and disease/injury prevention programs targeted at adults would be more effective if investments were made early in life on the origins of those diseases and conditions.36,37 Areas for Action While there is reason for concern regarding early childhood development, there is positive news as well. Just as children are susceptible to negative influences in early life, the period of rapid development also means that effective interventions can minimize or eliminate these outcomes. Intervening in the early years has been shown to have the potential to impact developmental trajectories and protect children from risk factors that are present in their daily environments.38 Government and National: Early Childhood Learning and Care Research suggests that 90% of a child's brain capacity is developed by age five, before many children have any access to formal education.39 More than one quarter of Canadian children start kindergarten vulnerable in at least one area of development.40 Approximately two thirds of these deficiencies can be considered preventable. Evidence suggests that each 1% of excess vulnerability in school readiness leads to a reduction in GDP of 1% over the course of that child's life.41 Children who aren't ready for kindergarten are half as likely to read by the third grade, a factor that increases the risk of high school drop-out significantly. 42 While it is possible to intervene later to address these learning deficiencies, these interventions are less effective and much more costly.43 High quality early childhood programs including programs to nurture and stimulate children and educate parents are highly correlated with the amelioration of the effects of disadvantage on cognitive, emotional and physical development among children.44,45 A recent analysis of 84 preschool programs in the United States concluded that children participating in effective pre-school programs can acquire about a third of a year of additional learning in math, language and reading skills.46 Since the implementation of the universal childcare program in Quebec, students in that province have moved from below the national average on standardized tests to above the average.47 In addition, effective early childhood learning programs offer a significant return on investment. Research done on US preschool programs found a return on investment of between four and seventeen dollars for every dollar spent on the program. Evidence from the Quebec universal child care program indicates that the program costs are more than covered by the increased tax revenues generated as a result of increased employment among Quebec mothers. For every dollar spent on the Quebec program, $1.05 is received by the provincial government with the federal government receiving $0.44.48 In terms of early childhood learning and care, Canada is lagging far behind - tied for last place among 25 countries in Organization for Economic Cooperation and Development (OECD) early childhood development indicators.b,49 Canada spends the least amount of money on early childhood learning and care of all countries in the OECD (0.25% of GDP)50, or one quarter of the recommended benchmark. Of this money, fully 65% is attributable to Quebec's universal daycare program.51 Canadian families face great pressures in finding affordable and accessible quality early childhood learning and care spots across the country. In Quebec 69% of children 2-4 regularly attend early childhood learning programs; outside of Quebec the number falls to 38.6%. The challenges for low-income families are even more pronounced with almost 65% of poor children 0-5 receiving no out-of home care.52 The federal government and the provinces and territories must work to bring Canada in line with other OECD countries on early childhood learning and care. The CMA Recommends that: 1. The federal government, in collaboration with the provinces and territories, implement a national early learning and care program that ensures all children have equal access to high quality child care and early learning. 2. The federal government commit to increasing funding for early childhood development to 1% of GDP to bring Canada in line with other OECD countries. Support for Parents A supportive nurturing caregiver is associated with better physical and mental health, fewer behavioural problems, higher educational achievement, more productive employment, and less involvement with the justice system and social services.53 Studies have demonstrated that improved parental-child relationships can minimize the effects of strong, prolonged and frequent stress, referred to as toxic stress54,55, and that the effects of poverty can be minimized with appropriate nurturing and supportive parenting.56 Parental support programs can act as a buffer for children at the same time as strengthening the ability of parents to meet their children's developmental needs.57 Caregivers who struggle with problems such as depression or poverty may be unable to provide adequate attention to their children undermining the attachment relationships that develop in early life. The relatively limited attention that is focused on addressing the deficiencies in time and resources of parents across all socio-economic groups can undermine healthy childhood development.58 One approach that has been shown to improve parental functioning and decrease neglect and child abuse is early childhood home visiting programs, sometimes referred to as Nurse Family partnerships. These programs provide nursing visits to vulnerable young mothers from conception until the children are between two and six depending on the program. The home visits provide prenatal support, educate parents about early childhood development, promote positive parenting, connect parents with resources, and monitor for signs of child-abuse and neglect.59 Results from several randomized controlled trials of these programs in the United States have shown that the program reduces abuse and injury, and improves cognitive and social and emotional outcomes in children. A 15 year follow-up study found lower levels of crime and antisocial behaviour in both the mothers and the children that participated in these programs.60 In Canada Nurse Family Partnerships were first piloted in Hamilton, Ontario. They are now undergoing a broader implementation and review in the Province of British Columbia. These programs should continue to be supported and expanded to all families who would benefit from this proven early childhood intervention. Many Canadian provinces have established community resources for parents. Alberta has recently announced plans to establish parent link centres across the province. These will deliver parenting programs, and be home to community resources and programs.61 Similar programs exist in other provinces such as the early years centres in Ontario62, and family resource centres in Manitoba.63 Early Childhood Development Centres in Atlantic Canada are combining child care, kindergarten and family supports into early childhood centres that are aligned with schools.64 While these programs can go a long way in reducing abuse and neglect, there is still a need for an overarching strategy to reduce neglect and child abuse across the country. As the ACE study in the United States clearly demonstrated, exposure to early adverse events such as family violence or neglect have troubling implications for adult health and behaviours.65 Action must be taken to ensure that avoidable adverse events are eliminated. The CMA Recommends that: 3. Programs such as early childhood home visiting be made available to all vulnerable families in Canada. 4. Governments support the expansion of community resources for parents which provide parenting programs and family supports. 5. A national strategy to decrease family violence and the maltreatment of children, including appropriate community resources, be developed and implemented in all provinces and territories. Poverty reduction In 1989 the Canadian government made a commitment to end child poverty by 2000. As of 2011, more Canadian children and their families lived in poverty than when the original declaration was made.66 Canada ranks 15th out of 17 peer countries with more than one in seven children living in poverty (15.1%).67 Canada is one of the only wealthy nations with a child poverty rate that is actually higher than the overall poverty rate.68 Child poverty is a provincial and territorial responsibility as well. As of 2012, only four provinces had child poverty strategies that met the guidelines put forward by the Canadian Paediatric Society.c,69 Poor children grow up in the context of poor families which means that solutions for child poverty must necessarily minimize the poverty of their parents.70 Efforts to increase the income as well as employment opportunities for parents, in particular single parents, must be part of any poverty reduction strategy.71 Programs, such as affordable child care, that allows parents to be active participants in the work force represent one approach72,73 Quebec's program of early childhood care has increased female workforce participation by 70,000 and reduced the child poverty rate by 50%.74 Addressing poverty could minimize problem areas in child development. According to a 2009 report by the Chief Public Health Officer of Canada, of 27 factors seen as having an impact on child development, 80% of these showed improvement as family income increased.75 Increasing income has the greatest impact on cognitive outcomes for children the earlier in life the reduction in poverty takes place.76 The federal government and the provinces and territories must work to ensure that poverty does not continue to be a barrier to the healthy development of Canadian children. The CMA Recommends that: 6. The federal government work with provinces and territories to adopt a national strategy to eradicate child poverty in Canada with clear accountability and measurable targets. 7. Provinces and territories implement comprehensive poverty reduction strategies with clear accountability and measurable targets. Data Collection for Early Childhood Development The evidence shows the importance of early childhood development for later success and health. In order to properly design effective interventions to mitigate developmental concerns, there is a need for appropriate data on early childhood health indicators and interventions. Given the variation in outcomes of children among different communities and demographic groups, there is a need for individual level data which is linked to the community level. This will allow providers and governments to develop appropriate interventions. Such an approach is being used by the Manitoba Centre for Health Policy, the Human Early Learning Partnership in British Columbia, and Health Data Nova Scotia. Researchers at these centres are creating a longitudinal data set by linking administrative data from a range of sources.77 Such data sets should be supported in all provinces and territories. Another tool being used to measure the progress of Canadian children is the Early Development Instrument (EDI). This tool is a 104 item checklist completed by teachers for every child around the middle of the first year of schooling. The checklist measures five core areas of early child development that are known to be good predictors of adult health, education and social outcomes. These include: physical health and well-being; language and cognitive development; social competence; emotional maturity; and communication skills and general knowledge.78,79 This tool has been used at least once in most of the provinces and territories with a commitment from most jurisdictions to continue this monitoring.80 While this is a good start, it gives only a snapshot of development. Ideally a monitoring system plots several points of time in development to identify trajectories of children. Ontario has introduced an enhanced well baby visit at 18 months. This clinical intervention could allow for the capture of development data at an earlier time. There is a need for more comprehensive information at the 18-month and middle childhood phases.81 The CMA Recommends that: 8. The federal government work with the provinces and territories to create a robust and unified reporting system on early childhood to ensure that proper monitoring of trends and interventions can take place. 9. The federal government work with the provinces and territories to continue to implement the early development index in all jurisdictions. In addition, work should be supported on similar tools for 18 months and middle childhood. 10. The federal government support the development of a pan-Canadian platform that can share evidence and best practice, and focus research questions around the early years. Medical Education: Given the importance of early childhood experiences on adult health there is a need for a greater understanding of the biological basis of adult diseases. The medical community needs to focus more attention on the roots of adult diseases and disabilities and focus prevention efforts on disrupting or minimizing these early links to later poor health outcomes.82 The science of early brain development and biology is rapidly evolving. There is a need to ensure that future and current physicians are up to date on this information and its implications for clinical practice.83 The Association of Faculties of Medicine and the Norlien foundation have partnered to provide funding and support for a series of e-learning tools on early brain and biological development.84 Continuing medical education does exist for some components of early childhood development and more work is underway. The Ontario College of Family Physicians has developed a CME that explores early childhood development for practitioners.85 These initiatives must be supported and expanded to all physicians who provide primary care to children and their families. The CMA Recommends that: 11. Curriculum on early brain, biological development and early learning be incorporated into all Canadian medical schools. 12. Continuing CME on early brain, biological development and early learning be available to all primary-care providers who are responsible for the health care of children. Clinical Practice: While many of the threats to early childhood development lie outside of the hospital or medical clinic, there are a number of ways that physicians can help to address this important determinant of health within their practices. Primary care practitioners are uniquely qualified to address this fundamental population health issue,86 and can provide one important component in a multi-sectoral approach to healthy early childhood development.87 Screening and support for parents The health care system is the primary contact for many child-bearing mothers, and for many families, health-care providers are the only professionals with whom they have regular contact during the early years.88,89 According to data from the Institute for Clinical Evaluative Sciences, 97% of Ontario children aged zero to two are seen by a family physician.90 Within a patient-centred medical home, health-care providers can give support and information to parents about issues such as parenting, safety, and nutrition, and can link them to early childhood resourcesd, and other supports such as housing and food security programs. 91,92 Primary-care providers can help patients connect with public health departments who have many healthy baby and healthy child programs.93 Primary-care providers can ensure that screening takes place to identify risk factors to appropriate development.94 This screening should take place as early as the prenatal stage and continue throughout childhood. Screening should include regular assessments of physical milestones such as height, weight and vision and hearing etc. In addition, providers can identify risk factors such as maternal depression, substance abuse, and potential neglect or abuse.95 Given the negative consequences of early violence and neglect on childhood development96, this is a key role for primary-care providers. Screening for social issues such as poverty, poor housing and food insecurity should also be completed.97 A significant time for screening occurs at 18 months. This is the time for the last set of immunizations and in many cases the last time a child will have a regularly scheduled physician visit before the start of school.98 The 18 month well baby visit provides an opportunity to screen for not only medical concerns but child development as well. The enhanced 18 month well baby visite developed in Ontario combines parental observations and clinical judgment to screen for any risks a child might have.99 In Ontario, parental observation is captured through the Nipissing District Developmental Screen (NDDS). The parents complete this standardized tool and report the results to their physicians or other primary-care providers. The NDDS checklist is not meant to be a diagnostic tool but instead helps to highlight any potential areas of concern while also providing information to parents about childhood development. The 'activities for your child' section which accompanies the tool can also help reinforce the importance of development.100 As part of the visit primary-care providers fill out a standardized tool known as the Rourke Baby Record. This tool is an evidence based guide which helps professionals deliver the enhanced visit. This combined with the parental report through the NDDS, allows for a complete picture of the physical as well as the development health of the child at 18 months. Primary-care providers can use the results to discuss parenting and development and link children to specialized services, as necessary, and other community supports and resources. In Ontario early child development and parenting resource system pathways have been developed in many communities to help ensure that primary care providers can be aware of the resources and supports available for their patients.101 As was already noted, almost two thirds of vulnerabilities in readiness for school can be prevented.102 Appropriate identification through screening is a first step in correcting these issues. While the expansion of this approach is currently being reviewed in Nova Scotia, it should be implemented in all provinces and territories with appropriate compensation mechanisms and community based supports. Additionally, consideration should be made to developing screening tools for physicians outside of primary care, ie. emergency departments, who see children who might not have regular primary care physicians. The CMA Recommends that: 13. All provinces and territories implement an enhanced 18 month well-baby visit with appropriate compensation and community supports. 14. Physicians and other primary care providers integrate the enhanced 18 month visit into their regular clinical practice. 15. Comprehensive resources be developed for primary-care providers to identify community supports and services to facilitate referral for parents and children. 16. Efforts be made to ensure timely access to resources and programs for children who have identified developmental needs. 17. Physicians serve as advocates on issues related to early childhood development. They should use their knowledge, expertise and influence to speak out on the need and importance of healthy development in the early years. Literacy By 18 months disparities in language acquisition begin to develop.103 According to US research, by age four, children of families on welfare will hear 30 million less words than children from families with professional parents.104 This can lead to ongoing disparities in childhood learning as evidence suggests that exposure to reading and language from parents is fundamental for success in reading by children.105 Physicians and other primary-care providers can play a role in helping to reduce these disparities. They can encourage reading, speaking, singing and telling stories as part of a daily routine.f Studies have demonstrated that when physicians discuss literacy with parents and provide them with appropriate resources, such as developmentally appropriate children's books, increases in reading frequency and preschool language scores have been found.106 One program which has integrated reading and literacy into clinical practice is the 'Reach out and Read' program in the United States. This program partners with physicians, paediatricians, and nurse practitioners to provide new developmentally appropriate books to children ages 6 months through 5 years, as well as guidance for parents about the importance of reading.107,108 The success of this program has been significant with parents in the program being four to ten times more likely to read frequently with their children, and children scoring much higher on receptive and expressive language scores on standardized tests.109 Given the success of this program for American children, a similar program should be explored in the Canadian context. The CMA Recommends that: 18. Physicians continue to include literacy promotion in routine clinical encounters with children of all ages. 19. National Medical Associations work with governments and the non-profit sector to explore the development of a clinically based child literacy program for Canada. Conclusion The early years represent the most important time of development. The first five years can 'get under the skin' and influence outcomes throughout the life course. Negative experiences such as poverty, violence, poor nutrition, and inadequate parenting can determine behaviours as well as adult health outcomes. Effective early interventions can help to minimize or capitalize on these experiences. Government actions and supports to reduce poverty, child abuse, violence and to enable parents to care for their children are necessary. In addition, appropriate high quality early childhood learning and care programs are required for all Canadians regardless of socio-economic status. Finally, health care providers can play a role in identifying children at risk, supporting their parents to encourage healthy childhood development, and advocating for communities that ensure all Canadian children have the opportunity to grow up happy and healthy. References a The adverse childhood events are: emotional abuse, physical abuse, sexual abuse, emotional neglect, physical neglect, mother treated violently, household substance abuse, household mental illness, parental separation or divorce, incarcerated household member. http://www.cdc.gov/ace/prevalence.htm#ACED b The indicators used for the comparison include: Parental leave of one year with 50% of salary; a national plan with priority for disadvantaged children; subsidized and regulated child care services for 25% of children under 3; subsidized and accredited early education services for 80% of 4 year-olds; 80% of all child care staff trained; 50% of staff in accredited early education services tertiary educated with relevant qualification (this is the only indicator that Canada met); minimum staff-to-children ratio of 1:15 in pre-school education; 1.0% of GDP spent on early childhood services; child poverty rate less than 10%; near-universal outreach of essential child health services. UNICEF (2008) The child care transition: A league table of early childhood education and care in economically advanced countries. Available at: http://www.unicef-irc.org/publications/pdf/rc8_eng.pdf c To meet the CPS guidelines a province/territory requires anti-poverty legislation promoting long-term action and government accountability for at least three years, and has a poverty reduction strategy with specific targets. d For a list of some of the resources available for early childhood development across the country please see the Canadian Paediatric Society Resource Page: http://www.cps.ca/en/first-debut/map/community-resources e For more detailed information on the enhanced 18 month well baby visit please see the Canadian Paediatric Society Position statement- Williams R & J Clinton. Getting it right at 18 months: In support of an enhanced well-baby visit. Canadian Paediatric Society. Ottawa, ON; 2011. Available: http://www.cps.ca/documents/position/enhanced-well-baby-visit (Accessed 2014 Jan 24). For resources available to Ontario primary-care providers please visit: http://machealth.ca/programs/18-month/default.aspx f For information and resources on early literacy please see the Canadian Paediatric Society at: http://www.cps.ca/issues-questions/literacy 1 Williams R et.al. The promise of the early years: How long should children wait? Paediatr Child Health Vol 17 No 10 December 2012. Available: http://www.cps.ca/issues/2012-early-years-commentary.pdf (accessed 2014 Feb 21) 2 Shonkoff JP et al. The Foundations of Lifelong Health Are Built in Early Childhood. Center on the Developing Child, Harvard University. Cambridge (MA); 2010. Available: http://developingchild.harvard.edu/resources/reports_and_working_papers/foundations-of-lifelong-health/ (accessed 2013 Dec 13). 3 Norrie McCain H.M, Mustard JF, McCuaig, K. Early Years Study 3: Making decisions Taking Action. Margaret and Wallace McCain Foundation. Toronto(ON); 2011. Available: http://earlyyearsstudy.ca/media/uploads/report-pdfs-en/i_115_eys3_en_2nd_072412.pdf (accessed 2014 Feb 11). 4 Braveman P, Egerter S. Robert Wood Johnson Foundation Commission to Build a Healthier America: Overcoming Obstacles to Health in 2013 and Beyond. Robert Wood Johnson Foundation. Princeton (NJ);2013. Available: http://www.rwjf.org/content/dam/farm/reports/reports/2013/rwjf406474 (accessed 2014 Jan 10). 5 Shonkoff JP & Garner AS. The Lifelong Effects of Early Childhood Adversity and Toxic Stress. Pediatrics. December 26, 2011. Available: http://pediatrics.aappublications.org/content/early/2011/12/21/peds.2011-2663.full.pdf+html (accessed 2013 Oct 28). 6 Hutchison P Chair. Inquiry into improving child health outcomes and preventing child abuse, with a focus on pre-conception until three years of age. New Zealand House of Representatives. Wellington (NZ); 2013. 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Available: http://developingchild.harvard.edu/resources/multimedia/interactive_features/five-numbers/ (accessed 2014 Feb 10). 14 Middlebrooks JS, Audage NC. The Effects of Childhood Stress on Health Across the Lifespan. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Atlanta (GA); 2008. Available: http://www.cdc.gov/ncipc/pub-res/pdf/childhood_stress.pdf (accessed 2014 Feb 24). 15 Shonkoff JP et al. The Foundations of Lifelong Health Are Built in Early Childhood. Center on the Developing Child, Harvard University. Cambridge (MA); 2010. Available: http://developingchild.harvard.edu/resources/reports_and_working_papers/foundations-of-lifelong-health/ (accessed 2013 Dec 13). 16 Center on the Developing Child, Harvard University. Five Numbers to Remember About Early Childhood Development. Cambridge(MA); N.D. 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Early Childhood Education and Care: Issues and Initiatives. Royal College of Physicians and Surgeons of Canada. Ottawa(ON); 2012. 41 Williams R & Clinton J. Getting it right at 18 months: In support of an enhanced well-baby visit. Canadian Paediatric Society. Ottawa(ON); 2011. Available: http://www.cps.ca/documents/position/enhanced-well-baby-visit (accessed 2012 Feb 20). 42 Arkin E, Braveman P, Egerter S & Williams D. Time to Act: Investing in the Health of Our Children and Communities: Recommendations From the Robert Wood Johnson Foundation Commission to Build a Healthier America. Robert Wood Johnson Foundation. Princeton (NJ); 2014. Available: http://www.rwjf.org/content/dam/farm/reports/reports/2014/rwjf409002 (accessed 2014 Feb 6). 43 Heckman JJ. The Case for Investing in Disadvantaged Young Children. Available: http://heckmanequation.org/content/resource/case-investing-disadvantaged-young-children (accessed 2014 Feb 6). 44 Braveman P, Egerter D & Williams DR. The Social Determinants of Health: Coming of Age. Annu Rev Publ Health. 32:3.1-3.18. 2011. 45 European Union. Commission Recommendation of 20.2.2013: Investing in children: breaking the cycle of disadvantage. Brussels (Belgium); 2013. Available: http://ec.europa.eu/justice/fundamental-rights/files/c_2013_778_en.pdf (accessed 2013 Jan 24). 46 Yoshikawa H et al. Investing in Our Future: The Evidence Base on Preschool Education. Society for Research in Child Development & Foundation for Child Development. New York (NY); 2013. Available: http://fcd-us.org/sites/default/files/Evidence%20Base%20on%20Preschool%20Education%20FINAL.pdf (accessed 2014 Feb 6). 47 Piano M. Canada 2020 Analytical Commentary No. 6: Are we ready for universal childcare in Canada? Recommendations for equality of opportunity through childcare in Canada. Canada 2020, Ottawa (ON); 2014. Available: http://canada2020.ca/wp-content/uploads/2014/01/Canada-2020-Analytical-Commentary-No.-6-Universal-childcare-Jan-29-2014.pdf (accessed 2014 Feb 13). 48 Norrie McCain H.M, Mustard JF, McCuaig, K. Early Years Study 3: Making decisions Taking Action. Margaret and Wallace McCain Foundation. Toronto(ON); 2011. Available: http://earlyyearsstudy.ca/media/uploads/report-pdfs-en/i_115_eys3_en_2nd_072412.pdf (accessed 2014 Feb 11). 49 Mikkonen J, Raphael D. Social Determinants of Health: The Canadian Facts. Toronto (ON); 2010. Available: http://www.thecanadianfacts.org/The_Canadian_Facts.pdf (accessed 2012 Jan 24). 50 Denburg A, Daneman D. The Link between Social Inequality and Child Health Outcomes. Healthcare Quarterly Vol. 14 Oct 2010. 51 Campaign 2000. Canada's Real Economic Action Plan Begins with Poverty Eradication: 2013 Report Card on Child and Family Poverty in Canada. Family Service Toronto. Toronto (ON); 2013. Available: http://www.campaign2000.ca/reportCards/national/2013C2000NATIONALREPORTCARDNOV26.pdf (accessed 2014 Mar 5). 52 Norrie McCain H.M, Mustard JF, McCuaig, K. Early Years Study 3: Making decisions Taking Action. Margaret and Wallace McCain Foundation. Toronto(ON); 2011. Available: http://earlyyearsstudy.ca/media/uploads/report-pdfs-en/i_115_eys3_en_2nd_072412.pdf (accessed 2014 Feb 11). 53 Shonkoff JP et.al. The Foundations of Lifelong Health Are Built in Early Childhood. Center on the Developing Child, Harvard University. Cambridge (MA); 2010. Available: http://developingchild.harvard.edu/resources/reports_and_working_papers/foundations-of-lifelong-health/ (accessed 2013 Dec 13). 54 Arkin E, Braveman P, Egerter S & Williams D. Time to Act: Investing in the Health of Our Children and Communities: Recommendations From the Robert Wood Johnson Foundation Commission to Build a Healthier America. Robert Wood Johnson Foundation. Princeton (NJ); 2014. Available: http://www.rwjf.org/content/dam/farm/reports/reports/2014/rwjf409002 (accessed 2014 Feb 6). 55 Shonkoff JP & Garner AS. The Lifelong Effects of Early Childhood Adversity and Toxic Stress. Pediatrics. December 26, 2011. Available: http://pediatrics.aappublications.org/content/early/2011/12/21/peds.2011-2663.full.pdf+html (accessed 2013 Oct 28). 56 Luby J et al. The Effects of Poverty on Childhood Brain Development: The Mediating Effect of Caregiving and Stressful Life Events. JAMA Pediatr. Published online October 28, 2013. 57 Arkin E, Braveman P, Egerter S & Williams D. Time to Act: Investing in the Health of Our Children and Communities: Recommendations From the Robert Wood Johnson Foundation Commission to Build a Healthier America. Robert Wood Johnson Foundation. Princeton (NJ); 2014. Available: http://www.rwjf.org/content/dam/farm/reports/reports/2014/rwjf409002 (accessed 2014 Feb 6). 58 Shonkoff JP et al. The Foundations of Lifelong Health Are Built in Early Childhood. Center on the Developing Child, Harvard University. Cambridge (MA); 2010. Available: http://developingchild.harvard.edu/resources/reports_and_working_papers/foundations-of-lifelong-health/ (accessed 2013 Dec 13). 59 Knoke D. Early childhood home visiting programs. Centres of Excellence for Children's Well-Being. Toronto(ON); 2009. Available: http://cwrp.ca/sites/default/files/publications/en/HomeVisiting73E.pdf (accessed 2014 Mar 7). 60 Mercy JA, Saul J. Creating a Healthier Future Through Early Interventions for Children. JAMA June 3, 2009 Vol 301, No.21. 61 Government of Alberta. Alberta improves supports for families. Edmonton(AB); 2014. Available: http://alberta.ca/release.cfm?xID=356434F454042-9B0A-23FD-4AD0402F87D70805 (accessed 2014 Jan 7). 62 Ontario Ministry of Education. Ontario Early Years Centres: Frequently asked questions. Toronto (ON):N.D. Available: http://www.oeyc.edu.gov.on.ca/questions/index.aspx (accessed 2015 Jan 30). 63 Healthy Child Committee of Cabinet. Starting Early, Starting Strong: Manitoba's Early Childhood Development Framework. Government of Manitoba, Winnipeg (MB); 2013. Available: http://www.gov.mb.ca/cyo/pdfs/sess_ECD_framework.pdf (accessed 2014 Jan 10). 64 Norrie McCain H.M, Mustard JF, McCuaig, K. Early Years Study 3: Making decisions Taking Action. Margaret and Wallace McCain Foundation. Toronto(ON); 2011. Available: http://earlyyearsstudy.ca/media/uploads/report-pdfs-en/i_115_eys3_en_2nd_072412.pdf (accessed 2014 Feb 11). 65 Middlebrooks JS, Audage NC. The Effects of Childhood Stress on Health Across the Lifespan. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Atlanta (GA); 2008. Available: http://www.cdc.gov/ncipc/pub-res/pdf/childhood_stress.pdf (accessed 2014 Feb 24). 66 Campaign 2000. Canada's Real Economic Action Plan Begins with Poverty Eradication: 2013 Report Card on Child and Family Poverty in Canada. Family Service Toronto. Toronto (ON); 2013. Available: http://www.campaign2000.ca/reportCards/national/2013C2000NATIONALREPORTCARDNOV26.pdf (accessed 2014 Mar 5). 67 Conference Board of Canada. Child Poverty. Ottawa (ON); 2013. Available: http://www.conferenceboard.ca/hcp/details/society/child-poverty.aspx (accessed 2013 Jun 20). 68 Canadian Paediatric Society. Are We Doing Enough? A status report on Canadian public policy and child and youth health. 2012 edition. Ottawa (ON); 2012. Available: http://www.cps.ca/advocacy/StatusReport2012.pdf (accessed 2014 Feb 14). 69 Ibid. 70 APA Task Force on Childhood Poverty. A Strategic Road-Map: Committed to Bringing the Voice of Pediatricians to the Most Important Problem Facing Children in the US Today. The American Academy of Pediatrics. Elk Grove Village (IL); 2013. Available: http://www.academicpeds.org/public_policy/pdf/APA_Task_Force_Strategic_Road_Mapver3.pdf (accessed 2013 Dec 9). 71 Campaign 2000. Canada's Real Economic Action Plan Begins with Poverty Eradication: 2013 Report Card on Child and Family Poverty in Canada. Family Service Toronto. Toronto (ON); 2013. Available: http://www.campaign2000.ca/reportCards/national/2013C2000NATIONALREPORTCARDNOV26.pdf (accessed 2014 Mar 5). 72 HM Treasury. Ending child poverty: mapping the route to 2020. London(UK); 2010. Available: http://www.endchildpoverty.org.uk/images/ecp/budget2010_childpoverty.pdf (accessed 2014 Jan 17). 73 Fauth B, Renton Z & Solomon E. Tackling child poverty and promoting children's well-being: lessons from abroad. National Children's Bureau. London (UK); 2013. Available: http://www.ncb.org.uk/media/892335/tackling_child_poverty_1302013_final.pdf (accessed 2014 Jan 10). 74 Norrie McCain H.M, Mustard JF, McCuaig, K. Early Years Study 3: Making decisions Taking Action. Margaret and Wallace McCain Foundation. Toronto(ON); 2011. Available: http://earlyyearsstudy.ca/media/uploads/report-pdfs-en/i_115_eys3_en_2nd_072412.pdf (accessed 2014 Feb 11). 75 Little L. Early Childhood Education and Care: Issues and Initiatives. Royal College of Physicians and Surgeons of Canada. Ottawa(ON); 2012. 76 Cooper K & Stewart K. Does Money Affect Children's Outcomes? Joseph Rowntree Foundation. London(UK); 2013. Available: http://www.jrf.org.uk/sites/files/jrf/money-children-outcomes-full.pdf (accessed 2014 Feb 20). 77 Hertzman C, Clinton J, Lynk A. Measuring in support of early childhood development. Canadian Paediatric Society, Ottawa (ON); 2011. Available: http://www.cps.ca/documents/position/early-childhood-development (accessed 2014 Feb 25). 78 Human Early Learning Partnership. Early Development Instrument. N.D. Available: http://earlylearning.ubc.ca/edi/ (accessed 2014 Oct 8). 79 Adamson P. Child well-being in rich countries: A comparative overview: Innocenti Report Card 11. UNICEF, Florrence, Italy; 2013. Available: http://www.unicef-irc.org/publications/pdf/rc11_eng.pdf (accessed 2014 Jan 10). 80 Norrie McCain H.M, Mustard JF, McCuaig, K. Early Years Study 3: Making decisions Taking Action. Margaret and Wallace McCain Foundation. Toronto(ON); 2011. Available: http://firstwords.ca/wp-content/uploads/2014/05/Early-Years-Study-3.pdf (accessed 2014 Feb 11). 81 Hertzman C, Clinton J, Lynk A. Measuring in support of early childhood development. Canadian Paediatric Society, Ottawa (ON); 2011. Available: http://www.cps.ca/documents/position/early-childhood-development (accessed 2014 Feb 25). 82 Shonkoff JP & Garner AS. The Lifelong Effects of Early Childhood Adversity and Toxic Stress. Pediatrics. December 26, 2011. Available: http://pediatrics.aappublications.org/content/early/2011/12/21/peds.2011-2663.full.pdf+html (accessed 2013 Oct 28). 83 Garner AS et al. Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science Into Lifelong Health. Pediatrics 2012;129;e224. Available: http://pediatrics.aappublications.org/content/early/2011/12/21/peds.2011-2662.full.pdf+html (accessed 2014 Feb 11). 84 Little L. Early Childhood Education and Care: Issues and Initiatives. Royal College of Physicians and Surgeons of Canada. Ottawa(ON); 2012. 85 Comley L, Mousmanis P. Improving the Odds: Healthy Child Development: Toolkit: Interdisciplinary MAINPRO CME for Family Physicians and other Primary Healthcare Providers, 6th Edition. Toronto (ON);2010. Available: http://ocfp.on.ca/docs/research-projects/improving-the-odds-healthy-child-development-manual-2010-6th-edition.pdf (accessed 2013 Dec 2). 86 Williams RC, Clinton J, Price DJ, Novak NE. Ontario's Enhanced 18-Month Well-Baby Visit: program overview, implications for physicians. OMR February 2010. Available: http://omr.dgtlpub.com/2010/2010-02-28/home.php (accessed 2012 Feb 20). 87 Shonkoff JP et al. The Foundations of Lifelong Health Are Built in Early Childhood. Center on the Developing Child, Harvard University. Cambridge (MA); 2010. Available: http://developingchild.harvard.edu/resources/reports_and_working_papers/foundations-of-lifelong-health/ (accessed 2013 Dec 13). 88 Commission on the Social Determinants of Health. Closing the gap in a generation: Health equity through action on the social determinants of health: Executive Summary. Geneva (CH) World Health Organization; 2008. Available: http://whqlibdoc.who.int/hq/2008/WHO_IER_CSDH_08.1_eng.pdf (accessed 2011 Jan 7). 89 Williams RC, Clinton J, Price DJ, Novak NE. Ontario's Enhanced 18-Month Well-Baby Visit: program overview, implications for physicians. OMR February 2010. Available: http://omr.dgtlpub.com/2010/2010-02-28/home.php (accessed 2012 Feb 20). 90 The Minister of Children and Youth announces that every child will receive and enhanced 18-month visit: Family Physicians Play Key Roles in Healthy Child Development. Toronto(ON). Available: http://ocfp.on.ca/docs/cme/enhanced-18-month-well-baby-visit-key-messages-for-family-physicians.pdf?sfvrsn=1 (accessed 2012 Feb 20). 91 Comley L, Mousmanis P. Improving the Odds: Healthy Child Development: Toolkit: Interdisciplinary MAINPRO CME for Family Physicians and other Primary Healthcare Providers, 6th Edition. Toronto (ON);2010. Available: http://ocfp.on.ca/docs/research-projects/improving-the-odds-healthy-child-development-manual-2010-6th-edition.pdf (accessed 2013 Dec 2). 92 Garg A, Jack B, Zuckerman B. Addressing the Social Determinants of Health Within the Patient-Centred Medical Home. JAMA. May 15, 2013 Vol. 309 No.19. 93 Comley L, Mousmanis P. Improving the Odds: Healthy Child Development: Toolkit: Interdisciplinary MAINPRO CME for Family Physicians and other Primary Healthcare Providers, 6th Edition. Toronto (ON);2010. Available: http://ocfp.on.ca/docs/research-projects/improving-the-odds-healthy-child-development-manual-2010-6th-edition.pdf (accessed 2013 Dec 2). 94 Commission on the Social Determinants of Health. Closing the gap in a generation: Health equity through action on the social determinants of health: Executive Summary. Geneva (CH) World Health Organization; 2008. Available: http://whqlibdoc.who.int/hq/2008/WHO_IER_CSDH_08.1_eng.pdf (accessed 2011 Jan 7). 95 Williams R et al. The promise of the early years: How long should children wait? Paediatr Child Health Vol 17 No 10 December 2012. Available: http://www.cps.ca/issues/2012-early-years-commentary.pdf (accessed 2014 Feb 21). 96 Middlebrooks JS, Audage NC. The Effects of Childhood Stress on Health Across the Lifespan. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Atlanta (GA); 2008. Available: http://www.cdc.gov/ncipc/pub-res/pdf/childhood_stress.pdf (accessed 2014 Feb 24). 97 Garg A, Jack B, Zuckerman B. Addressing the Social Determinants of Health Within the Patient-Centred Medical Home. JAMA. May 15, 2013 Vol. 309 No.19. 98 Williams R & Clinton J. Getting it right at 18 months: In support of an enhanced well-baby visit. Canadian Paediatric Society. Ottawa(ON); 2011. Available: http://www.cps.ca/documents/position/enhanced-well-baby-visit (accessed 2012 Feb 20). 99 Canadian Paediatric Society. Are We Doing Enough? A status report on Canadian public policy and child and youth health. 2012 edition. Ottawa (ON); 2012. Available: http://www.cps.ca/advocacy/StatusReport2012.pdf (accessed 2014 Feb 14). 100 Williams RC, Clinton J, Price DJ, Novak NE. Ontario's Enhanced 18-Month Well-Baby Visit: program overview, implications for physicians. OMR February 2010. Available: http://omr.dgtlpub.com/2010/2010-02-28/home.php (accessed 2012 Feb 20). 101 Williams R & Clinton J. Getting it right at 18 months: In support of an enhanced well-baby visit. Canadian Paediatric Society. Ottawa(ON); 2011. Available: http://www.cps.ca/documents/position/enhanced-well-baby-visit (accessed 2012 Feb 20). 102 Williams R & Clinton J. Getting it right at 18 months: In support of an enhanced well-baby visit. Canadian Paediatric Society. Ottawa(ON); 2011. Available: http://www.cps.ca/documents/position/enhanced-well-baby-visit (accessed 2012 Feb 20). 103 Center on the Developing Child, Harvard University. Five Numbers to Remember About Early Childhood Development. Cambridge(MA); N.D. Available: http://developingchild.harvard.edu/resources/multimedia/interactive_features/five-numbers/ (accessed 2014 Feb 10). 104 Denburg A, Daneman D. The Link between Social Inequality and Child Health Outcomes. Healthcare Quarterly Vol. 14 Oct 2010. 105 Shaw A. Read, speak, sing: Promoting literacy in the physician's office. Canadian Paediatric Society, Ottawa (ON); 2006. Available: http://www.cps.ca/documents/position/read-speak-sing-promoting-literacy (accessed 2014 Feb 10). 106 Ibid. 107 Reach out and Read. Reach Out And Read: The Evidence. Boston (MA); 2013. Available: https://www.reachoutandread.org/FileRepository/Research_Summary.pdf (accessed 2014 Mar 5). 108 Commission on the Social Determinants of Health. Closing the gap in a generation: Health equity through action on the social determinants of health: Executive Summary. Geneva (CH) World Health Organization; 2008. Available: http://whqlibdoc.who.int/hq/2008/WHO_IER_CSDH_08.1_eng.pdf (accessed 2011 Jan 7). 109 Shaw A. Read, speak, sing: Promoting literacy in the physician's office. Canadian Paediatric Society, Ottawa (ON); 2006. Available: http://www.cps.ca/documents/position/read-speak-sing-promoting-literacy (accessed 2014 Feb 10).
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Appropriateness in health care

https://policybase.cma.ca/en/permalink/policy11516
Last Reviewed
2020-02-29
Date
2014-12-06
Topics
Health care and patient safety
  1 document  
Policy Type
Policy document
Last Reviewed
2020-02-29
Date
2014-12-06
Topics
Health care and patient safety
Text
CMA POLICY Appropriateness in Health Care Summary This paper discusses the concept of appropriateness in health care and advances the following definition: The Canadian Medical Association adopts the following definition for appropriateness in health care: It is the right care, provided by the right providers, to the right patient, in the right place, at the right time, resulting in optimal quality care. Building on that definition it makes the following policy recommendations: * Provinces and territories should work with providers to develop a comprehensive framework by which to assess the appropriateness of health care. * Provinces and territories should work with providers to develop robust educational products on appropriateness in health care and to disseminate evidence-informed strategies for necessary changes in care processes. * Provinces and territories should work with providers to put in place incentives to decrease the provision of marginally useful or unnecessary care. Introduction As health systems struggle with the issue of sustainability and evidence that the quality of care is often sub-optimal, increasing attention is focused on the concept of appropriateness. A World Health Organization study published in 2000 described appropriateness as "a complex, fuzzy issue"1. Yet if the term is to be applied with benefit to health care systems, it demands definitional clarity. This policy document presents the Canadian Medical Association definition of appropriateness which addresses both quality and value. The roots of the definition are anchored in the evolution of Canadian health care over the last two decades. The document then considers the many issues confronting the operationalization of the term. It concludes that appropriateness can play a central role in positive health system transformation. Definition At the Canadian Medical Association General Council in 2013 the following resolution was adopted: The Canadian Medical Association adopts the following definition for appropriateness in health care: It is the right care, provided by the right providers, to the right patient, in the right place, at the right time, resulting in optimal quality care. This definition has five key components: * right care is based on evidence for effectiveness and efficacy in the clinical literature and covers not only use but failure to use; * right provider is based on ensuring the provider's scope of practice adequately meets but does not far exceed the skills and knowledge to deliver the care; * right patient acknowledges that care choices must be matched to individual patient characteristics and preferences and must recognize the potential challenge of reconciling patient and practitioner perceptions; * right venue emphasizes that some settings are better suited in terms of safety and efficiency to delivering a specific type of care than others; * right time indicates care is delivered in a timely manner consistent with agreed upon bench marks. It is essential to appreciate that the "right cost" is a consequence of providing the right care, that it is an outcome rather than an input. In other words, if all five components above are present, high quality care will have been delivered with the appropriate use of resources, that is, at the right cost. Equally, however, it should be cautioned that right cost may not necessarily be the affordable cost. For example, a new drug or imaging technology may offer small but demonstrable advantages over older practices, but at an enormous increase in cost. Some might argue that right care includes the use of the newer drug or technology, while others would contend the excessive opportunity costs must be taken into consideration such that the older practices remain the right care. An Evolving Canadian Perspective from 1996 to 2013 In a pioneering paper from 1996 Lavis and Anderson wrote: ...there are two distinct types of appropriateness: appropriateness of a service and appropriateness of the setting in which care is provided. The differences between the two parallel the differences between two other concepts in health care: effectiveness and cost-containment...An appropriate service is one that is expected to do more good than harm for a patient with a given indication...The appropriateness of the setting in which care is provided is related to cost effectiveness2. This very serviceable definition moved beyond a narrow clinical conception based solely on the therapeutic impact of an intervention on a patient, to broader contextual consideration focused on venue. Thus, for example, the care provided appropriately in a home-care setting might not be at all appropriate if given in a tertiary care hospital. Significantly, the authors added this important observation: "Setting is a proxy measure of the resources used to provide care"2. This sentence is an invitation to expand the original Lavis and Anderson definition to encompass other resources and inputs identified over the ensuing decades. Three elements are especially important. Timeliness became an issue in Canadian health care just as the Lavis and Anderson paper appeared. In 1997 almost two-thirds of polled Canadians felt surgical wait times were excessive, up from just over half of respondents a year earlier3. By 2004 concern with wait times was sufficiently pervasive that when the federal government and the provinces concluded the First Ministers' Agreement, it included obligations to provide timely access to cancer care, cardiac care, diagnostic imaging, joint replacement and sight restoration4. These rapid developments indicate that timeliness was now considered an essential element in determining the appropriateness of care. A second theme that became prominent in health care over the last two decades was the concept of patient-centredness. When the Canadian Medical Association released its widely endorsed Health Care Transformation in Canada in 2010, the first principle for reform was building a culture of patient-centred care. Succinctly put, this meant that "health care services are provided in a manner that works best for patients"5. To begin the process of operationalizing this concept CMA proposed a Charter for Patient-centred Care. Organized across seven domains, it included the importance of: allowing patients to participate fully in decisions about their care; respecting confidentiality of health records; and ensuring care provided is safe and appropriate. This sweeping vision underscores the fact that care which is not matched to the individual patient cannot be considered appropriate care. A third significant development over the last two decades was heightened awareness of the importance of scopes of practice. This awareness arose in part from the emphasis placed on a team approach in newer models of primary care6, but also from the emergence of new professions such as physician assistants, and the expansion of scopes of practice for other professionals such as pharmacists7. As the same health care activity could increasingly be done by a wider range of health professionals, ensuring the best match between competence required and the service provided became an essential element to consider when defining appropriateness. Under-qualified practitioners could not deliver quality care, while overly-qualified providers were a poor use of scarce resources. To summarize, as a recent scoping review suggested, for a complete conceptualization of appropriateness in 2013 it is necessary to add the right time, right patient and right provider to the previously articulated right care and right setting8. Why Appropriateness Matters The most frequent argument used to justify policy attention to appropriateness is health system cost. There is a wealth of evidence that inappropriate care - avoidable hospitalizations, for example, or alternative level of care patients in acute care beds - is wide spread in Canada9; eliminating this waste is critical to system sustainability. In Saskatchewan, for example, Regina and Saskatoon contracted in 2011 with private clinics to provide a list of 34 surgical procedures. Not only were wait times reduced, but costs were 26% lower in the surgical clinics than in hospitals for doing the same procedures10. There is, however, an equally important issue pointing to the importance of ensuring appropriate care: sub-optimal health care quality. In the United States, for example, a study evaluated performance on 439 quality indicators for 30 acute and chronic conditions. Patients received 54.9% of recommended care, ranging from a high of 78.7% for senile cataracts to 10.5% for alcohol dependence11. A more recent Australian study used 522 quality indicators to assess care for 22 common conditions. Patients received clinically appropriate care in 57% of encounters, with a range from 90% for coronary artery disease to 13% for alcohol dependence12. While no comparable comprehensive data exist for Canada, it is unlikely the practices in our system depart significantly from peer nations. Focusing on appropriateness of care, then, is justified by both fiscal and quality concerns. Methodology: the Challenge of Identifying Appropriateness While there is a clear need to address appropriateness - in all its dimensions - the methods by which to assess the appropriateness of care are limited and, to date, have largely focused on the clinical aspect. The most frequently used approach is the Rand/University of California Los Angeles (Rand) method. It provides panels of experts with relevant literature about a particular practice and facilitates iterative discussion and ranking of the possible indications for using the practice. Practices are labeled appropriate, equivocal or inappropriate13. A systematic review in 2012 found that for use on surgical procedures the method had good test-retest reliability, interpanel reliability and construct validity14. However, the method has been criticized for other short-comings: panels in different countries may reach different conclusions when reviewing the same evidence; validity can only be tested against instruments such as clinical practice guidelines that themselves may have a large expert opinion component2; Rand appropriateness ratings apply to an "average" patient, which cannot account for differences across individuals; and, finally, Rand ratings focus on appropriateness when a service is provided but does not encompass underuse, that is, failure to provide a service that would have been appropriate9. The Rand method, while not perfect, is the most rigorous approach to determining clinical appropriateness yet devised. It has recently been suggested that a method based on extensive literature review can identify potentially ineffective or harmful practices; when applied to almost 6000 items in the Australian Medical Benefits Schedule, 156 were identified that may be inappropriate15. This method also presents challenges. For example, the authors of a study using Cochrane reviews to identify low-value practices note that the low-value label resulted mainly from a lack of randomized evidence for effectiveness16. Assessing the appropriateness of care setting has focused almost exclusively on hospitals. Some diagnoses are known to be manageable in a community setting by primary care or specialty clinics. The rate of admissions for these ambulatory care sensitive conditions (ACSCs) - which fell from 459 per 100,000 population in 2001-02 to 320 per 100,00 in 2008-09 - is one way of gauging the appropriateness of the hospital as a care venue9. A second measure is the number of hospital patients who do not require either initial or prolonged treatment in an acute care setting. Proprietorial instruments such as the Appropriateness Evaluation Protocol (AEP)17or the InterQual Intensity of Service, Severity of Illness and Discharge Screen for Acute Care (ISD-AC)18 have been used to assess the appropriateness of hospital care for individual patients. While these instruments have been applied to Canadian hospital data19,20, there is a lack of consensus in the literature as to the reliability and utility of such tools21-23. Benchmarks exist for appropriate wait times for some types of care in Canada through the work of the Wait Time Alliance4. These include: chronic pain, cancer care, cardiac care, digestive health care, emergency rooms, joint replacement, nuclear medicine, radiology, obstetrics and gynecology, pediatric surgery, plastic surgery, psychiatric illness, and sight restoration. The recommendations are based on evidence-informed expert opinion. The other two domains of appropriateness - right patient, right provider - as yet have no objective tools by which to assess appropriateness. Barriers Determining appropriateness demands a complex and time-consuming approach, and its operationalization faces a number of barriers. The availability of some health care services may be subject to political influence which will over-ride appropriateness criteria. For example, recommendations to close smaller hospitals deemed to be redundant or inefficient may not be implemented for political reasons. Patient expectations can challenge evidence-based appropriateness criteria. In a primary care setting, for instance, it may be difficult to persuade a patient with an ankle sprain that an x-ray is unlikely to be helpful. The insistence by the patient is compounded by an awareness of potential legal liability in the event that clinical judgment subsequently proves incorrect. Choosing Wisely Canada recommends physicians and patients become comfortable with evidence-informed conversations about potentially necessary care24. Traditional clinical roles are difficult to revise in order to ensure that care is provided by the most appropriate health professional. This is especially true if existing funding silos are not realigned to reflect the desired change in practice patterns. Finally, and perhaps most importantly, even if agreed upon appropriateness criteria are developed, holding practitioners accountable for their application in clinical practice is extremely difficult due to data issues25. Chart audits could be conducted to determine whether appropriateness criteria were met when specific practices were deployed, but this is not feasible on a large scale. Rates of use of some practices could be compared among peers from administrative data; however, variation in practice population might legitimately sustain practice variation. For diagnostic procedures it has been suggested that the percentage of negative results is an indicator of inappropriate use; however, most administrative claim databases would not include positive or negative test result data26. This data deficit must be addressed with health departments and regional health authorities. Important Caveats There are several additional constraints on the use of the concept by health system managers. First, the vast majority of practices have never been subject to the Rand or any other appropriateness assessment. Even for surgical procedures clinical appropriateness criteria exist for only 10 of the top 25 most common inpatient procedures and for 6 of the top 15 ambulatory procedures in the United States. Most studies are more than 5 years old27. Second, while the notion is perhaps appealing to policy makers, it is incorrect to assume that high use of a practice equates with misuse: when high-use areas are compared to low use areas, the proportion of inappropriate use has consistently been shown to be no greater in the high-use regions28,29. Finally, it is uncertain how large a saving can be realized from eliminating problematic clinical care. For example, a US study modeling the implementation of recommendations for primary care found that while a switch to preferentially prescribing generic drugs would save considerable resources, most of the other items on the list of questionable activities "are not major contributors to health care costs"30. What is important to emphasize is that even if dollars are not saved, by reducing inappropriate care better value will be realized for each dollar spent. Policy Recommendations These methodological and other challenges31 notwithstanding, the Canadian Medical Association puts forward the following recommendations for operationalizing the concept of appropriateness and of clinical practice. 1. Provinces and territories should work with providers to develop a comprehensive framework by which to assess the appropriateness of health care. Jurisdictions should develop a framework32 for identifying potentially inappropriate care, including under-use. This involves selecting criteria by which to identify and prioritize candidates for assessment; developing and applying a robust assessment methodology; and creating mechanisms to disseminate and apply the results. Frameworks must also include meaningful consideration of care venue, timeliness, patient preferences and provider scope of practice. International examples exist for some aspects of this exercise and should be adapted to jurisdictional circumstances. Necessarily, a framework will demand the collection of supporting data in a manner consistent with the following 2013 General Council resolution: The Canadian Medical Association supports the development of data on health care delivery and patient outcomes to help the medical profession develop an appropriateness framework and associated accountability standards provided that patient and physician confidentiality is maintained. 2. Provinces and territories should work with providers to develop robust educational products on appropriateness in health care and to disseminate evidence-informed strategies for necessary changes in care processes. Both trainees and practicing physicians should have access to education and guidance on the topic of appropriateness and on practices that are misused, under-used, or over-used. Appropriately designed continuing education has been shown to alter physician practice. Point of care guidance via the electronic medical record offers a further opportunity to alert clinicians to practices that should or should not be done in the course of a patient encounter33. An initiative co-led by the Canadian Medical Association that is designed to educate the profession about the inappropriate over use of diagnostic and therapeutic interventions is Choosing Wisely Canada. The goal is to enhance quality of care and only secondarily to reduce unnecessary expenditures. It is an initiative consistent with the intent of two resolutions from the 2013 General Council: The Canadian Medical Association will form a collaborative working group to develop specialty-specific lists of clinical tests/interventions and procedures for which benefits have generally not been shown to exceed the risks. The Canadian Medical Association believes that fiscal benefits and cost savings of exercises in accountability and appropriateness in clinical care are a by-product rather than the primary focus of these exercises. 3. Provinces and territories should work with providers to put in place incentives to decrease the provision of marginally useful or unnecessary care. Practitioners should be provided with incentives to eliminate inappropriate care. These incentives may be financial - delisting marginal activities or providing bonuses for achieving utilization targets for appropriate but under-used care. Any notional savings could also be flagged for reinvestment in the health system, for example, to enhance access. Giving physicians the capacity to participate in audit and feedback on their use of marginal practices in comparison to peers generally creates a personal incentive to avoid outlier status. Public reporting by group or institution may also move practice towards the mean30. In any such undertakings to address quality or costs through changes in practice behaviour it is essential that the medical profession play a key role. This critical point was captured in a 2013 General Council resolution: The Canadian Medical Association will advocate for adequate physician input in the selection of evidence used to address costs and quality related to clinical practice variation. Conclusion When appropriateness is defined solely in terms of assessing the clinical benefit of care activities it can provide a plausible rational for "disinvestment in" or "delisting of" individual diagnostic or therapeutic interventions. However, such a narrow conceptualization of appropriateness cannot ensure that high quality care is provided with the optimal use of resources. To be truly useful in promoting quality and value appropriateness must be understood to mean the right care, provided by the right provider, to the right patient, in the right venue, at the right time. Achieving these five components of health care will not be without significant challenges, beginning with definitions and moving on to complex discussions on methods of measurement. Indeed, it may prove an aspirational goal rather than a completely attainable reality. But if every encounter in the health system - a hospitalization, a visit to a primary care provider, an admission to home care - attempted to meet or approximate each of the five criteria for appropriateness, a major step towards optimal care and value will have been achieved across the continuum. Viewed in this way, appropriateness has the capacity to become an extraordinarily useful organizing concept for positive health care transformation in Canada. Approved by CMA Board on December 06, 2014 References 1. World Health Organization. Appropriateness in Health Care Services, Report on a WHO Workshop. Copenhagen: WHO; 2000. 2. Lavis JN, Anderson GM. Appropriateness in health care delivery: definitions, measurement and policy implications. CMAJ. 1996;154(3):321-8. 3. Sanmartin C, Shortt SE, Barer ML, Sheps S, Lewis S, McDonald PW. Waiting for medical services in Canada: lots of heat, but little light. CMAJ. 2000;162(9):1305-10. 4. Wait Time Alliance. Working to Improve Wait Times Across Canada. Toronto: Wait Time Alliance; 2014. Available: http://www.waittimealliance.ca. (accessed April 18, 2013) 5. Canadian Medical Association. Health Care Transformation in Canada. Ottawa: Canadian Medical Association; 2010. 6. Canadian Medical Association. CMA Policy: Achieving Patient-centred Collaborative Care. Ottawa: Canadian Medical Association; 2008. 7. Maxwell-Alleyne A, Farber A. Pharmacists' expanded scope of practice: Professional obligations for physicians and pharmacists working collaboratively. Ont Med Rev. 2013;80(4):17-9. 8. Sanmartin C, Murphy K, Choptain N, et al. Appropriateness of healthcare interventions: concepts and scoping of the published literature. Int J Technol Assess Health Care. 2008;24(3)342-9. 9. Canadian Institute for Health Information. Health Care in Canada 2010. Ottawa: CIHI; 2010. 10. MacKinnon J. Health Care Reform from the Cradle of Medicare. Ottawa: Macdonald-Laurier Institute; 2013. 11. McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. NEJM. 2003;348(26):2635-45. 12. Runciman WB, Hunt TD, Hannaford NA, et al. CareTrack: assessing the appropriateness of health care delivery in Australia. Med J Aust. 2012;197(2):100-5. 13. Brook RH, Chassin MR, Fink A, Solomon DH, Kosecoff J, Park RE. A method for the detailed assessment of the appropriateness of medical technologies. Int J Technol Assess Health Care. 1986;2(1):53-63. 14. Lawson EH, Gibbons MM, Ko CY, Shekelle PG. The appropriateness method has acceptable reliability and validity for assessing overuse and underuse of surgical procedures. J Clin Epidemiol. 2012;65(11):1133-43. 15. Elshaug AG, Watt AM, Mundy L, Willis CD. Over 150 potentially low-value health care practices: an Australian study. Med J Aust. 2012;197(10):556-60. 16. Garner S, Docherty M, Somner J, et al. Reducing ineffective practice: challenges in identifying low-value health care using Cochrane systematic reviews. J Health Serv Res Policy. 2013;18(1):6-12. 17. Gertman PM, Restuccia JD. The appropriateness evaluation protocol: a technique for assessing unnecessary days of hospital care. Med Care. 1981;19(8):855-71. 18. Mitus AJ. The birth of InterQual: evidence-based decision support criteria that helped change healthcare. Prof Case Manag. 2008;13(4):228-33. 19. DeCoster C, Roos NP, Carriere KC, Peterson S. Inappropriate hospital use by patients receiving care for medical conditions: targeting utilization review. CMAJ. 1997;157(7):889-96. 20. Flintoft VF, Williams JI, Williams RC, Basinski AS, Blackstien-Hirsch P, Naylor CD. The need for acute, subacute and nonacute care at 105 general hospital sites in Ontario. Joint Policy and Planning Committee Non-Acute Hospitalization Project Working Group. CMAJ . 1998;158(10):1289-96. 21. Kalant N, Berlinguet M, Diodati JG, Dragatakis L, Marcotte F. How valid are utilization review tools in assessing appropriate use of acute care beds? CMAJ. 2000;162(13):1809-13. 22. McDonagh MS, Smith DH, Goddard M. Measuring appropriate use of acute beds. A systematic review of methods and results. Health policy. 2000;53(3):157-84. 23. Vetter N. Inappropriately delayed discharge from hospital: what do we know? BMJ. 2003;326(7395):927-8. 24. Choosing Wisely Canada. Recent News. Ottawa: Choosing Wisely Canada; 2015. Available: www.choosingwiselycanada.org. (accessed Dec 2014) 25. Garner S, Littlejohns P. Disinvestment from low value clinical interventions: NICEly done? BMJ. 2011;343:d4519. 26. Baker DW, Qaseem A, Reynolds PP, Gardner LA, Schneider EC. Design and use of performance measures to decrease low-value services and achieve cost-conscious care. Ann Intern Med. 2013;158(1):55-9. 27. Lawson EH, Gibbons MM, Ingraham AM, Shekelle PG, Ko CY. Appropriateness criteria to assess variations in surgical procedure use in the United States. Arch Surg. 2011;146(12):1433-40. 28. Chassin MR, Kosecoff J, Park RE, et al. Does inappropriate use explain geographic variations in the use of health care services? A study of three procedures. JAMA. 1987;258(18):2533-7. 29. Keyhani S, Falk R, Bishop T, Howell E, Korenstein D. The relationship between geographic variations and overuse of healthcare services: a systematic review. Med care. 2012;50(3):257-61. 30. Kale MS, Bishop TF, Federman AD, Keyhani S. "Top 5" lists top $5 billion. Arch Intern Med. 2011;171(20):1856-8. 31. Elshaug AG, Hiller JE, Tunis SR, Moss JR. Challenges in Australian policy processes for disinvestment from existing, ineffective health care practices. Aust New Zealand Health Policy. 2007;4:23. 32. Elshaug AG, Moss JR, Littlejohns P, Karnon J, Merlin TL, Hiller JE. Identifying existing health care services that do not provide value for money. Med J Aust. 2009;190(5):269-73. 33. Shortt S GM, Gorbet S. Making medical practice safer: the role of public policy. Int J Risk Saf Med. 2010;22(3):159-68.
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Putting Patients First : Comments on Bill C 6 (Personal Information Protection and Electronic Documents Act) : Submission to the Senate Standing Committee on Social Affairs, Science and Technology

https://policybase.cma.ca/en/permalink/policy1979
Last Reviewed
2019-03-03
Date
1999-11-25
Topics
Ethics and medical professionalism
Health care and patient safety
Health information and e-health
  2 documents  
Policy Type
Parliamentary submission
Last Reviewed
2019-03-03
Date
1999-11-25
Topics
Ethics and medical professionalism
Health care and patient safety
Health information and e-health
Text
CMA commends the federal government for taking this important first step that begins the debate on privacy and the protection of personal information. The issues are complex and the interests at stake significant. CMA welcomes the opportunity to provide comments on Bill C-6 and hopes that its input will strengthen the Bill by ensuring that patient privacy and the confidentiality of medical records are adequately protected. CMA’s chief concern with Bill C-6 is the inadequacy of its provisions to protect the right of privacy of patients and the confidentiality of their health information. The right of privacy encompasses both the right to keep information about ourselves to ourselves if we so choose and to exercise control over what subsequently happens to information we confide in trust for the purpose of receiving health care. In recent years, this right, and the ability of physicians to guarantee meaningful confidentiality, have becoming increasingly threatened. Computerization of health information facilitates easy transfer, duplication, linkage and centralization of health information. Captured in electronic form, patient information is potentially more useful for the purpose of providing care. However, thus captured, it also becomes much more valuable and technically accessible to various third parties -- private and public, governmental and commercial -- wishing to use this information for other purposes unrelated to providing direct care. An additional concern is that the demand for health information, referred to by some commentators as ‘data lust’, is growing, partly as a consequence of ‘information hungry’ policy trends such as population health. There is also a disturbing tendency toward ‘function creep’, whereby information collected for one purpose is used for another, often without consent or even knowledge of the individual concerned and without public knowledge or scrutiny. Furthermore, initiatives concerning health information technology tend to be dominated by those who seek access to this information for secondary purposes. From this perspective, privacy may appear less as a fundamental right than as a hindrance or even roadblock. As we move further into the information age there is some danger that we will become so spell-bound by the promise of information centralization and database linkages that we lose sight of the patients who confided this information or reduce them to impersonal ‘data subjects’. To avoid this danger and the allure of the technology we need to ground the application of information technology and practices in well-tested, enduring principles. We need to put privacy first rather than treat it as a nuisance or impediment. Rules and regulatory regimes concerning health information should be based on the principle of patient privacy because ultimately health information technology is not about ‘bits and bytes’ or ‘data’ or even ‘data subjects’ but about patients, and patients deserve to be treated with respect and dignity and to have their wishes and choices valued and respected. If we are to put patients first the right of privacy must be given primacy in rules concerning health information. This does not mean that this right is absolute. What it does mean is that the burden of proof must rest with those whose purposes, however compelling they may be, encroach upon the right of privacy. It means that we value patient privacy at least enough to demand explicit justification of any proposal that would diminish privacy. Bill C-6 begins with the right premise: that “rules to govern information collection, use and disclosure” should recognize the “right of privacy”. However, it fails to recognize the special nature of health information and to tailor its provisions accordingly. In consequence there is confusion and uncertainty about Bill C-6's application to health care. Even more seriously, however, Bill C-6 fails to recognize that health information requires stronger or greater privacy protection than other types of information. The inadequacy of Bill C-6 for health care is not surprising because clearly it was not drafted with health information in mind. Rather, it is written from the perspective of encouraging commerce. It appears to have access to information as its dominant value. The world of health care is very different from that of commerce and consequently requires distinct rules that are more protective of privacy. Confiding information to your physician under the trust of the patient-physician relationship is not on par with giving your address to a salesclerk when you purchase a toaster or rent a movie. Health information is special by nature. Canadians know this. In a recent Angus Reid poll commissioned by CMA Canadians told us loudly and clearly that they regard their health information as especially sensitive. However, the obvious sensitivity of health information is not the only thing that makes it special and in virtue of which it warrants distinct rules to strengthen privacy protection. It is important to recognize that this information is typically collected under the trust patients vest in their physicians. Patients confide their information for the purpose of receiving care and in the expectation that it will be held in the strictest confidence. This purpose, and the preservation of this trust, should be given primacy in rules concerning health information. It is also important to recognize that the trust under which patients confide in their physicians is fundamental to the patient-physician relationship. If patients can not trust their physicians to protect their information and keep it secret they will not confide it as freely as they do. In consequence, the ability of physicians to provide the care needed would be severely diminished. Rules relating to health information must be developed in recognition of its special nature and the circumstances of trust and vulnerability in which it is initially collected or confided. Patients confide in their physicians for the purpose of receiving care. The potential that the information thus confided may subsequently be used for other purposes must not impede the therapeutic purpose or diminish the trust and integrity of the patient-physician relationship. In recent years the secondary use of information for purposes other than those for which it was collected has been increasing without adequate oversight or public knowledge. This ‘function creep’ undermines the trust of patient-physician relationship. Collection and use beyond the therapeutic context and for purposes unrelated to the provision of direct care should be subjected to rigorous scrutiny before they are permitted to occur. To the extent that they are permitted to occur without patient consent they should be explicitly authorized in legislation to ensure transparency and adequate oversight. Putting patients first means ensuring that health information, in all but exceptional and justifiable circumstances, is used only under the strict control of the patient. The patient must be able to exercise control through voluntary, informed consent. Moreover, a distinction must be made between a patient’s right to know what can or must happen to health information and the right to consent to such use. Bill C-6 permits the collection, use and disclosure of information without knowledge or consent on grounds such as expediency, practicality, public good, research, offence investigation, historic importance and artistic purpose. The laxness and breadth of these exemptions as applied to health information is unacceptable. These uses, without the patient’s consent (or even knowledge), reduce the patient to a means to someone else’s end, however worthwhile that end may be. Moreover, the absence of consent (or even knowledge) undermines the integrity of the patient-physician relationship and has the potential to erode the trust patients have in their physicians - a trust that is essential to patients’ willingness to provide the complete information needed to provide them with care. CMA has developed and adopted a Health Information Privacy Code (Appendix A) in recognition of the special nature of health information and to give primacy to patients and to the right of privacy. This Code begins from the same starting point as Bill C-6, the Canadian Standards Association (CSA) Code which the Bill includes as Schedule 1. However, unlike Bill C-6, the CMA Code tailors the CSA Code to the specific circumstances of health information. The CMA Health Information Privacy Code, therefore, is able to address issues specific to health information that Bill C-6 either fails to address or, even worse, exacerbates. In light of the clear deficits in Bill C-6 and the inadequate protection of patient privacy and health information confidentiality, CMA urges this committee to accept the recommendations put forward in this brief to strengthen the Bill’s provisions for protecting privacy and to accept the amendment (Appendix B) CMA has prepared to give effect to these recommendations. CMA believes that Canadians desire and deserve no less than this as concerns the right of privacy with respect to health information. I. Introduction The Canadian Medical Association is the national voice of Canadian physicians. Our mission is to provide leadership for physicians and to promote the highest standard of health and health care for Canadians. The CMA is a voluntary professional organization representing the majority of Canada's physicians and comprising 12 provincial and territorial divisions and 43 affiliated medical organizations. On behalf of its 46,000 members and the Canadian public, CMA performs a wide variety of functions, including addressing the emerging issue of electronic health information and confidentiality and privacy. It is in this capacity that we present our position on Bill C 6, The Personal Information Protection and Electronic Documents Act. CMA commends the federal government for taking this important first step of beginning the debate on privacy and the protection of personal information. The issues are complex and the interests at stake significant. CMA welcomes the opportunity to provide comments on Bill C-6 and hopes that its input will strengthen the Bill by ensuring that patient privacy and the confidentiality of medical records are adequately protected. In preparing this brief CMA has had the benefit of the final report of the federal Advisory Council on Health Infostructure, Canada Health Infoway: Paths to Better Health: Final Report. (“Advisory Council Report”) Where appropriate, CMA cites the findings contained in the Report. CMA wishes to underscore the key themes of its brief: A. Health information is special by its nature. Rules relating to health information must be developed in recognition of its special nature. Ensuring protection of privacy and confidentiality of the patient record must take precedence over other considerations. Bill C-6 fails to do this. Bill C-6 is written from the perspective of encouraging commerce. It appears to have access to information as its dominant value. The world of health care is very different from that of commerce and consequently requires distinct rules. B. Typically, health information is confided in the context of the therapeutic relationship and under the trust upon which this relationship is built. Rules concerning health information -- and in particular its collection, disclosure and use for purposes unrelated to the provision of direct care -- must be consistent with the expectations of patients about confidentiality and must not exploit the trust patients have in their physicians or compromise the ability of physicians to earn and maintain this trust. C. Health information must, in all but exceptional and justifiable circumstances, be used only under the strict control of the patient. The patient must be able to exercise control through voluntary, informed consent. Moreover, a distinction must be made between a patient’s right to know what can or must happen to health information and the right to consent to such use. Bill C-6 permits the collection, use and disclosure of information without knowledge or consent on grounds such as expediency, practicality, public good, research, offence investigation, historic importance and artistic purpose. The laxness and breadth of these exemptions as applied to health information is unacceptable. These uses, without the patient’s consent (or even knowledge), reduce the patient to a means to someone else’s end, however worthwhile that end may be. Moreover, the absence of consent (or even knowledge) undermines the integrity of the patient-physician relationship and has the potential to erode the trust patients have in their physicians - a trust that is essential to patients’ willingness to provide the complete information needed to provide them with care. D. The root of most of the problems in applying Bill C-6 to health care information is its failure to distinguish among purposes for the collection, use and disclosure of health information. In particular, the Bill fails to distinguish between the primary purpose, which is to deliver care to and for the benefit of an individual patient, and secondary purposes, which are not for the direct benefit of the patient (and indeed may even use the patient’s information to his or her detriment). Provisions to protect privacy should give recognition to the difference between these purposes and should not hinder the ability of physicians and others to provide care consistent with the patient’s wishes. Moreover, the Bill has no effective mechanism to distinguish legitimate purposes, which should be permitted, from illegitimate purposes, which should not, notwithstanding the limitation to “purposes that a reasonable person would consider are appropriate in the circumstances” in Section 5(3). E. In recent years the secondary use of information for purposes other than the purpose for which it was collected has been increasing without adequate oversight or public knowledge. This ‘function creep’ undermines the trust of patient-physician relationship. Collection and use beyond the therapeutic context and for purposes unrelated to the provision of direct care should be subjected to rigorous scrutiny before they are permitted to occur. To the extent that they are permitted to occur without patient consent they should be explicitly authorized in legislation to ensure transparency and adequate oversight. This Brief will first look at the apparent rationale of Bill C-6 and its potential application to health information. The brief will then describe why CMA considers health information to be special in nature and worthy of special protection. Finally, the brief reviews the difference in approach between Bill C-6 and CMA’s Health Information Privacy Code to illustrate that Bill C-6 provides inadequate protection to patient privacy and medical confidentiality. II. Rationale and Scope of Bill C-6 A. Rationale of Bill C-6 The driving force behind Bill C-6 is the support and promotion of electronic commerce. The second part of the Bill is devoted to permitting electronic versions of documents and signatures to be legitimate or ‘originals’ if the provisions of the Act are followed. Part 2 of the Bill is quite distinct from Part 2 and both parts could stand alone as separate pieces of legislation. Part 2 simply allows electronic versions of documents and signatures to be recognized as legitimate. On its face, this has little to do with the protection of personal information except to the extent that storage of documents in electronic form provides greater ability to access, link and merge information. Certainly, the Bill appears to draw on this connection by including, in its statement of purpose, the provision of a right of privacy in an era in which technology increasingly facilitates the collection and free flow of information. Part 1 concerns all forms of personal information, electronic and otherwise. It gives some protection to personal information by requiring consent in some instances. In CMA’s view, a fundamental difficulty with Part 1 and with the Bill in general is that its goal is to promote commerce and thus all information is implicitly considered as falling within the ‘commercial’ realm. In the case of health information this is surely not the case or the only consideration. Moreover, this creates a clash of values when applied to a health care system that is a public system. The Advisory Council Report takes a firm stand on this issue and states that legislation respecting the privacy protection of health information, “should also contain a clear prohibition against all secondary commercial use of personal health information.”Moreover, Bill C-6 fails to distinguish and priorize different purposes for collecting, using and disclosing information and in doing so treats all purposes as more or less equal and subject to the same rules. CMA takes a quite a different view when it comes to health information and will expound its view throughout this brief. B. Scope - Application to Health Records CMA has argued from the outset that C 6 (and its predecessor C 54) will apply to some health information. This view now appears to be widely accepted. Nevertheless, it is unclear as to what extent Bill C 6 will apply to health records. The full name of the Act states, in part: An Act to support and promote electronic commerce by protecting personal information that is collected, used or disclosed in certain circumstances . . . . What are these circumstances? Section 4(1) states that Part 1 (the part protecting personal information) applies in respect of personal information that: (a) the organization collects, uses or discloses in the course of commercial activities; or (b) is about an employee of the organization and that the organization collects, uses or discloses in connection with the operation of a federal work, undertaking or business. The definition of commercial activity given in 2(1) that commercial activity Ameans any particular transaction, act or conduct or any regular course of conduct that is of a commercial character@ is circular and does nothing to clarify uncertainties concerning the Bill’s scope. There are two points to be made here as concerns the application of this Bill to health information. The first concerns clarity around where commercial ends and health care begins. Which health care settings that operate for profit are excluded from the Act? This question speaks to the difficulty of delineating what activity is considered health care and what activity is considered commercial. Moreover the increase in public/private partnerships and joint funding of endeavours within the health care sector, which the government appears to be promoting, may make it increasingly difficult to make this distinction; for example in the area of research. The second concerns the specification of different regimes for information protection and privacy rights, depending on whether the information is deemed to come under commercial activity. This is clearly not desirable. However, the solution to this problem is not to reduce the privacy rules for all health information to the lowest common denominator but to raise them to a higher level of protection than is afforded commercially acquired information. Subjecting all health information to the regime laid out in the CMA Health Information Privacy Code would achieve this objective. In preparing this brief CMA has assumed that the Bill will provide a scheme that applies to at least some health information. Three years after it is in force it will apply equally to activities that occur strictly within the provinces, unless there is legislation in the province that is substantially similar to the Bill (see sections 27(2)(b) and 30). No doubt the extent of the federal government’s ability to legislate in this area generally will be the subject of extensive debate. However, CMA has no comment on this debate and provides its opinion in the interests of ensuring that the rules that relate to health information are compatible with preserving the integrity of the patient physician relationship and the protection of patient privacy and health information confidentiality. The federal government has an opportunity to provide Canadians with strong privacy rights in health information. It is incumbent upon the government to do so. C. Scope - Government Excluded Bill C-6 expressly excludes a large part of government activity from its ambit. Although government activity is to some extent governed by the Privacy Act, R.S.C. 1985, P-21, the rules of this Act provide less protection than those of Bill C-6. Government should subject itself to at least the same rules that it requires of the private sector in so far as it is a collector and user of information. Indeed, government’s practices relating to the collection, storage, merging, transfer and use of health information should be subject to more stringent rules than those found in either the Privacy Act or Bill C-6. The Advisory Council Report also calls for the same rules to apply to the public and private sectors, rules that are more stringent than those found in the Privacy Act or Bill C-6. Therefore, CMA recommends: That, at least in connection with health information, the provisions of the Bill apply equally to the public and the private sectors. III. Considerations Regarding Patient Privacy and Confidentiality: Medical Context Versus Commercial Context A. CMA’s Position The world of health care is very different from that of commerce and consequently requires distinct rules that are more protective of privacy. Confiding information to your physician under the trust of the patient-physician relationship is not on par with giving your address to a salesclerk when you purchase a toaster or rent a movie. Health information is special by nature. Canadians know this. In a recent Angus Reid poll commissioned by CMA Canadians told us loudly and clearly that they regard their health information as especially sensitive. However, the obvious sensitivity of health information is not the only thing that makes it special and in virtue of which it warrants distinct rules to strengthen privacy protection. It is important to recognize that this information is typically collected under the trust patients vest in their physicians. Patients confide their information for the purpose of receiving care and in the expectation that it will be held in the strictest confidence. This purpose, and the preservation of this trust, should be given primacy in rules concerning health information It is also important to recognize that the trust under which patients confide in their physicians is fundamental to the patient-physician relationship. If patients could not trust their physicians to protect their information and keep it secret they would not confide it as freely as they do. In consequence, the ability of physicians to provide the care needed would be severely diminished. Rules relating to health information must be developed in recognition of its special nature and the circumstances of trust and vulnerability in which it is initially collected or confided. Patients confide in their physicians for the purpose of receiving care. The potential that the information thus confided may subsequently be used for other purposes must not impede the therapeutic purpose or diminish the trust and integrity of the patient-physician relationship. In recent years the secondary use of information for purposes other than those for which it was collected has been increasing without adequate oversight or public knowledge. This ‘function creep’ undermines the trust of patient-physician relationship. Collection and use beyond the therapeutic context and for purposes unrelated to the provision of direct care should be subjected to rigorous scrutiny before they are permitted to occur. To the extent that they are permitted to occur without patient consent they should be explicitly authorized in legislation to ensure transparency and adequate oversight. Putting patients first means ensuring that health information, in all but exceptional and justifiable circumstances, is used only under the strict control of the patient. The patient must be able to exercise control through voluntary, informed consent. Moreover, a distinction must be made between a patient’s right to know what can or must happen to health information and the right to consent to such use. Bill C-6 permits the collection, use and disclosure of information without knowledge or consent on grounds such as expediency, practicality, public good, research, offence investigation, historic importance and artistic purpose. The laxness and breadth of these exemptions as applied to health information is unacceptable. These uses, without the patient’s consent (or even knowledge), reduce the patient to a means to someone else’s end, however worthwhile that end may be. Moreover, the absence of consent (or even knowledge) undermines the integrity of the patient-physician relationship and has the potential to erode the trust patients have in their physicians - a trust that is essential to patients’ willingness to provide the complete information needed to provide them with care. CMA has developed and adopted a Health Information Privacy Code (Appendix A) in recognition of the special nature of health information and to give primacy to patients and to the right of privacy. In commenting on this Code the Advisory Council Report notes: The Code represents an important contribution to the deliberations of Canadians and legislators on how to safeguard privacy across the health domain. In his 1998-99 Annual Report, the Federal Privacy Commissioner writes in support of the Health Information Privacy Code: Legislators looking for guidance on health information privacy law need not re-invent the wheel; the Canadian Medical Association’s Health Information Privacy Code is a comprehensive benchmark for achieving a high national level of protection for personal information. The Code could be the basis for drafting legislation. Given the grumblings that the Code sets the bar too high, perhaps some Health Infoway funds should be used to study the impact of its implementation. The patients at the heart of this system deserve no less. There are several key principles that guided the development of the Health Information Privacy Code and upon which it is based: 1. The provision of health care to all Canadians irrespective of social circumstances or health status is a highly regarded value in Canadian society. The system is publicly funded and universally accessible. 2. The right of privacy is fundamental to a free and democratic society. 3. Rules relating to health information must recognize its special nature. Health information has a high level of sensitivity and is confided or collected in circumstances of vulnerability and trust for the primary purpose of benefiting the patient. 4. The hallmark of the medical profession since the time of Hippocrates has been the willingness and ability to hold information confided secret. 5. The patient-physician relationship is one of trust. A central feature of this trust is the belief of patients that information confided in or collected by physicians and other health care providers will be kept secret. 6. Patients believe that the information they disclose or that is gathered as a result of their seeking health care will be used to provide them with health care. Use beyond the provision of health care without knowledge or consent goes beyond what a patient’s reasonable expectations were when information was confided or collected and therefore is a breach of the trust patients place in their physicians. 7. Except in very limited circumstances, consent is required for health information collection, use, disclosure or access for any purpose. 8. Information required to provide patients with the health care sought should be readily available to those who require it to provide an aspect of care as consistent with the wishes of the patient. 9. Uses of health information for purposes other than the provision of health care to the person seeking care should be subject to rules that: - protect and promote privacy and confidentiality; - generally require express consent; - can be justified according to specific criteria. 10. Patients should know the uses to which their health information may be put prior to disclosing it. 11. Patients may be reluctant to disclose information if they are concerned about the uses to which the information is put or the persons entitled to access it. B. Public Opinion To determine the public’s views on issues concerning privacy and health information, CMA commissioned Angus Reid to conduct research in two forms, quantitative (survey) and qualitative (focus groups), and has found the following: 1. Canadians believe that health information is the most sensitive type of information, and indeed more sensitive than their financial information. 1. 2. Canadians believe that their health information will be kept confidential and consider this to be important. 3. Canadians believe it important to know and control how their health information is shared with others. 4. Canadians do not want their health information released to third parties (including governments and researchers) without their knowledge and consent. 5. Canadians have concerns about the release of delinked or anonymous information to third parties without their consent. 6. Some Canadians are reluctant to confide information to their physicians due to concerns about it subsequently being disclosed to others without their consent. 7. Patients believe that privacy rules should apply equally to the public and the private sector. These findings are consistent with the published literature and other findings relating to the public’s concerns about privacy and confidentiality. The CMA Health Information Privacy Code was developed in consideration of these views. Once developed, its principles were subsequently tested with the public in a series of cross-country focus groups and it was found that the Code appears to enjoy considerable public support. C. The Advisory Council Report The Advisory Council Report relates to the electronic health record. However, given the direction towards the greater use of technology and the underlying principles informing the Advisory Council, its recommendations are generalizable to all health information. A key principle of the Advisory Council Report is that access by health care professionals should be based on a need-to-know basis under the strict control of the patient. The Council, like CMA, calls for scrutiny and justification of secondary uses of health information. The Council is opposed to the use of multipurpose identifiers on the grounds that it becomes too easy for government officials from one department to gain access to a person’s health record or to combine a number of records to assemble a comprehensive profile. (Anecdotal evidence suggests that this concern may be justified and that there are insufficient safeguards preventing the flow of health information among government departments.) The Council recommends that all governments ensure that they have legislation to address privacy protection specifically aimed at protecting personal health information through explicit and transparent mechanisms. Included in these mechanisms are: * The provision of a precise definition of free and informed consent, as well as a statement of principle that informed consent should be the basis for sharing personal health information; * Any exemption to the requirement of informed consent should be clearly set out in law. More specifically, legislative guidance should be provided on how to balance the right of privacy with the public good for research purposes to implement a coherent and harmonized pan-Canadian system for independent, ethical review. * There should be provisions regulating secondary uses of non-identifiable health information. These provisions should address privacy concerns surrounding the degree to which data might be linked back to an identifiable individual. * Legislation should set clear limits on access to and use of health information by third parties outside the health care system. To prevent the serious invasions of privacy that can result from the unrestricted linking of personal health information with other kinds of information on the same individual, the legislation should contain provisions prohibiting the use for any other purpose of unique personal identifiers in health information systems. D. The Approach in Bill C-6 Bill C-6 begins with the right premise: that “rules to govern information collection, use and disclosure” should recognize the “right of privacy”. However, it fails to recognize the special nature of health information and to tailor its provisions accordingly. In consequence, there is confusion and uncertainty about Bill C-6's application to health care. Even more seriously, however, Bill C-6 fails to recognize that health information requires stronger or greater privacy protection than other types of information. The Bill makes a cursory attempt at distinguishing among varying types of personal information and gives inadequate additional protection to information that is highly sensitive (such as health information), notwithstanding the provisions in Paragraph 4.3.4 of Schedule 1 concerning consent which do provide some latitude for more stringent requirements in the case of sensitive information. The Bill permits the collection, use and disclosure of information without knowledge or consent on grounds such as expediency, practicality, public good, research, offence investigation, historic importance and artistic purposes. In the context of health information, these grounds should be subject to intense scrutiny to determine their relevance and legitimacy. Some of these grounds would not withstand scrutiny if subjected to the tests established in the CMA’s Health Information Privacy Code. E. Conclusion CMA believes that health information is special and deserves a higher level of privacy protection than other types of information. The Advisory Council Report also recognizes that distinct rules, more protective of privacy, are required for health information. The Council’s Report places strong emphasis on the protection of privacy, recognizes that, as a general rule, the flow of health information should be on a need-to-know basis and under the control of the patient through the exercise of free and informed consent, and requires limits on the secondary use of health information. The inadequacy of Bill C-6 for health care is not surprising because clearly it was not drafted with health information in mind. Rather, it is written from the perspective of encouraging commerce. It appears to have access to information as its dominant value. However, the world of health care is very different from that of commerce and distinct rules that are more protective of privacy. The CMA Health Information Privacy Code begins from the same starting point as Bill C-6, the Canadian Standards Association (CSA) Code which the Bill includes as Schedule 1. However, unlike Bill C-6, the CMA Code tailors the CSA Code to the specific circumstances of health information. The CMA Health Information Privacy Code, therefore, is able to address issues specific to health information that Bill C-6 either fails to address or, even worse, creates. It offers a template for the protection that should be specifically accorded to the right of privacy in health information, a template that appears to have considerable public support and is designed to uphold patient confidence in their physicians and the health care system. Amending Bill C-6 to incorporate the principles in the CMA Code would ensure adequate privacy protection. CMA recommends: That Bill C-6 be amended to incorporate specific provisions relating to health information and that the provisions of the CMA Health Information Privacy Code provide the basis of such provisions. CMA developed the Health Information Privacy Code in recognition of trends and developments that pose new threats to patient privacy and the trust of the therapeutic relationship. In recent years the secondary use of information for purposes other than the purposes for which it was collected has been increasing without adequate oversight or public knowledge. This ‘function creep’ undermines the trust of patient-physician relationship. Collection and use beyond the therapeutic context and for purposes unrelated to the provision of direct care should be subjected to rigorous scrutiny before they are permitted to occur. To the extent that they are permitted to occur without patient consent they should be explicitly authorized in legislation to ensure transparency and adequate oversight. CMA’s Health Information Privacy Code provides a test to which legislation addressing health information should be subjected. This test (found in section 3.6 of the CMA Code) states: Any proposed or existing legislation or regulation made under legislative authority that permits or requires health information collection, use, disclosure or access shall be subjected to the following legislative test: (a) There must be demonstration that: (i) a patient privacy impact assessment has been conducted, the analysis has been made public and has been duly considered prior to the introduction of legislation [section 3.5 of the Code provides guidance with respect to the patient privacy impact assessment]; (ii) collection, use, disclosure and access will be limited to the greatest degree possible to ensure that * the collection of health information by persons external to the therapeutic context will neither trade on nor compromise the trust of the patient-physician relationship; * patients are not likely to be inhibited from confiding information for primary purposes; * the ability of physicians to discharge their fiduciary duties to patients will not be compromised; and, * patient vulnerability will not be exploited; (iii) collection, use, disclosure and access will be restricted to what is necessary for the identified purpose(s) and will not impede the confiding or collection of information for primary purposes; (iv) provisions exist for ensuring that patients are provided with knowledge about the purpose(s) and that, subject to 3.6(b), patient consent is clearly voluntary; (v) the means used are proportionate and the collection will be limited to purposes consented to or made known to the patient; (vi) the patient’s privacy will be intruded upon to the most limited degree possible in light of the purpose(s) consented to or made known to the patient; (vii) linkage of the health information will be limited; and (viii) unless clear and compelling reasons exist: * all reasonable steps will be taken to make health information anonymous; and * if it has been demonstrated that making health information anonymous would render it inadequate for legitimate uses, the information will be collected and stored in a deidentified-relinkable format. (b) When nonconsensual collection, use, disclosure or access is permitted or required by legislation or regulation that meets the requirements of the Code, the following conditions must also be met: (i) the right of privacy has to be violated because the purpose(s) could not be met adequately if patient consent is required; and (ii) the importance of the purpose(s) must be demonstrated to justify the infringement of the patient’s right of privacy in a free and democratic society. (c) Any legislative provision or regulation that permits or requires health information collection, use, disclosure or access nonconsensually shall not, without compelling reasons, be applied retroactively to existing health information. In its current form, Bill C-6 would not pass the scrutiny of the test. Consequently, CMA recommends: That the proposed rules for health legislation be subject to the legislative test found in CMA’s Health Information Privacy Code and formulated in light of this process. IV. Specific Comments on Bill C-6 From the Perspective of CMA’s Health Information Privacy Code This section highlights some key distinctions between the approach taken by Bill C-6 and CMA’s Health Information Privacy Code. It uses examples to illustrate divergent approaches taken for the purpose of demonstrating that Bill C-6 is inadequate in the protection it accords health information and to show how the CMA Health Information Privacy Code would address the issues adequately. A. General Bill C-6 and CMA’s Health Information Privacy Code are based on the Canadian Standards Association’s Model Code for the Protection of Personal Information (CSA Code). Bill C-6 and the CMA Code also augment the CSA Code’s provisions where considered necessary. The need to extend the provisions of the CSA Code demonstrates that the CSA Code, being general in nature, provides inadequate protection to information in many instances. The CSA recognized this at the time it developed its Code and specifically issued additional, specific guidance for health information in the form of an appendix to the Workbook for applying the Code. The Workbook begins: Information regarding one’s health and health records may be among the most sensitive of all personal data. Individuals are concerned that inappropriate disclosure of such information could unduly affect their employment status or their lives in general. . . Some health information is obtained directly from health care providers who have been given a patient’s private information with the expectation that this information will remain as a private communication. Health care providers . . . in turn, feel that such concerns could influence individuals to withhold vital information or avoid treatment to ensure their private information remains as such. Implementation of privacy procedures that adhere to the principles in the CSA Code and rigid applications of such procedures are essential steps for organizations that require access to health information, to maintain an individual’s trust that sensitive personal information remains confidential. In designing and implementing such procedures, organizations should recognize the sensitive nature of such information and also the fact that the primary reason that health care providers maintain records is to ensure that safe and efficacious care is provided. The Workbook goes on to list 7 interpretative points to augment the CSA Code, providing additional privacy protection as it applies to health information, including the following: requirements for the individual’s knowledge and consent be rigidly followed. Consent to acquire and disclose health information should be undertaken with the individual’s full knowledge of the scope of information to be requested. Bill C-6 does not include these additional interpretive points. It does not give due recognition that health information, because of its high sensitivity, deserves even stronger protection than is provided in the CSA Code as appended in Schedule 1 of the Bill (which even the Committee that drafted the CSA Code recognized). Although Bill C-6 and the CMA Code are based on the CSA Code, each takes a different approach to the ultimate protection accorded information and to the right of privacy. This divergence demonstrates that there are many ways to resolve issues left unresolved by the CSA Code. In other words, it is not a foregone conclusion that basing provisions on the CSA Code will result in appropriate or adequate protection of information. Rather, resolution of issues requires thought and deliberation and will depend in some measure on the primacy given to certain values. Bill C-6 appears to have given access primacy in the pursuit of commerce, whereas CMA gives privacy protection primacy in the pursuit of the provision of health care in accordance with physicians’ fiduciary obligations to patients and the integrity of the patient-physician relationship. CMA did not develop its approach in a vacuum. It reviewed, and was inspired by, the report of the House of Commons Standing Committee on Human Rights and the Status of Persons with Disabilities, entitled Privacy: Where Do We Draw the Line? This report articulates and makes explicit many of the issues that should be informing the current debate on Bill C-6. In addition, the Report of the Advisory Council takes a very different approach than Bill C-6. The Report recognizes the need to pay more than lip service to protecting privacy and confidentiality and recommends specific measures aimed at doing this. B. Primacy of the Therapeutic Purpose The root of most of the problems in applying Bill C-6 to health care is its failure to distinguish among purposes for the collection, use and disclosure of health information. In particular, the Bill fails to distinguish between the primary purpose, which is to deliver care to and for the benefit of an individual patient, and secondary purposes, which are not for the direct benefit of the patient and indeed may even involve using the patient’s information to his or her detriment. Under Bill C-6, the same rules apply equally to both the primary and to secondary purposes. In other sectors this failure to distinguish different purposes and to fashion rules in light of salient differences may not pose problems. In the health care sector, however, the consequences could be quite serious. As applied to secondary purposes, the provisions in Bill C-6 fail to limit access appropriately. Access to information may occur in ways that are inappropriate and violate the privacy of patients. As applied to the primary purpose -- the use of a person`s information to provide that person with care -- the rules in the Bill, if rigidly construed, may inhibit access that would otherwise be appropriate and consistent with the patient`s right of privacy. For example, the consent provisions in the Bill could create impediments to information flow where various members of a ‘health care team’ require information about the patient in order to be effective for the patient’s benefit; the provisions in the Bill that seek to limit the extent of information collection could inhibit physicians from being as extensive as they sometimes are and should be in collecting information from patients for the purpose of providing care; the provisions in the Bill requiring that the patient`s request to review his or her record be in writing could in fact be a barrier to patient access which might otherwise be facilitated informally and consistently with the patient`s wishes by a simple verbal request. Such consequences no doubt would be unintended by the drafters of the Bill; the drafters might even argue that for someone to interpret the provisions mentioned above as potentially leading to these consequences would be to misinterpret them. Regardless, the fact is that the Bill, on these matters and others, is somewhat strained when its provisions are applied to health care. The CMA Health Information Privacy Code, however, is not. It begins from the same starting point as Bill C-6, which is the CSA Code. However, the CMA, recognizing (as the drafters of the CSA Code apparently also did) that the CSA Code would need to be tailored to deal adequately with health information, did so in drafting its Health Information Privacy Code. This document was written from the ground up not just with privacy first and foremost as a value but also with specific reference to the health sector. And it is based on the fundamental premise that not all purposes for the use of health care are equal and that the therapeutic purpose must be given primacy. Thus the CMA Health Information Privacy Code avoids the kind of problems identified above that might arise as Bill C-6 is applied to health information. For example, it specifies that the collection of health information for the primary purpose of providing care “may be as extensive as necessary to fulfil these purposes and reflect the high level of trustworthiness and accountability of health professionals in the therapeutic context” (3.2) but that for any secondary purposes it should be “as minimal as necessary in recognition of the need to protect the patient’s right of privacy in the therapeutic context” (3.3.). As concerns consent, which CMA recognizes to be core to the protection of privacy, the CMA Code articulates rules for consent in recognition of the importance of timely information flow in the team context and as appropriate to meet the purpose for which the patient has confided the information in the first place, which is to receive care. It stipulates that consent for the primary purpose may therefore be implied, albeit with certain qualifications. Moreover, where consent is required, the provisions of the Code allow that “the conveyance of generic information is a reasonable means of providing knowledge” in most circumstances, which means that this requirement is unlikely to create unreasonable burdens that would diminish rather than strengthen the therapeutic relationship. Finally, the CMA Code limits itself to issues of principle concerning patient access to their records; Bill C-6, by specifying that requests must be in writing, could in fact be creating a barrier to patient access or an undue burden upon the patient-physician relationship as there may be instances when an informal request would be quite appropriate. C. Knowledge of Purpose Prior to Collection Bill C-6 Bill C-6 is ambiguous in its provisions relating to whether or not a person should know the purposes for which information will be used prior to disclosure. This is due in part to the use of the term “knowledge and consent” as one concept rather than distinguishing the knowledge requirement from the consent requirement. What a person should know in relation to the purposes for which information might be used or disclosed, prior to its being given, is distinct conceptually from whether the person must consent before information can be used or disclosed for a particular purpose. Schedule 1 of the Bill contains a number of principles. For the purposes of this Brief the schedule will be referred to in terms of the principles (and their subparagraphs). Principle 2 addresses the identification of purposes for which information will be used or disclosed. Provided a purpose is identified it becomes a legitimate purpose (this Brief recognizes that the addition of the “reasonable person” clause in 5(3) takes precedence and provides some grounds for distinguishing legitimate and illegitimate purposes). Subparagraph 3 states that the identified purposes should be specified at or before the time of collection. Section 5(2) of the Bill states that the use of ‘should’ in schedule 1 indicates a recommendation and does not impose an obligation. Therefore, according to subparagraph 3, it is recommended but is not obligatory that disclosure occur. On the other hand, principle 3 addresses consent and appears to impose an obligation by stating that the knowledge and consent of the individual are required for the collection, use, or disclosure of personal information, except where inappropriate. Similarly subparagraph 2 appears to create something of an obligation by stating, “organizations shall make a reasonable effort to ensure that the individual is advised of the purposes for which the information will be used.” Section 7(1)(a) permits the collection of information without knowledge and consent when collection is clearly in the interests of the individual and consent cannot be obtained. The intent of this section could be made clearer, particularly in terms of who determines the “interests of the individual.” Otherwise this exception could give undesirable licence to collect without knowledge or consent. The provision in section 7(1)(b) is more problematic. This section appears to favour withholding knowledge from an individual if such knowledge would compromise accuracy, defeat the purpose for collection or prejudice the use. In some instances it may well be that, if an individual is provided with knowledge of the purposes for which information is collected and the uses to which it will be put, he or she may choose to withhold information rather than disclose it, and in doing so would clearly compromise accuracy, defeat the purpose for collection or prejudice the use to which the information will be put. This is contrary to principle 4.4.2, which recognizes that information should not be collected by misleading or deceiving individuals. The intent of this section should be far clearer and circumscribed in such a way as to make it clear that it is not permissible to withhold knowledge or not seek consent simply on the basis that if a person had knowledge they would not wish to disclose information. Section 7(1)(c) allows collection without knowledge or consent for journalistic, artistic or literary purposes. This provision is totally inappropriate in the case of health information. CMA Health Information Privacy Code The CMA Health Information Privacy Code is considerably more restrictive that Bill C-6. It recognizes that, in the therapeutic context, health information is confided or collected under the patient’s presumption that it is necessary to meet his or her therapeutic needs. The potential that health information may be subsequently collected, used, disclosed or accessed for other purposes without patient consent should be made known to patients before information is confided or collected for the primary therapeutic purpose. Moreover, it is not acceptable to withhold knowledge from patients deliberately out of concern that knowledge could inhibit them from confiding important information fully and truthfully. The CMA Health Information Privacy Code limits the nonconsensual collection of health information to circumstances where it is either permitted or required by legislation or ordered or decided by a court of law. In addition, the CMA Code gives explicit direction to legislators with respect to the conditions under which legislation should permit or require health information collection (see section 3.6 of CMA Code). In the case of nonconsensual collection, the following conditions are stipulated: 1. The right of privacy has to be violated because the purposes could not be met adequately if patient consent is required; and 2. The importance of the purposes must be demonstrated to justify the infringement of the patient’s right of privacy in a free and democratic society. D. Use Without Knowledge Or Consent Bill C-6 Once information has been collected and despite the limits, inadequate though they be, placed on collection without knowledge or consent, it can be put to even greater use than for the purposes for which it has been collected (with or without knowledge or consent). Section 7(2) opens up dramatically the uses to which collected information may be put without either knowledge or consent. At a minimum, and with little additional administrative effort, the enumerated grounds of section 7(2) (and 7(3) should be made known to an individual prior to their disclosure of information, which would be in keeping with the principle of openness and explicitness. Section 7(2)(a) allows use in connection with the investigation of an offence. In the medical context this could be problematic, particularly if it is interpreted to impose an obligation. Generally, there is no obligation to assist in the investigation of an offence, and indeed the fiduciary duty between patient and physician and the duty of confidentiality owed to the patient by the physician would suggest that physicians not offer information, despite its usefulness. Section 7(2)(b) recognizes emergency situations. However, as worded, section 7(2)(b) would allow access to anyone’s information if it is for the purpose of acting in an emergency threatening the life, health or security of an individual. The implications of this section should be carefully thought through. It is not desirable to give such a broad licence to access anyone’s information on the basis of an emergency. There should be some limiting principle that takes into account the prevailing view that people generally are not required to go to the assistance of others (emergency or otherwise) and that information about oneself is considered worthy of protection against use or disclosure, despite its potential benefit to others (for example, genetic information or HIV or Hepatitis C status). Section 7(2)(c) is very problematic as it permits the use of “identifiable” information for a host of purposes, including statistical and research, when it is impractical to seek consent. Even though the Commissioner must be informed of the use before the information is used the Commissioner has no power to approve or reject the use. If the use is legitimate under the Bill there would be no grounds open to the Commissioner to cause an audit to occur. This section gives significant scope for the secondary use of information that has been collected without knowledge or consent; in the case of health information it is very problematic. CMA Health Information Privacy Code The CMA Code makes a clear distinction between the primary purpose for the collection and use of health information and secondary purposes for its use. The key distinction between these two categories is that primary purposes relates to the provision of the health care benefit sought whereas secondary purposes are ends or aims that are not directly related to the provision of care. The CMA Code divides secondary purposes into two categories: 1. Secondary legislated purposes are those purposes that have been subjected to the legislative test specified in the Code and have subsequently been written into law; 2. Secondary nonlegislated purposes are any other purposes, such as education or research not governed by legislation, that meet the provisions of the CMA Code and the secondary nonlegislative test provided by the Code. The tests that the CMA Code requires of both relate to: 1. Impact on privacy. 2. Impact on the patient-physician relationship, especially confidentiality and trust. 3. Impact on the willingness of patients to disclose information. 4. Impact on patients’ ability to receive care. 5. Evidence of broad public support for the measure. 6. The use will not exploit or compromise the trust of the patient-physician relationship. 7. Patient vulnerability will not be exploited. 8. Under most circumstances patients will be fully informed of the purpose and patient consent will be clearly voluntary. 9. Patient privacy will be intruded upon to the most limited degree possible. 10. Linkage of health information will be restricted and consented to by patients. In other words, the CMA Code does not permit any and all secondary purposes for the use of health information. Rather, it requires justification for the secondary use and assurance that the secondary use will neither impede nor undermine the patient-physician relationship and the provision of health care to the patient. This test is much more privacy protective than the “reasonable person” test the Bill contains in Section 5(3). Moreover, the CMA Code only permits use without consent if it is permitted or required by legislation or when ordered or decided by a court of law. The Advisory Council Report Like the CMA, the Advisory Council Report makes distinctions among various types of uses. The Report calls for legislation to clearly prohibit all secondary commercial use of personal health information (in which respect the Advisory Council takes an even stronger position than the CMA). In addition, the Report recommends that there be provisions regulating secondary uses of non-identifiable health information and that such provisions should address privacy concerns surrounding the degree to which such data might be linked back to an identifiable individual. In this context, the Report recommends that legislation set clear limits on access to and use of health information by third parties outside the health care system. In addition the Report reviews the uses of health information for statistical and research purposes. In connection with research, the Report calls for a number of safeguards and restrictions: 1. Where the data sets used have a higher level of potential identifiability, “the general rule should be informed consent and stringent assurances about privacy protection and security arrangements are necessary before a researcher can have access to personally identifiable information.” 2. The Report recognizes that in some instances it may be impractical to obtain consent from patients. Whether in anonymous or identifiable form, the Report requires that notice be given about the use of the information. In the case of the use of identifiable information, the Report states that the research should be subject to independent ethics review with the onus on the person seeking to use the information without consent to demonstrate that: (a) a tangible public good of significant benefit will result; (b) consent is impossible to secure at a reasonable cost; (c) less identifiable data will not serve the same purpose; and (d) no harm can occur to any person directly or indirectly as a result of this use of his or her personal information. E. Disclosure Without Knowledge Or Consent Bill C-6 The comments found under C. and D. above apply equally here. Section 7(3) adds further instances when collected information can be disclosed to others without knowledge or consent. CMA Health Information Privacy Code In the case of secondary use of health information, the CMA Code takes a far more restrictive approach. As concerns use, disclosure or access, it states: The potential that health information, in whole or in part, may be subsequently collected, used, disclosed or accessed for other purposes without their consent, and what those purposes might be, must be made known to the patient by reasonable means before it is confided or collected for primary purposes. Moreover, the CMA Code recognizes that information disclosed by one organization is collected by another. The Code defines collection to mean: the act of accessing, receiving, compiling, gathering, acquiring or obtaining health information from any source, including third parties, and by any means. It includes information collected from the patient, as well as secondary collection of this information in whole or in part by another provider or user. The collecting organization should be bound by the provisions of the CMA Code, which generally requires consent for use for any purpose and always requires knowledge of the potential purposes that information will or must be put to prior to the information being disclosed. CMA’s Code states: Health information custodians must ensure that third parties privy to health information have adopted this Code or are bound by equivalent provisions. Finally, the CMA Code explicitly recognizes that information can be retrieved from a variety of sources to formulate records. Any and all such practices and the composite form developed are given the same degree of protection as that accorded information collected directly from the patient. F. Consent Bill C-6 In those cases where consent for collection, use or disclosure are required, the provisions in Bill C-6 are inadequate as applied to health care. Schedule 1 distinguishes between express and implied consent. Express consent is not adequately defined and it appears that this is not equivalent to what in health care is called ‘informed consent’. For example, Principle 4.3.2. says that “organizations shall make a reasonable effort to ensure that the individual is advised of the purposes for which the information will be used”. In the health care context, the notion of ‘reasonableness’ with respect to the doctrine of informed consent applies not to the effort to advise or inform (that much is assumed or given) but rather to determinations regarding what information should be provided to the patient. In addition, the application of some of the means described in Principle 4.3.7 by which individuals can give consent, and in particular the ‘negative option’ checkoff box in (b), may be quite problematic in the health care context. The broad scope allowed to implied consent in the Bill is also worrisome as applied to the health care setting. Principle 4.3.6 says “implied consent would generally be appropriate when the information is less sensitive”. However, with implied consent the issue is not the sensitivity of the information but rather the wishes of the patient. It is appropriate to infer consent even when the information is very sensitive provided one has reason to believe this is grounded in the patients wishes; conversely, it is not appropriate to infer consent, even in the case of information deemed not to be sensitive, if there is reason to believe the patient would object if asked explicitly. CMA Health Information Privacy Code The CMA Code furnishes clear definitions for consent: “Consent” means a patient’s informed and voluntary agreement to confide or permit access to or the collection, use or disclosure of his or her health information for specific purposes. For purposes other than the provision of direct care, which is the purpose for which the patient presents in the first place, the consent must always be explicit or express since there is no logical connection between secondary purposes and the desire to achieve care. Therefore inferences cannot be made with any confidence. The Code defines express consent as follows: “Express consent” is given explicitly, either orally or in writing. Express consent is unequivocal and does not require any inference on the part of the provider seeking consent. The CMA Code defines implied consent to disallow the loose use of the term, which is increasing today, to justify access for purposes (secondary purposes in particular) that the patient may not wish to occur: Implied consent arises where agreement may reasonably be inferred from the action or inaction of the individual and there is good reason to believe that the patient has knowledge relevant to this agreement and would give express consent were it sought. The CMA Code also lays out clear rules for the use of the concept of consent and makes clear that consent can be inferred for primary purposes (i.e., the provision of health care to the patient) but not for secondary ones, which require express consent. The Code grounds the notion of implied consent not in the desire to subvert express consent and thereby gain access to information that might otherwise be denied but rather in the wishes of the patient and the importance of providing health care for therapeutic purposes as consistent with those wishes. Advisory Council Report In addition to being more stringent than Bill C-6 about exemptions to consent, the Advisory Council Report also gives greater importance to defining the term clearly and strictly. It says that any legislation concerning health information should: contain a precise definition of free and informed consent, as well as a statement of principle that informed consent should be the basis for sharing personal health information. Although not as precise and emphatic on the subject of consent as is the CMA Health Information Privacy Code, the Report is certainly more so than is Bill C-6. G. Information Flow Within Organizations Bill C-6 Bill C-54 defined use to include “the transfer of personal information within an organization.” Bill C-6 no longer defines use, which leaves it uncertain whether the definition of use quoted above from Bill C-54 would be a reasonable interpretation of Bill C-6. If so, this would create a problem. Interpreting use in this way could have the effect of inappropriately restricting the free flow of information within an organization. In the health care context this is not a reasonable or desirable outcome and would hinder, rather than promotes, the patient’s right of privacy. CMA Code The CMA Code recognizes that the free flow of health information is desirable to the extent that it furthers the provision of the health care benefit sought and that it occurs with patient consent. The Code defines the primary purpose to mean: (i) Primary therapeutic purpose is the initial reason for a patient seeking or receiving care in the therapeutic context, and pertains to the delivery of health care to a particular patient with respect to the presenting health need or problem. It encompasses consultation with and referral to other providers on a need-to-know basis. (ii) Primary longitudinal purpose concerns developing composite health information about a particular patient, such as a detailed medical history, beyond direct application to the presenting health need or problem, in order to enhance ongoing care to that person. The Code goes on to state that: Health information collection, use, disclosure or access for the primary therapeutic and longitudinal purposes may be as extensive as necessary to fulfil these purposes and reflect the high level of trustworthiness and accountability of health professionals in the therapeutic context. And further states that: Security safeguards shall impede as little as possible health information collection, use, access and disclosure for primary purposes. Finally, in addressing consent the Code states: Consent to health information collection, use, disclosure and access for the primary therapeutic purpose may be inferred. Consent to subsequent collection, use, disclosure and access on a need-to-know basis by or to other physicians or health providers for this purpose, and for this purpose alone, may be inferred, as long as there is no evidence that the patient would not give express consent to share the information. The principles in the CMA Code that give effect to the patient’s right to control what happens to his or her information are not incompatible with the free flow of information among members of a health team for the purpose of providing care to the patient. Indeed, they facilitate and enable this flow to the extent this is in keeping with the patient’s wishes. H. Information Protected Bill C-6 The Bill covers “personal information” which is defined to mean “information about an identifiable individual, but does not include the name, title or business address or telephone number of an employee of an oganization.” This definition raises a host of questions: 1. Does the Bill cover information that has been delinked to an identifiable individual but that could be relinked to identify them? 2. Does the Bill only exclude anonymous information - that is, information that could never be relinked to an identifiable individual? And if so, is there an unjustified assumption that information can, in all cases, be rendered truly anonymous? 3. In the case of delinked and anonymous information, who decides that information about an identifiable individual can be rendered delinked or anonymous? The holder of the information or the person to whom the information pertains? 4. Is it accurate or reasonable to assume that people have no interest in information emanating from them once it has been rendered delinked or anonymous? 5. Given that anonymous information is generated from personal information, is the act or process rendering personal information into anonymous form considered a use under the terms of the Bill, and if so does this use require consent? In considering these questions, it is important to keep in mind that the concept of “anonymity” means different things to different people. Moreover, there are no generally used or accepted standards that address what is required to render identifiable information truly anonymous. As a consequence, different people use different standards (of varying degrees of rigour), if they use a standard at all. It is also important to note that, in virtue of sophisticated techniques for identifying individuals from supposedly anonymous information, there is debate about the extent to which true anonymity can ever be achieved or guaranteed. CMA Health Information Privacy Code In light of issues concerning the definition of ‘personal information’ and in the interest of ensuring a thorough scrutiny of information practices, the CMA Code provides a broad definition of health information: Health information means any information about a patient that is confided or collected in the therapeutic context, including information created or generated from this information and information that is not directly or indirectly linked to the provision of health care. It includes all information formats. The CMA Code covers identifiable information, delinked information, anonymous information and any composite form that is produced when health information is linked to other information about the patient. CMA’s research indicates that patients have an interest in their information even when it is in delinked and in anonymous formats. This view has recently received support from a decision of the High Court of Justice in England that is particularly relevant in the context of the commercial use of health information (Source Informatics Ltd. v. Department of Health). The issue arose because a prescription database company sought judicial review of a Department of Health policy document that advised National Health Service GPs and pharmacists not to sell “anonymous” prescribing or dispensing information. The document contained the following analysis: Anonymisation (with or without aggregation) does not, in our view, remove the duty of confidence towards the patients who are the subject of the data. Apart from the risk of identification of a patient despite anonymisation, the patient would not have entrusted the information to the GP or the pharmacist for it to be provided to the data company. The patient would not be aware of or have consented to the information being given to the data company, but would have given it to be used in connection with his care and treatment and wider NHS purposes. Anonymisation of the data (with or without aggregation) would not obviate a breach of confidence. . . .The duty of confidence may in some circumstances be outweighed by the public interest in disclosure. However we have severe reservations that disclosure by GPs or NHS pharmacists of dispensing information to X or other data companies would be argued to be in the public interest. Indeed it might well be contrary to the public interest if the data company is further selling the information on doctors prescribing habits to the pharmaceutical industry. High Court Justice Latham upheld the policy document, arguing that the information in question, though anonymous, was nonetheless confidential. He also argued that consent to its release was necessary and could not be implied, and that the breach of confidentiality involved in selling this information could not be justified as being in the public interest: In my view, it is impossible to escape the logic . . . that the proposal involves the unauthorised use by the pharmacist of confidential information. . . . In my judgement what is proposed will result in a clear breach of confidence unless the patient gives consent, which is not part of the proposal at present. Nor is it suggested that the patient can be said to have given implied consent. . . . I recognize that, for some, the sensitivity, as they see would see it, of the information may be such that they would feel that any use of the information without their consent, would be unconscionable. In other words it would be a breach of trust which they were reposing in the pharmacist. . . I have come to the conclusion that . . . this [is] a type of situation . . . in which there is a public interest in ensuring that confidences are kept. It is important that those who require medical assistance should not be inhibited in any way from seeking or obtaining. As I have indicated, I believe that there may be some patients who will feel very strongly that the pharmacist should not give any information obtained from the prescription without their consent. In view of the fact that there is a growing industry in so-called anonymous health information, it is important to ensure that this information is protected as consistent with the duties of health care providers and the expectation patients have that their providers will keep their information confidential. Advisory Council Report The Advisory Council Report addresses this issue in a number of ways. In making recommendations concerning the definition of health information, the Report calls for legislation that embodies: a clear definition of health information, broad enough to incorporate health information collected in public and private systems and to ensure that equal obligations and penalties apply to both public and private sectors. The Report recognizes a spectrum of data formats: completely anonymous, linked to pseudo-identities, code linked and reidentifiable, completely identifiable. In terms of sensitivity, the Report notes that information that can be re-identified is somewhat more sensitive than completely anonymous data or anonymous data linked to pseudo-identities and that completely identifiable health information is the most sensitive type of health information. The Report also notes that there can be some degree of risk of re-identification of what was believed to be anonymous data through such processes as data matching and the results of analysis using small cells. In this light, the Report recommends that legislation should recognize: A definition of personal health information, which takes into account the spectrum of potential identifiability in the case of health information. Furthermore, in the case of secondary uses of health information, the Report notes that provisions regulating secondary uses of non-identifiable health information must form part of any comprehensive legislation. Such provisions should address privacy concerns surrounding the degree to which data might be linked back to an identifiable individual. The Report raises further issues relating to the use of delinked and anonymous data. The Report notes that there may be group interests and concerns regarding data collected and states: Privacy can also be a concern for groups such as Aboriginal and immigrant communities. These communities worry that research on their members could be released to the media without notice and used in a negative way. This emerging issue is growing in importance and, in the Council’s view, should be a serious consideration in the context of ethical reviews of proposed research projects. It is important to note that, in these instances, it is not the fact that data is linked to an identifiable individual that is of concern. Rather, it is the ability to accumulate, process and dissect information that has ramifications for an individual because they are part of a group segregated and identified by the research. Finally, the Report considers the use of person-oriented data (data linked to individuals in a form where personal identifiers have been replaced by a code) for statistical purposes and notes that this too raises concerns about privacy. The Report notes that: “These concerns have traditionally been seen as a tradeoff against data access for research and analysis in the public interest.” The Report restates this to provide a more positive view of privacy and states: the best way for analysts to maintain the public’s consent to use sensitive (but anonymous) health data is to show the public that privacy, confidentiality and security are being taken seriously. In view of the issues concerning the definition of personal information and in the interest of ensuring maximum scrutiny of practices concerning health information and maximum protection of the right of privacy with respect to health information, CMA recommends: That there be a clear definition of the information being accorded a right of privacy and that this definition, at least in the case of health information, include identifiable information, delinked information, anonymous information and any composite information produced when health information is linked to any information about a person from any other source. I. Individual Access Bill C-6 Bill C-6 restricts the right of individual access to personal information. The grounds for denying access to information are inappropriate in the health care context. CMA Code The CMA Code follows the prevailing case law as it relates to medical records. Primarily this gives patients a right of access to their record in all but very limited circumstances. These circumstances are when there is a significant likelihood of a substantial adverse effect on the physical, mental or emotional health of the patient or substantial harm to a third party. The onus lies on the provider to justify denial of access on these grounds. J. Accuracy and Amendment Bill C-6 Bill C-6 requires that information be as accurate, complete and up-to-date as possible and that it shall not be routinely updated unless this is necessary to fulfil the purpose for its collection. In so far as amendment is concerned, Bill C-6 permits amendment to the record in specified circumstances. CMA Code The CMA Code takes a different approach in light of the nature and purpose of health information. The Code recognizes that the recording of statements of fact, clinical judgements and determinations or assessments should reflect as nearly as possible what has been confided by the patient and what has been ascertained, hypothesized or determined to be true using professional judgement. In terms of amending the record in light of a patient’s request, the CMA Code seeks to preserve the original record but also provide for noting the patient’s concerns. To accommodate both requirements the CMA Code states: Patients who have reviewed their information and believe it to be inaccurately recorded or false have the right to suggest amendments and to have their amendments appended to the health information. K. Sensitivity Bill C-6 Schedule 1 recognizes that medical records have a high level of sensitivity attached. For this reason this information may warrant special attention concerning consent, reasonable expectations, individual access and the degree of security that is appropriate. CMA Code The CMA Code recognizes that, even as all health information is sensitive (when considered against other forms of information about individuals), there are also variations in the level of sensitivity in various aspects of the health record. The CMA Code defines the “sensitivity of health information” to refer to: the patient’s interest in keeping the information secret. It varies according to the nature of the information, its form, and the potential negative repercussions of its collection, use or disclosure on the patient’s interests. Under the Code’s consent provisions it is stated that: Although all health information is sensitive and should be treated as such, the more sensitive the health information is likely to be, given what is known about the circumstances or preferences of the patient, the more important it is to ensure that consent is voluntary and informed. With respect to security the Code states: The development of security safeguards with respect to levels of access for various users shall recognize the differences in the sensitivity of health information and permit access accordingly. Moreover, the Code recognizes that health information is special and therefore requires distinct rules that afford stronger privacy protection not just due to its sensitivity but also to the circumstances of vulnerability and trust under which it is initially confided or collected. These special circumstnaces, which include much more than sensitivity, are outlined in Principle 2 of the Code. Bill C-6, by contrast, fails to consider these other features that make health information a special case. In consequence its provisions are not adquately tailored to the special nature of health information and do not accord it the strong privacy protection it warrants. V. Conclusions The increased capacity to collect, store, transfer, merge and access information, coupled with trends that support increased use of and access to information, have the potential to erode our traditional understanding and protection of privacy and confidentiality. The issues are complex and the choices we must make are difficult. Nevertheless, these issues should be squarely on the table and the choices that we make must be clear, transparent and defensible. Of paramount importance is that the public is not mislead into believing that their information is being protected or kept confidential when in fact it is not. Therefore, even to refer to Bill C-6 as the “Personal Information Protection and Electronic Documents Act” should be the subject of debate. Is the Bill truly about information protection or is it actually about permitting access to information? The approach to rules for information in Bill C-6 is directed toward commerce and appears to have access, and not privacy, as its dominant value, notwithstanding the Bill’s reference to a “right of privacy”. In CMA’s view, the Bill’s approach is inadequate when applied to health information. Based on the evidence, it seems highly likely that the public would also find Bill C-6 inadequate. Bill C-6 was not developed with health information in mind. In consequence there is confusion and uncertainty about its application to the health care context. Even more seriously, however, Bill C-6 fails to recognize that privacy with respect to health information requires stronger or greater protection than other types of information. CMA presents a different approach, an approach that recognizes the special nature of health information; an approach that puts patients first and values privacy and the preservation of the trust and integrity of the patient-physician relationship. This approach appears to be well-grounded in the values that Canadians hold about privacy and would likely enjoy broad public support. In addition, the CMA approach draws support from the Federal Advisory Council Report, which like CMA recognizes the importance of preserving patient privacy and the confidentiality of the health record in an era of increased use of technology. Implicitly, the Report recognizes that the benefits of such technology cannot be realized if public support, based on respect for privacy, cannot be secured. The CMA’s Health Information Privacy Code does what Bill C-6 fails to do. Amending Bill C-6 to incorporate the principles in the CMA Code would ensure adequate privacy protection. In light of the clear deficits in Bill C-6 and the inadequate protection of patient privacy and health information confidentiality, CMA urges this Committee to accept its recommendations and the amendment that incorporates them. Nothing less would give Canadians the high level of privacy protection they desire and deserve when it comes to their health information. VI. Summary of Recommendations That Bill C-6 be amended to incorporate specific provisions relating to health information and that the provisions of the CMA Health Information Privacy Code provide the basis of such provisions; and That any proposed rules for health legislation be subject to the legislative test found in CMA’s Health Information Privacy Code and formulated in light of this process; and That there be a clear definition of the information being accorded a right of privacy and that this definition, at least in the case of health information, include identifiable information, delinked information, anonymous information and any composite information produced when health information is linked to any other information about a person from any other source; and That, at least in connection with health information, the provisions of the Bill apply equally to the public and the private sectors. CMA has drafted an amendment to Bill C-6 (Appendix B) which, if accepted, would achieve all of these recommendations and adequately give Canadians the kind of privacy protection with respect to their health information that they deserve and desire.
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Listening to our Patient's Concerns : Comments on Bill C 54 (Personal Information Protection and Electronic Document Act) : Submission to the House of Commons Standing Committee on Industry

https://policybase.cma.ca/en/permalink/policy1980
Last Reviewed
2019-03-03
Date
1999-03-18
Topics
Health care and patient safety
Health information and e-health
Ethics and medical professionalism
  2 documents  
Policy Type
Parliamentary submission
Last Reviewed
2019-03-03
Date
1999-03-18
Topics
Health care and patient safety
Health information and e-health
Ethics and medical professionalism
Text
Over the last year, CMA has become increasingly concerned that debate on the issues concerning health information have been framed in terms of access to information with an attendant erosion of privacy and confidentiality. This one-sided approach comes at a time of expansion in our capacity to collect, store, merge, transfer and access information, coupled with trends both in the health care sector and generally related to the use of information To address these concerns and to ensure that privacy and confidentiality in the medical context are valued, protected and preserved, CMA developed and adopted a Health Information Privacy Code. This Code should form the basis of all legislation governing the collection, use and disclosure of health information. Health information is special by its nature. Rules relating to health information must be developed in recognition of its special nature. Ensuring protection of privacy and confidentiality of the patient record must take precedence over other considerations. Bill C-54 fails to do this. Bill C-54 is written from the perspective of encouraging commerce. It appears to have access to information as its dominant value. CMA considers the world of health care to be very different from that of commerce and consequently requiring distinct rules. Health information use must, in all but exceptional and justifiable circumstances, occur only under the strict control of the patient. The patient must be able to exercise control through voluntary, informed consent. Bill C-54 permits the collection, use and disclosure of information without knowledge or consent on grounds such as expediency, practicality, public good, research, offence investigation, historic importance and artistic purpose. The evident lack of protection accorded health information based on such ground, is unacceptable. The absence of protection undermines the integrity of the patient-physician relationship and has the potential to erode the trust patients have in their physicians - a trust that is essential to patients’ willingness to provide the complete information needed to provide them with care. Moreover, distinctions must be made between a patient’s right to know what can or must happen to health information and the right to consent to such use. Not all purposes for the collection and use of health information are equal. Collection and use beyond the therapeutic context should be subjected to rigorous scrutiny before they are permitted to occur. Bill C-54 fails to make such a distinction and treats all purposes that could be identified for information collection or use as equal. Moreover, the Bill has no mechanism to distinguish legitimate purposes, which should be permitted from illegitimate purposes, which should not. In light of the clear deficits in Bill C-54 and the inadequate protection of patient privacy and health information confidentiality, CMA makes the following recommendations: That Bill C-54 be amended to incorporate specific provisions relating to health information and that the provisions of the CMA Code provide the basis of such provisions; and That the proposed rules for health legislation be subject to the legislative test found in CMA’s Code and formulated in light of this process; and That there be a clear definition of the information being accorded a right of privacy and that this definition, at least in the case of health information, include identifiable information, delinked information, anonymous information and any composite form produced when information is linked to any information about a person from any other source; and That, at least in connection with health information, the provisions of the Bill apply equally to the public and the private sectors. I. Introduction The Canadian Medical Association is the national voice of Canadian physicians. Our mission is to provide leadership for physicians and to promote the highest standard of health and health care for Canadians. The CMA is a voluntary professional organization representing the majority of Canada's physicians and comprising 12 provincial and territorial divisions and 43 affiliated medical organizations. On behalf of its 45,000 members and the Canadian public, CMA performs a wide variety of functions, including addressing the emerging issue of electronic health information and confidentiality and privacy. It is in this capacity that we present our position on Bill C 54, The Personal Information Protection and Electronic Documents Act. CMA commends the government for taking the first, important step of beginning the debate on the protection of personal information. The issues are complex and the interests at stake significant. CMA welcomes the opportunity to provide comments on Bill C-54. CMA hopes that its input will strengthen the Bill by ensuring that patient privacy and the confidentiality of medical records are adequately protected. In preparing this brief CMA has had the benefit of the final report of the federal Advisory Council on Health Infostructure, Canada Health Infoway: Paths to Better Health: Final Report. (“Advisory Council Report”) Where appropriate, CMA cites the findings contained in the report. CMA wishes to underscore the key themes of its brief: A. Health information is special by its nature. Rules relating to health information must be developed in recognition of its special nature. Ensuring protection of privacy and confidentiality of the patient record must take precedence over other considerations. Bill C-54 fails to do this. Bill C-54 is written from the perspective of encouraging commerce. It appears to have access to information as its dominant value. CMA considers the world of health care to be very different from that of commerce and consequently requiring distinct rules. B. Health information use must, in all but exceptional and justifiable circumstances, occur only under the strict control of the patient. The patient must be able to exercise control through voluntary, informed consent. Bill C-54 permits the collection, use and disclosure of information without knowledge or consent on grounds such as expediency, practicality, public good, research, offence investigation, historic importance and artistic purpose. The evident lack of protection accorded health information based on such ground, is unacceptable. The absence of protection undermines the integrity of the patient-physician relationship and has the potential to erode the trust patients have in their physicians - a trust that is essential to patients’ willingness to provide the complete information needed to provide them with care. Moreover, distinctions must be made between a patient’s right to know what can or must happen to health information and the right to consent to such use. C. Not all purposes for the collection and use of health information are equal. Collection and use beyond the therapeutic context should be subjected to rigorous scrutiny before they are permitted to occur. Bill C-54 fails to make such a distinction and treats all purposes that could be identified for information collection or use as equal. Moreover, the Bill has no mechanism to distinguish legitimate purposes, which should be permitted from illegitimate purposes, which should not. This brief will first look at the apparent rationale of Bill C-54 and its potential application to health information. The brief will next describe why CMA considers health information to be special in nature and worthy of special protection. Finally, the brief reviews the difference in approach between Bill C-54 and CMA’s Health Information Privacy Code to illustrate that Bill C-54 provides inadequate protection to patient privacy and health record confidentiality. II. Rationale and Scope of Bill C-54 A. Rational of Bill C-54 The driving force behind Bill C-54 is the support and promotion of electronic commerce. The second part of the Bill is devoted to permitting electronic versions of documents and signatures to be legitimate or ‘originals’ if the provisions of the Act are followed. Part two of the Bill is quite distinct from part one and both parts could stand alone as separate pieces of legislation. Part two simply allows electronic versions of documents and signatures to be recognized as legitimate. On its face, this has little to do with the protection of personal information except to the extent that storage of documents in electronic form provides greater ability to access, link and merge information. Certainly, the Bill appears to draw on this connection by including, in its statement of purpose, the provision of a right of privacy in an era in which technology increasingly facilitates the collection and free flow of information. Part one concerns all forms of information, electronic and otherwise. It gives some protection to personal information by requiring consent in some instances. In CMA’s view, a fundamental difficulty with part one and the Bill in general is that it’s goal is to promote commerce and thus all information is implicitly considered as falling within the ‘commercial’ realm. In the case of health information this is surely not the case or the only consideration. Moreover, this creates a clash of values when applied to a health care system that is a public system. The Advisory Council Report takes a hard line on this issue and states that legislation respecting the privacy protection of health information, “should also contain a clear prohibition against all secondary commercial use of personal health information.” Because all information is subjected to similar rules, there is no attempt within the Bill to distinguish some purposes for collecting information from other purposes. The Bill takes the approach that the purposes should be known and documented. While not stated explicitly, the assumption is that all purposes identified are legitimate and are permitted. CMA has quite a different view when it comes to health information and will expound its view throughout this brief. B. Scope - Application to Medical Records CMA is uncertain whether or to what extent Bill C-54 will apply to health records. The full name of the Act states, in part: An Act to support and promote electronic commerce by protecting personal information that is collected, used or disclosed in certain circumstances.... What are these circumstances? Section 4(1) states that Part 1 (the part protecting personal information) applies in respect of personal information that: (a) the organization collects, uses or discloses in the course of commercial activities; (b) the organization collects, uses or discloses interprovincially or internationally; or (c) is about an employee of the organization and that the organization collects, uses or discloses in connection with the operation of a federal work, undertaking or business. It should further be noted that three years after the Act is in force it will apply equally to activities that occur strictly within the province unless there is legislation in the province that is substantially similar to the Bill (see sections 27(2)(d) and section 30). The first issue is the provision of section 4(1)(a) - collection, use and disclosure in the course of commercial activities. There seems to be an assumption on the part of government that this automatically excludes health records, (although the Act fails to define what is meant by commercial activity). Is this accurate or does the assumption fail to recognize that there is not a clear, unambiguous distinction between what might constitute commercial activity or other activity? There are two points to be made here. The first concerns clarity around where commercial ends and health care begins. Which health care settings that operate for profit are excluded from the Act? This question speaks to the difficulty of delineating what activity is considered health care and what activity is considered commercial. Moreover it recognizes that the increased encouragement to public/private funding of endeavours within the health care sector may make it increasingly difficult to make this distinction; for example in the area of research. The second concerns the movement of health information from the health care setting (recognizing that this is not easily distinguished from the commercial setting) to the commercial setting; for example, health information provided to insurance companies. When health care information is collected in a health care setting and transferred to a commercial setting, which rules apply - Bill C-54 or no rules? In CMA’s view, there is no clear way of distinguishing commercial activity from health care activity in a way that ensures that the health care record is subject to different rules than those pertaining to other records. Moreover, the dilemma for government is that even if such distinction could occur, would it be desirable that health records be subject to no rules? Put in another way, will those organizations that currently collect health care information be entitled to claim that since the information forms part of the health record they are not subject to the provisions of C-54? Under such a regime health care records would be subject to an even lower standard than that provided for information collected in the commercial context. In terms of the provisions of 4(1)(b) - interprovincial and international transfer of information. This appears to apply to all information. In the existing environment and developments such as the “health information highway,” interprovincial transfers of information, the capacity for the central collection and storage of information, mechanisms such as telephone and cable to transfer information and general trends related to population health, it seems likely that interprovincial traffic will grow rather than diminish. The significance of this section, therefore, cannot be underestimated. Finally, the provisions of 4(1)(c) may well contain health information about the employee. In preparing this brief CMA has assumed that the Bill will provide a scheme that applies to some health information. No doubt the extent of the federal governments ability to legislate in this area generally will be the subject of extensive debate. However, CMA has no comment on this debate and provides its opinion in the interests of ensuring that the rules that relate to health information are compatible with preserving the integrity of the patient-physician relationship and the protection of patient privacy and health information confidentiality. CMA considers that the government has an opportunity to provide Canadians with strong privacy rights in health information. Indeed, CMA believes that it is incumbent upon the government to do so. C. Scope - Government Excluded Bill C-54 expressly excludes a large part of government activity from its ambit. While government activity is to some extent governed by the Privacy Act, R.S.C. 1985, P-21, the rules of this act provide less protection than those of Bill C-54. Government should subject itself to at least the same rules that it requires of the private sector in so far as it is a collector and user of information. Moreover, CMA is of the view that government’s practices relating to the collection, storage, merging, transfer and use of health information must be subject to more stringent rules than those found in either the Privacy Act or Bill C-54. The Advisory Council Report also calls for the same rules to apply to the public and private sectors, rules that are more stringent than those found in the Privacy Act or Bill C-54. Therefore, CMA recommends: That, at least in connection with health information, the provisions of the Bill apply equally to the public and the private sectors. III. Considerations Regarding Patient Privacy and Confidentiality: Medical Context Versus Commercial Context A. CMA’s Opinion Over the last year, CMA has become increasingly concerned that debate on the issues concerning health information have been framed in terms of access to information with an attendant erosion of privacy and confidentiality. This one-sided approach comes at a time of expansion in our capacity to collect, store, merge, transfer and access information, coupled with trends both in the health care sector and generally related to the use of information To address these concerns and to ensure that privacy and confidentiality in the medical context are valued, protected and preserved, CMA developed and adopted a Health Information Privacy Code, which is appended to and forms part of this brief. In commenting on this Code the Advisory Council Report notes: The code represents an important contribution to the deliberations of Canadians and legislators on how to safeguard privacy across the health domain. There are a number of principles underpinning the Health Information Privacy Code: 1. The provision of health care to all Canadians irrespective of social circumstances or health status is a highly regarded value in Canadian society. The system is publicly funded and universally accessible. 2. The right of privacy is fundamental to a free and democratic society. 3. Rules relating to health information must recognize its special nature. Health information has a high level of sensitivity, it is confided or collected in circumstances of vulnerability and trust for the primary purpose of benefiting the patient. 4. Physicians now and historically promise that they will keep their patients’ information secret; this is a hallmark of the profession. 5. The patient-physician relationship is one of trust and a central feature of this trust is the belief in patients that information confided in or collected by physicians and other health care providers will be kept secret. 6. Patients believe that the information they disclose or that is gathered as a result of their seeking health care will be used to provide them with health care; uses beyond the provision of health care without knowledge or consent go beyond what a patient’s reasonable expectations were when information was disclosed or gathered and is a breach of the trust patients place in their physicians. 7. Except in very limited circumstances, consent is required for health information collection, use, disclosure or access for any purpose. 8. Information required to provide patients with the health care sought should be readily available to those who require it to provide an aspect of care. 9. Uses of health information for purposes other than the provision of health care to the person seeking care should be subject to rules that: - protect and promote privacy and confidentiality; - generally require express consent; - can be justified according to specific criteria. 10. Patients should know the uses to which their health information is put prior to their disclosure of it. 11. Patients may be reluctant to disclose information if they are concerned about the uses to which the information is put or the persons entitled to access it. B. Public Opinion To determine the public’s view on these issues, CMA commissioned Angus Reid to conduct research in two forms, quantative (survey) and qualitative (focus groups), and has found the following: 1. Patients believe that their health information will be kept confidential and consider this to be important. 2. Patients believe it important to know and control how their health information is shared with others. 3. Patients do not want their health information released to third parties (including governments and researchers) without their knowledge and consent. 4. Patients may have concerns about the release of delinked or anonymous information to third parties without their consent. 5. Patients may be reluctant to confide information as a result of concerns related to its use or disclosure. These findings are consistent with general findings relating to the public’s concerns about privacy and confidentiality. C. The Advisory Council Report The Advisory Council Report relates to the electronic health record. However, given the direction towards the greater use of technology and the underlying principles informing the Advisory Council, CMA believes that the recommendations are generalizable to all health information. A key principle of the Advisory Council is that access by health care professionals should be based on a need-to-know basis under the strict control of the patient. The Council, like CMA calls for scrutiny and justification of secondary uses of health information. The Council is opposed to the use of multipurpose identifiers on the grounds that it becomes too easy for government officials from one department to gain access to a person’s health record or combine a number of records to assemble a comprehensive profile. (Anecdotal evidence suggests that this concern may be justified and that there are insufficient safeguards preventing the flow of health information among government departments) The Council recommends that all governments ensure that they have legislation to address privacy protection specifically aimed at protecting personal health information through explicit and transparent mechanisms. Included in these mechanisms are: * The provision of a precise definition of free and informed consent, as well as a statement of principle that informed consent should be the basis for sharing personal health information; * Any exemption to the requirement of informed consent should be clearly set out in law. More specifically, legislative guidance should be provided on how to balance the right of privacy with the public good for research purposes to implement a coherent and harmonized pan-Canadian system for independent, ethical review. * There should be provisions regulating secondary uses of non-identifiable health information. These provisions should address privacy concern surrounding the degree to which data might be linked back to an identifiable individual. * Legislation should set clear limits on access to and use of health information by third parties outside the health care system. To prevent the serious invasions of privacy that can result from the unrestricted linking of personal health information with other kinds of information on the same individual, the legislation should contain provisions prohibiting the use for any other purpose of unique personal identifiers in health information systems. D. The Approach in Bill C-54 Bill C-54 is inadequate in its protection of health information. The Bill makes a meagre attempt at distinguishing among varying types of personal information and gives no additional protection to information that is highly sensitive (such as health information). The Bill permits the collection, use and disclosure of information without knowledge or consent on grounds such as expediency, practicality, public good, research, offence investigation, historic importance and artistic purposes. In the context of health information, these grounds should be subject to intense scrutiny to determine their relevance and legitimacy. In CMA’s view and according to the tests established in the CMA’s Code, some of these grounds would not withstand such scrutiny. E. Conclusion CMA’s Code offers a template for the protection that should be accorded health information, a template that appears to have some public support and that strives to retain patient confidence in their physicians and the health care system. The Report of the Federal Advisory Council also recognizes that special rules are required for health information. The Council’s Report places strong emphasis on the protection of privacy, recognizes that as a general rule the flow of health information should be on a need-to-know basis and under the control of the patient through the exercise of free and informed consent and requires limits on the secondary use of health information. In CMA’s view, Bill C-54 should incorporate specific rules relating to health information and CMA’s Code should form the basis of these rules. CMA recommends: That Bill C-54 be amended to incorporate specific provisions relating to health information and that the provisions of the CMA Code provide the basis of such provisions. In addition, CMA’s Code provides a test that legislation addressing health information should be subjected to. This test (found in section 3.6 of the CMA Code) states: Any proposed or existing legislation or regulation made under legislative authority that permits or requires health information collection, use, disclosure or access shall be subjected to the following legislative test: (a) There must be demonstration that: (i) a patient privacy impact assessment has been conducted, the analysis has been made public and has been duly considered prior to the introduction of legislation [section 3.5 of the Code provides guidance with respect to the patient privacy impact assessment]; (ii) collection, use, disclosure and access will be limited to the greatest degree possible to ensure that * the collection of health information by persons external to the therapeutic context will neither trade on nor compromise the trust of the patient-physician relationship; * patients are not likely to be inhibited from confiding information for primary purposes; * the ability of physicians to discharge their fiduciary duties to patients will not be compromised; and, * patient vulnerability will not be exploited; (iii) collection, use, disclosure and access will be restricted to what is necessary for the identified purpose(s) and will not impede the confiding or collection of information for primary purposes; (iv) provisions exist for ensuring that patients are provided with knowledge about the purpose(s) and that, subject to 3.6(b), patient consent is clearly voluntary; (v) the means used are proportionate and the collection will be limited to purposes consented to or made known to the patient; (vi) the patient’s privacy will be intruded upon to the most limited degree possible in light of the purpose(s) consented to or made known to the patient; (vii) linkage of the health information will be limited; and (viii) unless clear and compelling reasons exist: * all reasonable steps will be taken to make health information anonymous; and * if it has been demonstrated that making health information anonymous would render it inadequate for legitimate uses, the information will be collected and stored in a deidentified-relinkable format. (b) When nonconsensual collection, use, disclosure or access is permitted or required by legislation or regulation that meets the requirements of the Code, the following conditions must also be met: (i) the right of privacy has to be violated because the purpose(s) could not be met adequately if patient consent is required; and (ii) the importance of the purpose(s) must be demonstrated to justify the infringement of the patient’s right of privacy in a free and democratic society. (c) Any legislative provision or regulation that permits or requires health information collection, use, disclosure or access nonconsensually shall not, without compelling reasons, be applied retroactively to existing health information. In its current form, Bill C-54 would not pass the scrutiny of the test. Consequently, CMA recommends: That the proposed rules for health legislation be subject to the legislative test found in CMA’s Code and formulated in light of this process. IV. Specific Comments on Bill C-54 From the Perspective of CMA’s Health Information Privacy Code This section highlights some key distinctions between the approach taken by Bill C-54 and CMA’s Health Information Privacy Code. The purpose of this section is to illustrate through examples the divergence of approaches taken with the ultimate aim of demonstrating that Bill C-54 is inadequate in the protection it accords health information. A. General Bill C-54 and CMA’s Health Information Privacy Code are based on the Canadian Standards Association’s Model Code for the Protection of Personal Information (CSA Code). Bill C-54 and the CMA Code also augment the CSA Code’s provisions where considered necessary. The need to extend the provisions of the CSA Code demonstrates that the CSA Code, being general in nature, provides inadequate protection to information in many instances. Although Bill C-54 and the CMA Code are based on the CSA Code, each takes a different approach to the ultimate protection accorded information. This divergence demonstrates that there are many ways to resolve issues left unresolved by the CSA Code. In other words, it is not a foregone conclusion that basing provisions on the CSA Code will result in appropriate or adequate protection of information. Rather, resolution of issues requires thought and deliberation and will depend in some measure on the primacy given to certain values. Bill C-54 appears to have given access primacy in the pursuit of commerce, whereas CMA gives privacy protection primacy in the pursuit of the provision of health care in accordance with physicians fiduciary obligations to patients and the integrity of the patient-physical relationship. CMA did not develop its approach in a vacuum. It reviewed and was inspired by the report of the House of Commons Standing Committee on Human Rights and the Status of Persons with Disabilities, entitled Privacy: Where Do We Draw the Line? This report articulates and makes explicit many of the issues that should be informing the current debate on Bill C-54. In addition, the Report of the Advisory Council takes a very different approach to Bill C-54. The Report recognizes the need to pay more than lip service to protecting privacy and confidentiality and recommends specific measures aimed at doing this. B. Information Protected Bill C-54 The Bill covers “personal information” which is defined to mean “information about an identifiable individual that is recorded in any form.” This definition raises a host of questions: 1. Does the Bill cover or not information that has been delinked to an identifiable individual but that could be relinked to identify them? 2. Does the Bill only exclude anonymous information - that is, information that could never be relinked to an indentifiable individual? And if so, is there an unjustified assumption that information can, in all cases, be rendered truly anonymous? 3. In the case of delinked and anonymous information, who decides that information about an identifiable individual can be rendered delinked or anonymous? The holder of the information or the person to whom the information pertains? 4. Is it accurate or reasonable to assume that people have no interest in information emanating from them once it has been rendered delinked or anonymous? CMA Health Information Privacy Code The CMA Code provides a broad definition of health information: Health information means any information about a patient that is confided or collected in the therapeutic context, including information created or generated from this information and information that is not directly or indirectly linked to the provision of health care. It includes all information formats. In addition, the CMA Code covers identifiable information, delinked information, anonymous information and any composite form that is produced when health information is linked to other information about the patient. CMA’s research indicates that patients may have an interest in their information when it is in delinked and anonymous formats. Advisory Council Report The Advisory Council Report addresses this issue in a number of ways. In making recommendations concerning the definition of health information the Report calls for legislation that embodies: a clear definition of health information, broad enough to incorporate health information collected in public and private systems and to ensure that equal obligations and penalties apply to both public and private sectors. The report recognizes a spectrum of data formats: completely anonymous, linked to pseudo-identities, code linked and reidentifiable, completely identifiable. In terms of sensitivity, the Report notes that information that can be re-identified is somewhat more sensitive that completely anonymous data or anonymous data linked to pseudo-identities and that completely identifiable health information is the most sensitive type of health information. The Report also notes that there can be some degree of risk of re-identification of what was believed to be anonymous data through such processes as data matching and the results of analysis using small cells. In this light, the Report recommends: A definition of personal health information, which takes into account the spectrum of potential identifiability in the case of health information. Furthermore, in the case of secondary uses of health information, the Report notes that provisions regulating secondary uses of non-identifiable health information must form part of the legislation. Such provisions should address privacy concerns surrounding the degree to which data might be linked back to an identifiable individual. The Report raises further issues relating to the use of delinked and anonymous data. The Report notes that there may be group interests and concerns regarding data collected and states: Privacy can also be a concern for groups such as Aboriginal and immigrant communities. These communities worry that research on their members could be released to the media without notice and used in a negative way. This emerging issue is growing in importance and, in the Council’s view, should be a serious consideration in the context of ethical reviews of proposed research projects. It is important to note that in these instances it is not the fact that data is linked to an identifiable individual that is of concern. Rather, it is the ability to accumulate, process and dissect information that has ramifications for an individual because they are part of a group segregated and identified by the research. Finally, the Report considers the use of person-based data but not people’s names, for statistical purposes and notes that this too raises concerns about privacy. The Report notes that: “These concerns have traditionally been seen as a tradeoff against data access for research and analysis in the public interest.” The Report restates this to provide a more positive view of privacy and states: “the best way for analysts to maintain the public’s consent to use sensitive (but anonymous) health data is to show the public that privacy, confidentiality and security are being taken seriously.” Recommendation That there be a clear definition of the information being accorded a right of privacy and that this definition, at least in the case of health information, include identifiable information, delinked information, anonymous information and any composite form produced when information is linked to any information about a person from any other source. C. Knowledge of Purpose Prior to Collection Bill C-54 Bill C-54 is ambiguous in its provisions relating to whether or not a person should know the purposes for which information will be used prior to disclosure. This is due in part to the use of the term “knowledge and consent” as one concept rather than distinguishing the knowledge requirement from the consent requirement. What a person should know in relation to the purposes information might be used or disclosed for, prior to its being given is distinct conceptually from whether the person must consent before information can be used or disclosed for a particular purpose. Schedule 1 of the Bill contains a number of principles. For the purposes of this brief the schedule will be referred to in terms of the principles (and their subparagraphs). Principle 2 addresses the identification of purposes that information will be used or disclosed for. Provided a purpose is identified it becomes a legitimate purpose under the Bill. Subparagraph 3 states that the identified purposes should be specified at or before the time of collection. Section 5(2) of the Bill states that the use of ‘should’ in schedule 1 indicates a recommendation and does not impose an obligation. Therefore, according to subparagraph 3, it is recommended but is not obligatory that disclosure occur. On the other hand, principle 3 addresses consent and appears to impose an obligation by stating that the knowledge and consent of the individual are required for the collection, use, or disclosure of personal information, except where inappropriate. Similarly subparagraph 2 appears to create something of an obligation by stating, “organizations shall make a reasonable effort to ensure that the individual is advised of the purposes for which the information will be used.” The relationship between these sections should be clarified and made consistent. CMA is pleased to note that principle 3 has been modified to define when, and only when, organizations may collect information without knowledge or consent. Section 7(1)(a) permits the collection of information without knowledge and consent when collection is clearly in the interests of the individual and consent cannot be obtained. The intent of this section could be made clearer, particularly in terms of who determines the “interests of the individual.” Otherwise this exception could give undesirable license to collect without knowledge or consent. The provision in section 7(1)(b) is more problematic. This section appears to favour withholding knowledge from an individual if such knowledge would compromise accuracy, defeat the purpose for collection or prejudice the use. In some instances it may well be that if an individual is provided with knowledge of the purposes for which information is collected and the uses to which it will be put, they may choose to withhold information rather than disclose it, and in doing so would clearly compromise accuracy, defeat the purpose for collection or prejudice the use the information will be put to. This is contrary to the principle found in principle 4.1 which recognizes that information should not be collected by misleading or deceiving individuals. The intent of this section should be far clearer and circumscribed in such a way as to make it clear that it is not permissible to withhold knowledge or not seek consent simply on the basis that if a person had knowledge they would not wish to disclose information. Section 7(1)(c) allows collection without knowledge or consent for journalistic, artistic or literary purposes. This provision is totally inappropriate in the case of health information. CMA Health Information Privacy Code The CMA Code is considerably more restrictive that Bill C-54. It recognizes that in the therapeutic context, health information is confided by or collected from patients under the patient presumption that it is necessary to meet his or her therapeutic needs. CMA also believes that the potential that health information may be subsequently collected, used, disclosed or accessed for other purposes without patient consent should be made known to patients before information is confided or collected for the primary therapeutic purpose. CMA further notes that it is not acceptable to withhold knowledge from patients deliberately out of concern that knowledge could inhibit them from confiding important information fully and truthfully. CMA limits the circumstances the nonconsensual collection of health information to those: 1. Permitted or required by legislation; 2. When ordered or decided by a court of law. Moreover, the CMA gives explicit direction to legislators with respect to the conditions under which legislation should permit or require health information collection (see section 3.6 of CMA Code). In the case of nonconsensual collection, the following conditions are stipulated: 1. The right of privacy has to be violated because the purposes could not be met adequately if patient consent is required; and 2. The importance of the purposes must be demonstrated to justify the infringement of the patient’s right of privacy in a free and democratic society. While Bill C-54 is clearly enabling the collection of information, it does not, in CMA’s opinion put sufficient emphasis on or provide protections that preserve privacy and confidentiality, especially in the medical context. D. Use Without Knowledge Or Consent Bill C-54 Once information has been collected and despite the, albeit inadequate, limits placed on collection without knowledge or consent, it can be put to even greater use than the purposes it has been collected for with or without knowledge or consent. Section 7(2) opens up dramatically the uses to which collected information may be put without either knowledge or consent. At a minimum and without little additional administrative effort, the enumerated grounds of section 7(2) (and 7(3))should be made known to an individual prior to their disclosure of information, which would be in keeping with the principle of openness and explicitness. Section 7(2)(a) allows use in connection with the investigation of an offence. In the medical context this might be problematic particularly if it is interpreted to impose an obligation. Generally, there is no obligation to assist in the investigation of an offence and indeed the fiduciary duty between patient and physician and the duty of confidentiality owed to the patient by the physician would suggest that physicians not offer information despite its usefulness. Section 7(2)(b) recognizes emergency situations. However, as worded, section 7(2)(b) would allow access to anyone’s information if it is for the purpose of acting in respect of an emergency threatening the life, health or security of an individual. The implications of this section should be carefully thought through. Do we really intend to give such a broad licence to access anyone’s information on the basis of an emergency. In CMA’s view there should be some limiting principle that takes into account the prevailing view that people generally are not required to go to the assistance of others (emergency or otherwise) and that information about oneself is considered worthy of protection against use or disclosure despite its potential benefit to others for example, genetic information or HIV, Hepatitis C status. Section 7(2)(c) is very problematic as it permits the use of “identifiable” information for a host of purposes, including statistical and research, when it is impractical to seek consent. Even though the Commissioner must be informed of the use before the information is used the Commissioner has no power to approve or reject the use, and since the use is legitimate under the Bill provided the Commissioner has been notified there would be no grounds open to the Commissioner to cause an audit to occur. This section gives significant scope to use information that has been collected without knowledge or consent and certainly in the case of health information is problematic. CMA Health Information Privacy Code The CMA Code makes a clear distinction between the primary purpose for the collection and use of health information and secondary purposes for its use. The key distinction between these two categories is that primary purposes relates to the provision of the health care benefit sought whereas secondary purposes are ends or aims that are not directly related to the provision of care. The CMA Code divides secondary purposes into two categories: 1. Secondary legislated purposes, those purposes that have been subjected to the legislative test specified in the Code and have subsequently been written into law; 2. Secondary nonlegislated purposes are any other purposes, such as education or research not governed by legislation, that meet the provisions of the CMA Code and the secondary nonlegislative test provided by the Code. The tests that CMA requires both to go through relate to: 1. Impact on privacy. 2. Impact on the patient-physician relationship, especially confidentiality and trust. 3. Impact on the willingness of patients to disclose information. 4. Impact on patients’ ability to receive care. 5. Evidence of broad public support for the measure. 6. The use will not exploit or compromise the trust of the patient-physician relationship. 7. Patient vulnerability will not be exploited. 8. Under most circumstances patients will be fully informed of the purpose and patient consent will be clearly voluntary. 9. Patient privacy will be intruded upon to the most limited degree possible. 10. Linkage of health information will be restricted and consented to by patients. In other words, CMA is not satisfied that any and all secondary purposes for the use of health information should be permitted. Rather, CMA seeks justification for the secondary use and assurance that the secondary use will neither impede nor undermine the patient-physician relationship and the provision of health care to the patient. Moreover, the CMA Code only permits use without consent if it is permitted or required by legislation or when ordered or decided by a court of law. The Advisory Council Report Like CMA, the Advisory Council Report makes distinctions among various types of uses. The report calls for legislation to clearly prohibit all secondary commercial use of personal health information. In addition, the Report recommends that there be provisions regulating secondary uses of non-identifiable health information and that such provisions should address privacy concerns surrounding the degree to which such data might be linked back to an identifiable individual. In this context, the Report recommends that legislation set clear limits on access to and use of health information by third parties outside the health care system. In addition the Report reviews the uses of health information for statistical and research purposes. The Report’s findings with respect to statistical use have already been discussed. In connection with research, the Report calls for a number of safeguards and restrictions: 1. Where the data sets used have a higher level of potential identifiability, “the general rule should be informed consent and stringent assurances about privacy protection and security arrangements are necessary before a researcher can have access to personally identifiable information.” 2. The Report recognizes that in some instances it may be impractical to obtain consent from patients. Whether in anonymous or identifiable form the Report requires that notice be given about the use of the information in either form. In the case of the use of identifiable information, the Report states that the research should be subject to independent ethics review with the onus on the person seeking to use the information without consent to demonstrate that: (a) a tangible public good of significant benefit will result; (b) consent is impossible to secure at a reasonable cost; (c) less identifiable data will not serve the same purpose; and (d) no harm can occur to any person directly or indirectly [note the above discussion on group privacy] as a result of this use of his or her personal information. E. Disclosure Without Knowledge Or Consent Bill C-54 The comments found under C. and D. above apply equally here. Section 7(3) adds further instances when collected information can be disclosed to others without knowledge or consent. CMA Code In the case of health information CMA takes a far more restrictive approach. In the case of use, disclosure or access the CMA Code states: The potential that health information, in whole or in part, may be subsequently collected, used, disclosed or accessed for other purposes without their consent, and what those purposes might be, must be made know to the patient by reasonable means before it is confided or collected for primary purposes. Moreover, the CMA Code recognizes that information disclosed by one organization is collected by another. The Code defines collection to mean: the act of accessing, receiving, compiling, gathering, acquiring or obtaining health information from any source, including third parties, and by any means. It includes information collected from the patient, as well as secondary collection of this information in whole or in part by another provider or user. The collecting organization should be bound by the provisions of the CMA Code, which generally requires consent for use for any purpose and always requires knowledge of the potential purposes that information will or must be put to prior to the information being disclosed. CMA’s Code states: Health information custodians must ensure that third parties privy to health information have adopted this Code or are bound by equivalent provisions. Finally, the CMA Code explicitly recognizes that information can be retrieved from a variety of sources to formulate records. Any and all such practices and the composite form developed are given the same degree of protection as that accorded the original data collected by or through the patient. F. Information Flow Within Organizations Bill C-54 Bill C-54 defines use to include, “the transfer of personal information within an organization.” Therefore, to the extent that Bill C-54 restricts the free flow of information it restricts in within an organization. In the health care context this is not a reasonable or desirable outcome. CMA Code The CMA Code recognizes that the free flow of health information is desirable to the extent that it furthers the provision of the health care benefit sought and that it occurs with patient consent. The CMA Code defines the primary purpose to mean: (i) Primary therapeutic purpose is the initial reason for a patient seeking or receiving care in the therapeutic context, and pertains to the delivery of health care to a particular patient with respect to the presenting health need or problem. It encompasses consultation with and referral to other providers on a need-to-know basis. (ii) Primary longitudinal purpose concerns developing composite health information about a particular patient, such as a detailed medical history, beyond direct application to the presenting health need or problem, in order to enhance ongoing care to that person. The Code goes on to state that: Health information collection, use, disclosure or access for the primary therapeutic and longitudinal purposes may be as extensive as necessary to fulfil these purposes and reflect the high level of trustworthiness and accountability of health professionals in the therapeutic context. And further states that: Security safeguards shall impede as little as possible health information collection, use, access and disclosure for primary purposes. Finally, in addressing consent the Code states: Consent to health information collection, use, disclosure and access for the primary therapeutic purpose may be inferred. Consent to subsequent collection, use, disclosure and access on a need-to-know basis by or to other physicians or health providers for this purpose, and for this purpose alone, may be inferred, as long as there is no evidence that the patient would not give express consent to share the information. G. Individual Access Bill C-54 Bill C-54 restricts the right of individual access to personal information. The grounds for denying access to information are inappropriate in the health care context. CMA Code The CMA Code follows the prevailing case law as it relates to medical records. Primarily this gives the patients a right of access to their record in all but very limited circumstances. These circumstances are, if there is a significant likelihood of a substantial adverse effect on the physical, mental or emotional health of the patient or substantial harm to a third party. The onus lies on the provider to justify denial of access. H. Accuracy and Amendment Bill C-54 Bill C-54 requires that information be as accurate, complete and up-to-date as possible and that it shall not be routinely updated unless this is necessary to fulfil the purpose for its collection. In so far as amendment is concerned, Bill C-54 permits amendment to the record in specified circumstances. CMA Code The CMA Code takes a different approach in light of the nature and purpose of health information. The Code recognizes that the “recording of statements of fact, clinical judgements and determinations or assessments should reflect as nearly as possible what has been confided by the patient and what has been ascertained, hypothesized or determined to be true using professional judgement.” In terms of amending the record in light of a patient’s request, the CMA Code seeks to preserve the original record but also note the patient’s concerns. To accommodate both requirements the CMA Code states: Patients who have reviewed their information and believe it to be inaccurately recorded or false have the right to suggest amendments and to have their amendments appended to the health information. I. Sensitivity Bill C-54 In a number of instances Bill C-54 and in particular schedule 1 recognize that medical records have a high level of sensitivity attached. Which in turns warrants special attention concerning consent, reasonable expectations, individual access and implicity, the degree of security that is appropriate. CMA Code The CMA Code seeks to recognize that while all health information is sensitive (when considered against other forms of information about individuals) there are also variations in the level of sensitivity in various aspects of the health record. The CMA Code defines the “sensitivity of health information” to refer to: the patient’s interest in keeping the information secret. It varies according to the nature of the information, its form, and the potential negative repercussions of its collection, use or disclosure on the patient’s interests. Under the Code’s consent provisions it is stated that: Although all health information is sensitive and should be treated as such, the more sensitive the health information is likely to be, given what is known about the circumstances or preferences of the patient, the more important it is to ensure that consent is voluntary and informed. With respect to security the Code states: The development of security safeguards with respect to levels of access for various users shall recognize the differences in the sensitivity of health information and permit access accordingly. V. Conclusions The increased capacity to collect, store, transfer, merge and access information coupled with trends that support increased use of and access to information have the potential to erode our traditional understanding and protection of privacy and confidentiality. The issues are complex and the choices we must make are difficult. Nevertheless, these issues should be squarely on the table and the choices that we make must be clear, transparent and defensible. Of paramount importance is that the public is not mislead into believing that their information is being protected or kept confidential when in fact it is not. Therefore, even to refer to Bill C-54 as the “Personal Information Protection and Electronic Documents Act” should be the subject of debate. Is the Bill truly about information protection or is it actually about permitting access to information? Bill C-54 presents one approach, an approach that values commerce and access. In CMA’s view the approach is totally inadequate when applied to health information. CMA also believes that the public would also find Bill C-54 inadequate. CMA presents a different approach, an approach that values privacy and the preservation of the trust and integrity of the patient-physician relationship. CMA believes that its approach would receive broad public support. Moreover, CMA believes that to the extent the CMA Code presents tests rather than conclusions, these tests should be administered in good faith prior to legislative initiatives related to health information or in the case of secondary usage of health information in general. CMA believes that its approach draws support from the Federal Advisory Council Report, which also recognizes the importance of preserving patient privacy and the confidentiality of the health record in an era of increased use of technology. Implicitly, the Report recognizes that the benefits of such technology cannot be realized if public support, based on assurance of privacy protection, cannot be secured. CMA urges this committee to implement CMA’s recommendations and in doing so provide the type of protection that health information deserves and that Canadians desire. VI. Summary of Recommendations That Bill C-54 be amended to incorporate specific provisions relating to health information and that the provisions of the CMA Code provide the basis of such provisions; and That the proposed rules for health legislation be subject to the legislative test found in CMA’s Code and formulated in light of this process; and That there be a clear definition of the information being accorded a right of privacy and that this definition, at least in the case of health information, include identifiable information, delinked information, anonymous information and any composite form produced when information is linked to any information about a person from any other source; and That, at least in connection with health information, the provisions of the Bill apply equally to the public and the private sectors.
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Cannabis for Medical Purposes

https://policybase.cma.ca/en/permalink/policy10045
Last Reviewed
2019-03-03
Date
2010-12-04
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Policy document
Last Reviewed
2019-03-03
Date
2010-12-04
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
The Canadian Medical Association (CMA) has always recognized the unique requirements of those individuals suffering from a terminal illness or chronic disease for which conventional therapies have not been effective and for whom cannabis may provide relief. However, there are a number of concerns, primarily related to the limited evidence to support many of the therapeutic claims made regarding cannabis for medical purposes, and the need to support health practitioners in their practice.1,2,3,4 While the indications for using cannabis to treat some conditions have been well studied, less information is available about many potential medical uses. Physicians who wish to authorize the use of cannabis for patients in their practices should consult relevant CMPA policy5 and guidelines developed by the provincial and territorial medical regulatory authorities to ensure appropriate medico-legal protection. The CMA’s policy Authorizing Marijuana for Medical Purposes6, as well as the CMA’s Guidelines For Physicians In Interactions With Industry7 should also be consulted. The CMA makes the following recommendations: 1. Increase support for the advancement of scientific knowledge about the medical use of cannabis. The CMA encourages the government to support rigorous scientific research into the efficacy for therapeutic claims, safety, dose-response relationships, potential interactions and the most effective routes of delivery, and in various populations. 2. Apply the same regulatory oversight and evidence standards to cannabis as to pharmaceutical products under the Food and Drug Act, designed to protect the public by the assessment for safety and efficacy. 3. Increase support for physicians on the use of cannabis for medical purposes in their practice settings. As such, CMA calls on the government to work with the CMA, The College of Family Physicians of Canada, the Royal College of Physicians and Surgeons, 2 and other relevant stakeholders, to develop unbiased, accredited education options and licensing programs for physicians who authorize the use of cannabis for their patients based on the best available evidence. Background In 2001, Health Canada enacted the Marihuana Medical Access Regulations (MMAR). These were in response to an Ontario Court of Appeal finding that banning cannabis for medicinal purposes violated the Charter of Rights and Freedoms.8 The MMAR, as enacted, was designed to establish a framework to allow legal access to cannabis, then an illegal drug, for the relief of pain, nausea and other symptoms by people suffering from serious illness where conventional treatments had failed. While recognizing the needs of those suffering from terminal illness or chronic disease, CMA raised strong objections to the proposed regulations. There were concerns about the lack of evidence on the risks and benefits associated with the use of cannabis. This made it difficult for physicians to advise their patients appropriately and manage doses or potential side effects. The CMA believes that physicians should not be put in the untenable position of gatekeepers for a proposed medical intervention that has not undergone established regulatory review processes as required for all prescription medicines. Additionally, there were concerns about medico-legal liability, and the Canadian Medical Protective Association (CMPA), encouraged those physicians that were uncomfortable with the regulations to refrain from authorizing cannabis to patients. Various revisions were made to the MMAR, and then these were substituted by the Marihuana for Medical Purposes Regulations (MMPR) in 2013/ 2014 and subsequently by the Access to Cannabis for Medical Purposes Regulations (ACMPR) in 2016 and now as part of the Cannabis Act (Section 14)9. Healthcare practitioners that wish to authorize cannabis for their patients are required to sign a medical document, indicating the daily quantity of dried cannabis, expressed in grams. For the most part, these revisions have been in response to decisions from various court decisions across the country.10,11,12 Courts have consistently sided with patients’ rights to relieve symptoms of terminal disease or certain chronic conditions, despite the limited data on the effectiveness of cannabis. Courts have not addressed the ethical position in which physicians are placed as a result of becoming the gate keeper for access to a medication without adequate evidence. The CMA participated in many Health Canada consultations with stakeholders as well as scientific advisory committees and continued to express the concerns of the physician community. As previously noted, the Federal government has been constrained by the decisions of Canadian courts. 3 The current state of evidence regarding harms of cannabis use is also limited but points to some serious concerns. Ongoing research has shown that regular cannabis use during brain development (up to approximately 25 years old) is linked to an increased risk of mental health disorders including depression, anxiety, and schizophrenia, especially if there is a personal or family history of mental illness. Long term use has also been associated with issues of attention, impulse control and emotional regulation. Smoking of cannabis also has pulmonary consequences such as chronic bronchitis. It is also linked to poorer pregnancy outcomes. Physicians are also concerned with dependence, which occurs in up to 10% of regular users. From a public and personal safety standpoint, cannabis can impact judgement and increases the risk of accidents (e.g. motor vehicle incidents). For many individuals, cannabis use is not without adverse consequences.3,13,14 Pharmaceutically prepared alternative options, often administered orally, are also available and regulated in Canada.15 These drugs mimic the action of delta-9-tetra-hydrocannabional (THC) and other cannabinoids and have undergone clinical trials to demonstrate safety and effectiveness and have been approved for use through the Food and Drug Act. Of note is that in this format, the toxic by-products of smoked marijuana are avoided.16 However, the need for more research is evident. Approved by the CMA Board in December 2010. Last reviewed and approved by the CMA Board in March 2019. References 1 Allan GM, Ramji J, Perry D, et al. Simplified guideline for prescribing medical cannabinoids in primary care. Canadian Family Physician, 2018;64(2):111-120. Available: http://www.cfp.ca/content/cfp/64/2/111.full.pdf (accessed 2019 Jan 8). 2 College of Family Physicians of Canada (CFPC). Authorizing Dried Cannabis for Chronic Pain or Anxiety: Preliminary Guidance. Mississauga: CFPC; 2014. Available: https://www.cfpc.ca/uploadedFiles/Resources/_PDFs/Authorizing%20Dried%20Cannabis%20for%20Chronic%20Pain%20or%20Anxiety.pdf (accessed 2019 Jan 8). 3 The National Academies of Sciences, Engineering and Medicine. The health effects of cannabis and cannabinoids: the current state of evidence and recommendations for research. Washington, DC: National Academies Press; 2017. 4 Whiting PF, Wolff RF, Deshpande S, et al. Cannabinoids for medical use: a systematic review and meta-analysis. JAMA 2015;313(24):2456-73. 5 Canadian Medical Protective Association (CMPA). Medical marijuana: considerations for Canadian doctors. Ottawa: CMPA; 2018. Available: https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2014/medical-marijuana-new-regulations-new-college-guidance-for-canadian-doctors (accessed 2019 Jan 8). 6 Canadian Medical Association (CMA). Authorizing marijuana for medical purposes. Ottawa: CMA; 2014. Available: https://policybase.cma.ca/en/permalink/policy11514 http://policybase.cma.ca/dbtw-wpd/Policypdf/PD15-04.pdf (accessed 2019 Jan 8). 7 Canadian Medical Association. (CMA) Guidelines for Physicians In Interactions With Industry. Ottawa: CMA; 2007. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD08-01.pdf. (accessed 2019 Jan22). 4 8 R. v. Parker, 2000 CanLII 5762 (ON CA). Available: http://canlii.ca/t/1fb95 (accessed 2019 Jan 8). 9 Cannabis Act. Access to Cannabis for Medical Purposes. Section 14. 2018. Available: https://laws-lois.justice.gc.ca/eng/regulations/SOR-2018-144/page-28.html#h-81 (accessed 2019 Jan 8). 10 Hitzig v. Canada, 2003 CanLII 3451 (ON SC). Available: http://canlii.ca/t/1c9jd (accessed 2019 Jan 8). 11 Allard v. Canada, [2016] 3 FCR 303, 2016 FC 236 (CanLII), Available: http://canlii.ca/t/gngc5 (accessed 2019 Jan 8). 12 R. v. Smith, 2014 ONCJ 133 (CanLII). Available: http://canlii.ca/t/g68gk (accessed 2019 Jan 8). 13 Volkow ND, Baler RD, Compton WM, Weiss SRB. Adverse health effects of marijuana use. N Engl J Med. 2014;370(23):2219–2227. 14 World Health Organization. The health and social effects of nonmedical cannabis use. Geneva: World Health Organization; 2016. Available: https://www.who.int/substance_abuse/publications/msbcannabis.pdf (accessed 2019 Jan 8). 15 Ware MA. Is there a role for marijuana in medical practice? Can Fam Physician 2006;52(12):1531-1533. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1952544/pdf/0530022a.pdf (accessed 2019 Jan 8). 16 Engels FK, de Jong FA, Mathijssen RHJ, et.al. Medicinal cannabis in oncology. Eur J Cancer. 2007;43(18):2638-2644. Available: https://www.clinicalkey.com/service/content/pdf/watermarked/1-s2.0-S0959804907007368.pdf?locale=en_US (accessed 2019 Jan 8).
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Management of physician fatigue

https://policybase.cma.ca/en/permalink/policy11127
Last Reviewed
2019-03-03
Date
2014-05-24
Topics
Health human resources
  1 document  
Policy Type
Policy document
Last Reviewed
2019-03-03
Date
2014-05-24
Topics
Health human resources
Text
Health systems around the world are struggling with how to best meet the health needs of their populations. Health leaders speak with urgency about the need to improve the individual experience of care, improve the health of populations, and maximize return on investments. Physicians concur - they are continually focused on providing better care to their patients. Concurrently, concerns over patient safety have arisen over the last two decades, rooted in studies of adverse events. The incidence of adverse events (AEs) in acute care hospitals has been reported in the United States (US),1,2,3 Australia,4 United Kingdom,5 and Canada.6 Between 5% and 20% of patients admitted to hospital experience one or more AEs; between 36.9% - 51% of these AEs are preventable; and AEs contribute billions of dollars through additional hospital stays as well as other costs to the system, patients and the broader society.7 Leape et al. maintain that more than two-thirds of AEs are preventable.8 These outcomes have prompted decision makers, policy makers and healthcare providers to examine contributing factors, including the increasingly complex health system and its impact on the well-being of providers. Patient safety and physician well-being are the key drivers leading to restrictions on resident and/or physician duty hours aimed at reducing their fatigue. The European Working Time Directive (EWTD) was first established in 1993 to place limits on all workers' hours throughout Europe under the umbrella of health and safety legislation. That directive included physicians but excluded doctors in training. In 2000, a new directive passed to include the "junior doctor" constituency accompanied by a requirement that by 2009 all health systems in the European Union limit resident work to a maximum of 48 hours averaged per week. The intention was to improve the working lives of doctors in training and to increase patient safety. A systematic review on the impact of the EWTD on postgraduate medical training, patient safety, or clinical outcomes found studies to be of poor quality with conflicting results.9 In 2003, the Accreditation Council for Graduate Medical Education (ACGME) in the US adopted a set of duty hour regulations for physicians in training. The ACGME issued revised regulations that went into effect in July 2011, reflecting the recommendations of a 2008 Institute of Medicine report Resident Duty Hours: Enhancing Sleep, Supervision, and Safety, calling for elimination of extended duty shifts (more than 16 hours) for first year residents, increasing days off, improving sleep hygiene by reducing night duty and providing more scheduled sleep breaks, and increasing oversight by more senior physicians.10 The Institute of Medicine's report bases its recommendations on the growing body of research linking clinician fatigue and error. In 2013, the National Steering Committee on Resident Duty Hours released Canada's first comprehensive, collaborative and evidence-based report on fatigue and duty hours for Canada's approximately 12,000 residents. The Committee stresses that a comprehensive approach is necessary in order to enhance safety and wellness outcomes. Fatigue risk management is a predominant theme in the recommendations. Fatigue management systems are in place in other sectors/industries that have a low threshold for adverse outcomes including aviation, transportation, and the Department of National Defence. In 2010, the Canadian Nurses Association released a position statement Taking Action on Nurse Fatigue that speaks to system, organizational and individual level responsibilities of registered nurses. There are currently no specific policies in Canada for physicians in practice with respect to fatigue management. Given the heterogeneity of medical practice (i.e. various specialties) and of the practice settings (i.e. rural and remote versus urban, clinic versus hospital, etc.), the solutions emanating from a fatigue management policy may be different - one size will not fit all. Impact of Physician Fatigue Patient Safety Sleep deprivation is the condition of not having enough sleep and can be either chronic or acute. It impairs cognitive and behavioural performance. "Sleep is required for the consolidation of learning and for the optimal performance of cognitive tasks. Studies of sleep deprivation have shown that one night without sleep negatively affects the performance of specific higher cognitive functions of the prefrontal cortex and can cause impairment in attention, memory, judgment, and problem solving."(p. 1841)11 A seminal study by Williamson and Feyer found that after 17-19 hours without sleep, performance on some cognitive and motor performance tests was equivalent or worse than that at a blood alcohol concentration (BAC) of 0.05%.12 Wakefulness for 24 hours is equivalent to a blood alcohol level of 0.10%.13 A chronic sleep-restricted state can cause fatigue, which is a subjective feeling of tiredness, lack of energy and motivation. A large body of research exists linking sleep deprivation/fatigue, performance and adverse patient outcomes, particularly for medical residents. 14,15,16,17,18,19, 20, 21,22, 23,24 However, literature on the impact on performance varies based on a number of factors. There are significant inter-individual differences in the global response to sleep loss, as well as significant intra-individual variations in the degree to which different domains of neurobehavioral function (e.g., vigilance, subjective sleepiness, and cognitive performance) are affected. Inter-individual differences are not merely a consequence of variations in sleep history. Rather, they involve trait-like differential vulnerability to impairment from sleep loss. 25 Evidence suggests an inconclusive relationship between duty hour reductions (primarily those implemented in the US) and patient safety, suggesting that restrictions on consecutive duty hours have not had the anticipated impact on this crucial outcome as anticipated.26 Several large studies have revealed only neutral or slightly improved patient mortality and other clinical parameters since implementation of the ACGME work hour limits in the US.27,28, 29,30 In complex and ever changing health systems, it is difficult to isolate the impact of restricted duty hours alone. Research on the effects of practicing physician sleep deprivation and extended work shifts on clinical outcomes is limited and inconclusive.31, 32 The issue of physician fatigue is complex, and is affected by much more than duty hours. Other contributing factors affect performance including work patterns, individual response to sleep loss, experience of the worker, the context of which sleep deprivation is necessary, hours of actual sleep, patient volume, patient turnover and patient acuity, environmental factors, personal stressors, workload, etc. Limiting work hours alone is not sufficient to address sleep deprivation among physicians. Reduced or disturbed periods of sleep, more consecutive days or nights of work, shift variability, and the volume of work all increase fatigue and thus can contribute to errors. One of the biggest concerns with a fatigue management strategy is continuity of care, linked to the number of transfers of care (handover) among providers. Transfers of care inevitably increase in an environment of work hour limitations.33, 34 Handovers are considered critical moments in the continuity of patient care and have been identified as a significant source of hospital errors, often related to poor communication. There is a growing body of literature on how to do these well and how to teach this well. This is an important skill for physicians in the context of a fatigue management strategy: "Standardization of the handover process has been linked to a reduction in the number of errors related to information transfers. In addition, effective mechanisms for the transfer of information at transition points have been recognized as patient safety enablers."35 Provider Well-being Provider well-being (physical, mental, occupational) is linked to system performance and patient outcomes. It is affected by fatigue and work patterns including night shift and extended hours. Comprehensive, systematic reviews of the health effects of on-call work in 2004 showed that nighttime work interrupted sleep patterns, aggravated underlying medical conditions, and increased the risk of cardiovascular, gastrointestinal, and reproductive dysfunction.36,37.38 Other research suggests an elevated risk of breast cancer,39,40 prostate cancer,41 colorectal cancer,42 asthma43, diabetes,44 and epilepsy45 for shift workers. Disruption of the body's circadian rhythms is thought to be one of the main pathways for adverse health effects from shift work, particularly for work schedules that involve night work. Given that 24-hour work is unavoidable in various industries, including healthcare, researchers have evaluated different shift schedules designed to reduce some of the negative health effects of working at night. Optimal shift schedules are aligned as much as possible with the circadian rhythm, promote adaptation of the circadian rhythm with shift work, reflect workers' needs and preferences, and meet organizational or productivity requirements. The following interventions appear to have the most beneficial effects on the health of shift workers:46 * Schedule changes including changing from backward (counterclockwise) to forward (clockwise) rotation, from eight hour to 12 hour shifts, and flexible working conditions, self-scheduling, and ergonomic shift scheduling principles * Controlled exposure to light and day; * Behavioural approaches such as physical activity, scheduled naps and education about sleep strategies; and * Use of pharmacotherapy (i.e. caffeine and melatonin) to promote sleep, wakefulness, or adaptation Sleep deprivation and on-call shifts consistently point to deterioration of mood resulting in depression, anger, anxiety, hostility, and decreased vigilance.47 ,48, 49 A Canadian study found that shift workers reported significantly higher burnout, emotional exhaustion, job stress and psychosomatic health problems (e.g. headaches, upset stomach, difficulty falling asleep) than workers on a regular day schedule.50 Prolonged duty hours by residents has been found to contribute to marital problems, pregnancy complications, depression, suicide and substance abuse,51 as well as serious conflicts with attending physicians, other residents, and nurses, in addition to increased alcohol use and instances of unethical behaviour.52 Surprisingly however, the abolishment of 24-hour continuous medical call duty for general surgery residents at one facility in Quebec was associated with self-reported poorer quality of life.53 In contrast to other recommendations on the health benefits of 8 hr shifts, the risk of a work safety incident increases markedly after more than eight hours on duty. The risk in the twelfth hour is almost double than in the eighth hour (and more than double the average risk over the first eight hours on duty).54 Extended work duration and nighttime work by interns is associated with an increased risk of reported percutaneous injuries (PIs).55 Fatigue was reported more often as a contributing factor for nighttime compared with daytime injuries. Fatigue was also more commonly reported as a contributing factor to PIs that occurred after extended work than those that occurred after non-extended work.56 Other research found that residents were most exposed to blood-borne pathogens through needle punctures or cuts during overnight duty periods.57 Health care facilities that have physicians working in them have a role in supporting and promoting provider well-being, including providing enablers of extending and continuing resiliency such as nutritious food, on call rooms, appropriate numbers of staff, locums, etc. They also have a role in working jointly and collaboratively with physicians to ensure that on-call schedules do not place work demands on individual physicians that prevent the physicians from providing safe patient care and service coverage. For example, research with emergency physicians suggests that a nap at 3 AM improves performance in physicians and nurses at 7:30 AM compared to a no-nap condition despite the fact that memory temporarily worsened immediately after the nap.58 Individual resilience, intergenerational differences, illness-related issues, as well as family commitments also need to be considered. Physicians should also be encouraged to take the necessary time to rest and recover on their time off. The obligation of physicians to provide after hour coverage and care is unavoidable and should be considered by an individual when they choose a career in medicine, and as a physician in managing their schedule/call. A review of 100 studies from around the world indicates the culture of medicine contributes to doctors ignoring the warning signs of fatigue and stress and in many cases suffering from undiagnosed ailments such as stress and depression, or from burnout.59 The authors suggest the culture of medicine is such that doctors feel they don't need help; they put their patients first. Of the 18% of Canadian doctors who were identified as depressed, only a quarter of them considered getting help and only two per cent actually did. The report suggests that burnout from working long hours and sleep deprivation because of understaffing seems to be the biggest problem worldwide.60 The Canadian Medical Protective Association (CMPA) states that physicians should consider their level of fatigue and if they are clinically fit to provide treatment or care.61 Fatigue is not a sign of weakness. All members of the health care team should support their colleagues in recognizing and managing sleep deprivation and fatigue. Physician fatigue has several ethical dimensions. The Canadian Medical Association Code of Ethics states that physicians have an ethical responsibility to self-manage their fatigue and well-being. 62 However, physicians must be trained and competent to know their own limits and evaluate their own fatigue level and well-being. The system must then support physicians in this recognition. The doctrine of informed consent is another dimension of physician fatigue. If physician fatigue is an added risk for any aspect of patient care, whether it is surgical or medical, elective or emergent, then some have argued that the doctrine of informed consent suggests that physicians have an obligation to inform patients of that risk.63 ,64 "The medico-legal considerations for physicians centre on the ethical duty to act in the best interests of their patients. This may mean that if a physician feels that his or her on-call schedule endangers or negatively impacts patient care, reasonable steps are taken to ensure patients do not suffer as a result and that the physician is able to continue providing an adequate level of care for patients."65 System Performance Addressing physician fatigue may have workforce implications. Physician workload is multifaceted comprised of clinical, research, education and administrative activities. If physician workload or duty hours are reduced, any one of these activities may be impacted. It has been suggested that implementing fatigue management strategies such as a workload ceiling for physicians may result in a greater need for physicians and thus increase system costs. However, new models of team based care delivery that incorporate technology, reduce redundancy, utilize a team based approach, and optimize the role of physicians offer an opportunity to better manage physician fatigue without necessarily requiring more physicians. Other strategies also need to be explored to improve the on-the-ground efficiency of physicians. Some of the strategies to address practicing physician sleep deprivation/fatigue such as scheduling changes and reduced workload may affect access to care, including wait times. Surgeons or others may have to cancel surgeries or other procedures because of fatigue and hours of work, forcing rescheduling of surgery/procedures and potentially increasing wait times. This is particularly relevant given Canada's large geography and varied distribution of physicians. Therefore, flexibility in strategies to address physician sleep deprivation/fatigue are needed to reflect the variety of practice types and settings in existence across the country, in particular solo practices; rural, remote and isolated sites; community locations; etc. The same holds true for smaller specialties, which has been the experience in the UK with the implementation of the EWTD. Fatigue management is a competency that needs to be taught, modelled, mentored, and evaluated across the medical education continuum, from medical student to practicing physician. Recommendations 1. Educate physicians about the effects of sleep deprivation and fatigue on the practice of medicine and physician health, and how to recognize and manage their effects. 2. Create a national tool-box of self-awareness tools and fatigue management strategies and techniques. 3. Advocate for the integration of fatigue management into the continuum of medical education. 4. Advocate for the creation of system enablers with the flexibility to: * Consider the full workload of physicians (clinical, teaching, administrative, research, etc.); * Optimize scheduling to coordinate on call and other patient care following call; and * Implement organizational/institutional level fatigue risk management plans. 5. Develop and advocate for implementation of standardized handover tools. 6. Enhance and reaffirm a culture within medicine that focuses on patient-centered care. 7. Reaffirm the culture shift within medicine that encompasses physician well-being. 8. Encourage physicians treating physicians to be aware of the aggravating effects of fatigue on their well-being and practice. Conclusion Physicians are interested in how to best meet the needs of the population, in continually improving the care provided to Canadians. To do so requires that they also care for themselves including managing the effects of sleep deprivation and fatigue. It is a complex issue that requires multifaceted solutions. Strategies must address physician fatigue at an individual, organizational/institutional and system level. References 1 Leape, LL, Brennan, TA, Laaird, N, Lawthers, AG, Logalio, AR, Barnes, BA et al. (1991).The nature of adverse events in hospitalized patients. New England Journal of Medicine 324 (6): 377-384 2 Brennan, TA, Leape, LL, Nan, M, et al. (1991). Incidence of adverse events and negligence in hospitalized patients: Results of the Harvard Medical Practice Study I. New England Journal of Medicine 324:370-376. 3 Thomas, E., Studdert, D., Burstin, H., et al. (2000). Incidence and types of adverse events and negligent care in Utah and Colorado. Medical Care 38(3): 261-71. 4 Wilson, RL, Runciman, WB, Gibberd, RW, et al. (1995). The Quality in Australian Health Care Study. Medical Journal of Australia 163: 458-471. 5 Vincent, C, Neale, G, & Woloshynowych, M. (2001). 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Mortality Among Patients in VA Hospitals in the First 2 Years Following ACGME Resident Duty Hour Reform. JAMA 298(9): 984-992. 29 Antiel, R., Reed, D., Van Arendonk, K., Wightman, S., Hall, D., Porterfield, J., et al. (2013). Effects of Duty Hour Restrictions on Core Competencies, Education, Quality of Life, and Burnout Among General Surgery Interns. JAMA Surg 148(5):448-455. 30 Drolet, B., Sangisetty, S., Tracy, T., & Cioffi, W. (2013). Surgical Residents' Perceptions of 2011 Accreditation Council for Graduate Medical Education Duty Hour Regulations. JAMA Surg 148(5): 427-433. 31 Chang, L., Mahoney, J., Raty, S., Ortiz, J., Apodaca, S., & De La Garza II, R. (2013). Neurocognitive effects following an overnight call shift on faculty anesthesiologists. Acta Anaesthesiol Scand 57: 1051-1057. 32 Sharpe, J., Weinberg, J., Magnotti, L., Nouer, S., Yoo, W., Zarzaur, B. et al. (2013). Outcomes of Operations Performed by Attending Surgeons after Overnight Trauma Shifts. J Am Coll Surg 216:791- 799. 33 Olsen, E., Drage, L., Auger, R. (2009). Sleep Deprivation, Physician Performance, and Patient Safety. Chest 136: 1389-1396. 34 Choma, N., Vasilevskis, E., Sponsler, K., Hathaway, J., & Kripalani, S. Effect of the ACGME 16-Hour Rule on Efficiency and Quality of Care: Duty Hours 2.0. JAMA INTERN MED 173 (9): 819-821. 35 Canadian Medical Protective Association. (2013). CMPA Risk Fact Sheet: Patient Handover. Retrieved January 13, 2014 from https://oplfrpd5.cmpa-acpm.ca/documents/10179/300031190/patient_handovers-e.pdf 36 Nicol, A., Botterill, J., (2004). On-call Work and Health: A Review. Environmental Health 3: 1-11. 37 Knutsson, A. & Boggild, H. (2010). Gastrointestinal disorders among shift workers. Scand J Work Environ Health 36(2): 85-95. 38 Vyas, M., Garg, A., Iansavichus, A., Costella, J., Donner, A., Laugsand, L., et al. (2012). Shift work and vascular events: systematic review and meta-analysis. British Medical Journal 345: e4800 doi: 10.1136/bmj.e4800 39 Shields, M. (2002). Shift work and health. Health Reports 13(4):11-33. 40 Fritschi, L., Glass, D., Heyworth, J., Aronson, K., Girschik, J., Boyle, T., et al. (2011). Hypotheses for mechanisms linking shiftwork and cancer. Medical Hypotheses 77:430-436. 41 Kubo, T., Ozasa, K., Mikami, K., Wakai, K., Fujino, Y., Watanabe, Y., et al. (2006). Prospective cohort study of the risk of prostate cancer among rotating-shift workers: findings from the Japan Collaborative Cohort Study. American Journal of Epidemiology 164(6): 549-555. 42 Schernhammer, E., Laden, F., Speizer, F., Willett, W., Hunter, D., Kawachi, I., et al. (2003). Night-shift work and risk of colorectal cancer in the Nurses' Health Study. Journal of the National Cancer Institute 95(11):825-828. 43 Shields, M. (2002). Shift work and health. Health Reports 13(4):11-33. 44 Ibid 45 Ibid 46 Occupational Cancer Research Centre and the Institute for Work & Health. 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Stress and Health 20:113-119. 51 Woodrow, S., Segouin, C., Armbruster, J., Hamstra, S., & Hodges, B. (2006). Duty Hours Reforms in the United States, France and Canada: Is It Time to Refocus our Attention on Education? Academic Medicine 81(12): 1045-1051. 52 Baldwin, D., Daugherty, S., Tsai, R., et al. (2003). A National Survey of Residents' Self-reported Work Hours: Thinking Beyond Specialty. Academic Medicine 78:1154-1163. 53 Hamadani, F., Deckelbaum, D., Sauve, D., Khwaja, K., Razek, T., & Fata, P. (2013). Abolishment of24-HourContinuousMedical Call Duty in Quebec: A Quality of Life Survey of General Surgical Residents Following Implementation of the New Work-Hour Restrictions. J Surg 70: 296-303. 54 Folkard, S. & Tucker, P. (2003). Shift work, safety and productivity. Occupational Medicine 53: 95-101. 55 Ayas, N., Barger, L., Cade, B., et al. (2006). Extended Work Duration and the Risk of Self-reported Percutaneous Injuries in Interns. JAMA 296(9): 1055-62. 56 Ayas, N., Barger, L., Cade, B., et al. (2006). Extended Work Duration and the Risk of Self-reported Percutaneous Injuries in Interns. JAMA 296(9): 1055-62. 57 Parks, D., Yetman, R., McNeese, M., Burau, K., & Smolensky, M. (2000). Day-night pattern in accidental exposures to blood-borne pathogens among medical students and residents. Chronobiology International 17(1): 61-70. 58 Smith-Coggins, R., Howard, S., Mac D., Wang, C., Kwan, S., Rosekind, M., Sowb, Y., Balise, R., Levis, J., Gaba, D. (2006). Improving alertness and performance in emergency department physicians and nurses: the use of planned naps. Ann Emerg Med, 48(5): 596-604. 59 Wallace, J., Lemaire, J., & Ghali, W. (2009). Physician wellness: a missing quality indicator. The Lancet 374 (9702): 1714-1721. 60 Wallace, J., Lemaire, J., & Ghali, W. (2009). Physician wellness: a missing quality indicator. The Lancet 374 (9702): 1714-1721. 61 Canadian Medical Protective Association. The new realities of medical care. Originally published September 2012. Retrieved January 12, 2014 from https://oplfrpd5.cmpa-acpm.ca/en/duties-and-responsibilities/-/asset_publisher/bFaUiyQG069N/content/the-new-realities-of-medical-care 62 Canadian Medical Association. (2011). Canadian Medical Association Code of Ethics. Ottawa: Author. 63 Mercurio. M. & Peterec, S. (2009). Attending Physician Work Hours: Ethical Considerations and the Last Doctor Standing. Pediatrics 124:758-762. 64 Czeisler, C., Pellegrini, C., & Sade, R. (2013). Should Sleep-Deprived Surgeons Be Prohibited From Operating Without Patients' Consent? Ann Thorac Surg 95:757-766. 65 Canadian Medical Protective Association. The new realities of medical care. Originally published September 2012. Retrieved January 12, 2014 from https://oplfrpd5.cmpa-acpm.ca/en/duties-and-responsibilities/-/asset_publisher/bFaUiyQG069N/content/the-new-realities-of-medical-care
Documents
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Medical assistance fund

https://policybase.cma.ca/en/permalink/policy11699
Last Reviewed
2019-03-03
Date
2014-08-20
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Resolution
GC14-85
The Canadian Medical Association recommends that the federal government establish a medical assistance fund to enable people residing in Canada who have no medical coverage to receive critical emergency medical care
Policy Type
Policy resolution
Last Reviewed
2019-03-03
Date
2014-08-20
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Resolution
GC14-85
The Canadian Medical Association recommends that the federal government establish a medical assistance fund to enable people residing in Canada who have no medical coverage to receive critical emergency medical care
Text
The Canadian Medical Association recommends that the federal government establish a medical assistance fund to enable people residing in Canada who have no medical coverage to receive critical emergency medical care
Less detail

Towards a Sustainable Health Care System in the New Millennium : Submission to the House of Commons Standing Committee on Finance 2000 Pre-Budget Consultation Process

https://policybase.cma.ca/en/permalink/policy1977
Last Reviewed
2018-03-03
Date
1999-09-10
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
  2 documents  
Policy Type
Parliamentary submission
Last Reviewed
2018-03-03
Date
1999-09-10
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Text
On the cusp of the new millennium, it is appropriate to reflect with pride on our nation's past and to plan with compassion, innovation and creativity for our nation's future. The new century will present us with many challenges-an ageing population, increased knowledge with corresponding advances in technology and research, competitiveness at home and abroad- to meet the needs of Canadians. CMA recognizes that we live in a world that is increasingly interdependent. A world where globalization has meant that we, as a country, must look forward and beyond our borders when it comes to determining how we can reach our collective potential. [BOX CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [BOX END] As we plan for the future it is vital to recognize the importance of the social programs that must remain essential features of our society. Our health care system is an important and defining feature of what it is to be Canadian. CMA believes a well funded, sustainable, quality health care system must be at the forefront of the federal government's strategic priorities. The haste to reduce health care costs over the past several years has left a destabilized and demoralized health system in its wake. Diminished access to critical health care services and insufficient human resources are only part of the legacy. Rebuilding Canadians' confidence in the health care system will not be easy. CMA noted the important first step that was taken by the federal government in its 1999 budget. A reinvestment of $11.5 billion earmarked for health care was an important signal to Canadians. However, with the complete restoration of funds in 2003/04 the health care system will only be back to its 1995 nominal spending levels, some seven years after the fact - with no adjustment for the increasing health care needs of an increased number of more aged Canadians, inflation or economic growth. CMA is encouraged with federal government's recent initiatives to increase health research funding. This is of direct benefit to the health of Canadians; to the health care system; to foster the development of health care as an industry and to ensure our best and brightest medical scientists and health researchers are educated and remain in Canada. However, we know that more needs to be done to ensure innovation and competitiveness. We would like to echo the words of the Prime Minister who said we consider Medicare to be the best example of how good social policy can be good economic policy, too. While reflecting the desire of Canadians to show compassion for their fellow citizens, Medicare also serves as one of our key competitive advantages. A sustained health care system will ensure a healthy population, and a healthy labour force that contributes to the productivity of the nation. In seeking to place the health care system on the road to long-term sustainability, the CMA is committed to working in close partnerships with the federal government and others in identifying, developing and implementing policy initiatives that serve to strengthen Canadians' access to quality health care The CMA looks forward to contributing to the search for solutions. To work with the federal government and others in building a responsive, flexible and sustainable health care system for all Canadians. In this spirit of co-operation the CMA offers the following recommendations: 1. That the federal government fund Canada's publicly financed health care system on a long-term, sustainable basis to ensure quality health care for all Canadians. 2. That the federal government introduce a health-specific portion of federal cash transfers to the provinces and territories to promote greater public accountability, transparency and visibility. 3. That the federal government, at a minimum, increase federal cash for health care by an additional $1.5 billion, effective April 1, 2000. 4. That beginning, April 1, 2001, the federal government fully index the total cash entitlement allocated to health care through the use of a combination of factors that would take into account the changing needs of Canadians based on population growth, ageing, epidemiology, current knowledge and new technologies, and economic growth. 5. That the federal, provincial and territorial governments adopt the guiding principle of national self-sufficiency in the production and retention of physicians to meet the medical needs of the population, including primary to highly specialized medical care, and the requirements for a critical mass for teaching and research. 6. That the federal government establish and fund a national pool of re-entry positions in postgraduate medical education. 7. That the federal government establish a National Centre for Health Workforce Research. 8. That the federal government enhance financial support systems, such as the Canada Student Loans Program, for medical students in advance of any future tuition increase, and ensure that these support systems are set at levels that meet the financial needs of students. 9. That health care services funded by the provinces and territories be zero-rated. 10. That the federal government establish a National Health Technology Fund to increase country-wide access to needed health technologies. 11. That the federal government continue to increase funding for health research on a long-term, sustainable basis. 12. That the federal government commit stable funding for a comprehensive tobacco control strategy; this strategy should ensure that the funds are invested in evidence-based tobacco control projects and programs, which would include programs aimed at prevention and cessation of tobacco use and protection of the public from tobacco's harmful effects. 13. That the federal government support the use of tobacco tax revenues for the purpose of developing and implementing tobacco control programs. 14. That the federal government place a high priority for funding tobacco prevention and evidence-based cessation programs for young Canadians as early as primary school age. 15. That the federal government follow a comprehensive integrated tobacco tax policy a) To implement selective stepwise tobacco tax increases to achieve the following objectives: (1) reduce tobacco consumption, (2) minimize interprovincial/territorial smuggling of tobacco products, and (3) minimize international smuggling of tobacco products; b) To apply the export tax on tobacco products and remove the exemption available on tobacco shipments in accordance with each manufacturers historic levels; and c) To enter into discussions with the US federal government to explore options regarding tobacco tax policy, raising Canadian tobacco price levels in line with or near the US border states, in order to minimize international smuggling. 16. That the dollar limit of RRSPs at $13,500, increase to $15,500 for the year 2000/01. 17. That the federal government explore mechanisms to increase RRSP contribution limits in the future given the delay in achieving pension parity, since 1988. 18. That the 20% Foreign Property Rule for deferred income plans such as Registered Retirement Savings Plans and Registered Retirement Income Funds be increased in 2% annual increments to 30% over a five year period, effective the year 2000. 19. That the federal government explores the regulatory changes necessary to allow easier access to RRSP funds for investment in small and medium-size businesses. 20. That the federal government undertake the necessary steps to creditor-proof RRSPs and RRIFs. I. INTRODUCTION The Canadian Medical Association (CMA) commends the federal government in its second mandate, for continuing with the pre-budget consultation process. This visible and accountable process encourages public dialogue in the consideration and development of finance, economic and social policies of the country. [BOX CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [BOX END] As part of the 2000 pre-budget consultation process, the CMA welcomes the opportunity to submit its views to the House of Commons Standing Committee on Finance, and looks forward to meeting with the Committee at a later date to discuss our recommendations and their rationale in greater detail. II. POLICY CONTEXT Over the past few years, there has been a significant amount of attention placed on the fact that Canada is living in a world that is increasingly interdependent. A world where globalization has meant that we, as a country, must look forward, outward and with others when it comes to determining how we can reach our collective potential. While further political and economic change is likely to continue, it is important to recognize that there are important social programs that must remain essential features of our society. One such program is our health care system - an important and defining feature of what it is to be Canadian. The CMA believes that when it comes to maintaining and enhancing the health of Canadians, a well-funded, sustainable health care system must be at the forefront of the federal government's strategic priorities. By 2002, it is estimated that there will be 2.3 million more Canadians and 444,000 more Canadians over the age of 65. As a consequence, Canada's health care system will continue to face significant challenges in the near future. The pan-Canadian haste of governments across the country to reduce health care costs as quickly as possible over the past several years left a destabilized and demoralized health system in its wake. Diminished access to critical health care services and insufficient human resources are only part of the legacy. The initial federal reinvestment will help ease some of the pressures but it will not be much more than a short-term solution given that expectations and demands on the system will continue to rise. Rebuilding Canadians' confidence in the health care system will not be easy. Reports of overcrowded emergency rooms, physician and nursing shortages, and of patients being sent to the United States for treatment to reduce waiting times will not help restore their faith. The CMA fully recognises the importance of the first step taken by the federal government. However, fundamental questions remain about future steps needed to sustain our cherished health care system over the short-, medium- and long-term - ensuring that all Canadians will have ready access when they or their families are in need. Given this first step, the CMA believes that we must shift our focus to the vision and overarching strategic framework the federal government must develop to ensure that the health care system will be funded on a sustainable basis. In seeking to place the health care system on the road to long-term sustainability, the CMA is committed to working closely with the federal government in identifying, developing and implementing policy initiatives that serve to strengthen Canadians' access to quality health care. III. TOWARDS A SUSTAINABLE HEALTH CARE SYSTEM In its 1999 budget, the federal government took an important first step forward toward stabilizing Canada's health care system. The government announced a five-year fiscal framework, effective April 1, 1999 that reinvested $11.5 billion, on a cumulative basis, in the health care system. While this is an important first step, it must be placed in perspective. The $11.5 billion is a cumulative figure over five consecutive years. On an annual basis, this means that federal cash for health care is scheduled to increase by $2.0 billion for 1999/2000; it will remain at the same level for 2000/01 and then increase by $500 million (to $2.5 billion) in 2001/02, and remain at that level for the years 2002/03 and 2003/04. Only in year 4 does the CHST cash floor increase by a total of $2.5 billion. 1 Restoring $2.5 billion to the Canada Health and Social Transfer (CHST) cash floor in 2002/03, the fourth year of the government's five-year timetable, means that the health system will only be back to its 1995 nominal spending levels, 7 years after the fact - with no adjustment for the increasing health care needs of Canadians, inflation or economic growth. 2 [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [TABLE END] In current dollars, it is estimated that the federal government allocates approximately 41% of CHST cash for health care. Based on a cash floor of $12.5 billion this amounts to $5.13 billion. The CMA recognizes that the federal amount has increased cash by a minimum of $2.0 billion in 1999/00 to $7.13 billion, however, once again this figure must be placed in context; $7.13 billion represents only 9 cents of each dollar spent on health care in Canada. Another way to express the $11.5 billion is to adjust the figure by the number of Canadians (i.e., a per capita basis - see Figure 1). 3 Scenario 1 illustrates nominal per capita federal CHST cash for health care prior to the 1999 budget with projections to 2003/04. In absence of a five-year fiscal framework introduced by the government, federal CHST cash (formerly Established Programs Financing and the Canada Assistance Plan) would have gone from $247 in 1990/01 to $163 per Canadian in 2003/04 - a decrease of 34%. Adjusting for inflation, federal CHST cash for health care would have dropped from $247 to $131 per Canadian - a decrease of 47%. With the introduction of the $11.5 billion in 1999 (Scenario 2), nominal per capita CHST cash for health care increases from $168 to $233 in 1999/00. This, however, falls short of the $258 per capita in 1995/96. With an estimated population of 30.6 million Canadians, the CHST shortfall is estimated to be $765 million (i.e., $258 - $233 x 30.6 million). Recognizing that inflation since 1995 has eroded the value of the federal CHST cash in 1999, the figure is estimated to be closer to $1.5 billion than $1.0 billion. Furthermore, there is no escalator attached to the federal CHST cash to account for inflation, a growing and ageing population, epidemiological trends or the diffusion of new technologies. This is a departure from previous formulae under Established Programs Financing (EPF) and the CHST which included an escalator (i.e., a three-year moving average of nominal Gross Domestic Product) to grow the value of the cash transfer. 4 In summary, the context placed around $11.5 billion is important, for it underscores the importance of the initial step that has been taken by the federal government when it comes to shoring up funding for health care in Canada. However, the critical issue now becomes what immediate and successive steps will be taken by the government to place the funding of our health care system on a longer-term and sustainable basis. The CMA is not alone in its view that there must be a full restoration of CHST cash. The Communiqué issued by the First Ministers at the recent 40th Annual Premiers Conference in Quebec City was clear in the interpretation of sustainability. While we consider how to ensure that the health care system will be here for all Canadians over the short, medium and long-term, we know that our society is growing and ageing. It is projected that individuals over the age of 65 will increase from just over one in ten (12.2%) in 1996 to one in five (21.7%) in 2031. 5 [BOX CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [BOX END] The combination of population growth and ageing will place additional pressure on health expenditures. Estimated per capita health expenditures by age for 1994 (see Table 1), shows that per capita expenditures for the 65 and over age group were $8,068, in comparison to $2,478 for the population as a whole-just over a three-to-one ratio. 6 Of interest, while the 65 and over population represented less than 12% of the population in 1994, it is estimated to have accounted for almost 40% of total health expenditures. The Auditor General of Canada, using age-specific per capita health spending, has projected that government health expenditures may reach 12% of GDP. 7 This is a large estimated increase given that the 1998 total health expenditures, which includes both government and private sources, is approximately 9% of GDP. [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Table 1 Per Capita Health Expenditures By Age Group, 1994 Age Group Expenditures per capita 0-14 $1,156 15-44 $1,663 45-64 $2,432 65+ $8,068 Source: National Health Expenditures, CIHI, 1996. [TABLE END] While it may be argued that those are only estimates, the OECD study on population shows that they are not at all atypical of the international experience. 8 This information alone will present the health care system with a number of challenges when it comes to meeting the future needs of the population. Given the current and impending pressures on the health care system, it is incumbent on the federal government - the guardian of Medicare - to think how we, as a society, will be able to maintain our health care system well beyond the new millennium. [BOX CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [BOX END] The CMA therefore recommends: 1. That the federal government fund Canada's publicly financed health care system on a long-term, sustainable basis to ensure quality health care for all Canadians. 2. That the federal government introduce a health-specific portion of federal cash transfers to the provinces and territories to promote greater public accountability, transparency and visibility. 3. That the federal government, at a minimum, increase federal cash for health care by an additional $1.5 billion, effective April 1, 2000. 4. That beginning April 1, 2001, the federal government fully index the total cash entitlement allocated to health care through the use of a combination of factors that would take into account the changing needs of Canadians based on population growth, ageing, epidemiology, current knowledge and new technologies, and economic growth. Recommendation 1 is principle-based and speaks to the importance of moving away from managing Canada's health care system on a crisis-to-crisis basis. While the balance between affordability and sustainability of our system should be at the forefront of our thinking, it must not deny Canadians reasonable access to quality health care. It also recognizes that although the federal government has an essential role to play, it cannot do it alone; it must work in close partnership with the provinces and territories. Consistent with the Minister of Health's call for increased accountability and transparency in our health care system, Recommendation 2 calls on the federal government to be measured by the very same principle when it comes to funding Canada's health care system. It is also consistent with the Social Union Agreement calling for greater public accountability on all levels of government. While last year's allocation under the CHST for health care sends an important message, consideration must be given as to how the CHST can be restructured to promote greater transparency and linkage between the sources of federal funding for health care and their intended uses at the provincial/territorial level. This is particularly important when one considers the need to better understand the relationship between defined health care expenditures and their relationship to health outcomes. In fact, it could be argued that last year's federal budget implicitly re-introduced the concept of earmarking CHST cash to health care. At a time of increased demand for accountability, the CHST mechanism appears to be anachronistic by having one indivisible cash transfer that does not recognize explicitly the federal government's contribution to health in a post-Social Union Agreement world. Last year, the CMA recommended to the federal government that it reinvest a total of $3.5 billion effective April 1, 1999 into the health care system with the principal objectives of: stabilizing the health care system; and assisting in the transitional process of expanding the continuum of care. As part of the $3.5 billion, the CMA recommended the creation of a Health System Renewal Fund which focused on four discrete areas of need: (1) acute care infrastructure; (2) community care infrastructure; (3) support Canadians at risk; and (4) health information technology. Given that the government reinvested $2.0 billion in 1999/2000, the CMA recommends that the federal government move immediately to reinvest an additional $1.5 billion for health care to facilitate continued system stabilization as well as further development toward an expanded continuum of care. These additional and necessary resources would be welcomed in addressing strategic policy challenges related to health human resource requirements - particularly those associated with the need for an adequate and stable supply of physicians and nurses; the cornerstone of our health care system. Furthermore, these resources would assist in the development of necessary capital infrastructure required to assist in the transition from institutional to community-based models of care, within a more integrated framework. While more specific and substantial funding announcements would be expected with any new shared programs announced by the federal and provincial/territorial governments (e.g., home care and pharmacare), there is a need now, while the system is in flux to ensure that no one falls through the cracks. This transitional funding will assist in the stabilization of the system and will also serve to ensure that as the system evolves toward an expanding continuum of care, it will remain accessible, with minimal interruption of service to Canadians. Based on recent estimates of the government's surplus in 1999 (standing at $4.8 billion through the first three months of fiscal 1999) and beyond, (9) it would appear that the government has an opportunity to make good on its commitment to make health care a key priority for future action. [BOX CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [BOX END] Recommendation 4 addresses the need for a fully indexed escalator to ensure that the federal cash contribution will continue to grow to meet the future health needs of Canadians. The escalator formula recognizes that health care needs are not always synchronized with economic growth. In fact, in times of economic hardship (e.g., unemployment, stress, and familial discord), a greater burden is placed on the health care system. If left as is, the current federal cash value will continue to erode over time with increasing demands from an ageing and growing population, and inflation. Combined, these recommendations speak not only to the fundamental principles of the necessity of having a sustainable health care system, but also in terms of the federal government continuing to take the necessary concrete leadership steps to ensure that adequate and long-term funding is available to meet the health care needs of all Canadians. The recommendations are strategic and targeted, and serve to build on and strengthen the core foundation of our health care system. If Canada's health care system is not only to survive, but thrive in the new millennium, we must give serious consideration to a range of possible solutions that place our system, and the federal role in that system, on a more secure and sustainable financial foundation. The CMA is prepared to continue to work with governments and others in developing innovative and lasting solutions to the challenges that face the health care system. IV. SUSTAINABLE HEALTH CARE AND PRODUCTIVITY In last year's report tabled in the House of Commons, the Standing Committee on Finance proposed the development of a productivity covenant. The Covenant "should subject all existing government initiatives (spending, taxation, regulation) to an assessment which evaluates their expected effects on productivity and hence the standard of living of Canadians. Every new budgetary initiative should be judged according to this productivity benchmark." 10 [BOX CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [BOX END] In the context of reinvesting in health care, the Standing Committee's Covenant asks that a "business case" be made. The CMA is of the view that there exists an important relationship between a well-funded, sustainable, public health care system and economic productivity. Just as strong economic fundamentals are generally viewed as an essential requirement for Canada's prosperous future, stable, adequate and where required, increased resources for health and health care funding should also be considered as an investment in the future well-being of Canadians, and by extension, our economic ability to compete. Framed in this context, these "investments" strengthen the capacity of Canadians to live rewarding and productive lives. From a structural perspective, studies have recognized the link between a well-funded, sustainable health care system as an important contributor to Canada's economic performance. 11 [BOX CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [BOX END] The studies suggest that the nature in which Canada largely finances its health care system through general taxes is more efficient compared to the United States which finances its system predominantly through employer-sponsored programs. Compared to the United States, Canada finances its health care system more equitably by spreading the financial risk across all taxpayers. As well, issues related to job mobility and the portability of health care benefits are not in question in the Canadian system. However, recent federal underfunding in health care has significantly contributed to impaired access to care by injured and sick workers delaying their return to work, decreasing productivity and increasing the cost of doing business and the cost to society. 12 A well-funded, sustainable health care system can be viewed as an important component in the decision-making process of businesses to locate in Canada. 13 In this context, there are a number of benefits that may accrue to Canadians at the individual and societal level, for example: * it can attract medium- and long-term business investment; * lead to the development of new infrastructure (e.g., facilities, equipment); * nurture the development of new long-term (value-added) jobs; * generate real and growing incomes; * increase individual and societal economic activity/consumption, wealth and investment capital; * reduce overall dependence on publicly funded social programs (e.g., employment insurance, income support programs); and * contribute to a growing and sustainable tax base. Underscoring the important linkages between the quality of life of Canadians and productivity is the important role of an efficient and well-funded public health care system and sustained economic growth. Given that policy decisions impact on the economy, health and health care should not necessarily be considered in isolation. In fact, wherever possible, good economic policy and good health and health care policy should be mutually reinforcing, or at a minimum, better synchronized. In an increasingly global, interdependent and competitive marketplace, businesses are not looking to assume greater costs. When it comes to health care, they are not looking to absorb high risk and high cost cases that are currently funded through the public sector. Instead, it would appear that they prefer a well-funded, sustainable health care system that is responsive to the health and health care needs of Canadians. 14 As well, a sustainable publicly funded health care system affords Canadians full mobility (i.e., portability) when it comes to pursuing job opportunities, which in turn, improves productivity. Good economic policy and good health care policy are compatible Canadian societal priorities. One need not be sacrificed to achieve the other nor should they be considered to be in competition with each other. Access to quality health and health care services is an important contributor towards Canada's ability to remain competitive in an increasingly complex global economic environment. Governments at all levels, must take responsibility to ensure that the health system remains on a long-term sustainable financial footing to the extent that it continues to benefit Canadians at the individual and societal level, and in terms of maximizing our quality of life and our ability to be productive. V. PHYSICIAN WORKFORCE ISSUES Canada is now beginning to experience a physician shortage that will be significantly exacerbated in the early decades of the next century. One of the chief contributing factors to the emerging shortage of physicians has been the almost singular focus of governments in their efforts to contain health care costs in the 1990s. A key policy approach introduced by governments to reduce cost growth in health has been to decrease the supply of physicians. A 12-point accord on physician resource management reached by Health Ministers in Banff, Alberta in 1992 included a recommendation for a 10% reduction in undergraduate enrolment in medical schools, which was implemented in the fall of 1993, and a recommendation for a similar percentage reduction in the number of postgraduate training positions. In addition, the introduction in 1992 of the requirement for a minimum of 2 years of prelicensure training removed most of the flexibility that used to exist in the number of postgraduate training slots. For instance, the opportunity for re-entry was no longer available to practising physicians; these re-entry opportunities ensured that young graduates (in general and family medicine) who had opted to go out and do locums or rural placements could then come back into the system at a later date for skills enhancement or speciality training. What the federal/provincial/territorial Ministers of Health did not take into account, however was that the output of Canada's medical schools peaked in the mid-1980s. Between 1986 and 1989, physician supply increased on average by 1,900 per year. This growth was halved between 1989 and 1993 - dropping to an average increase of 960 physicians per year. After 1993, total physician supply dropped in three successive years. This period of declining growth occurred well before the 1993 reductions have had an opportunity to work through the undergraduate education and post-MD training systems. Part of the reason for the decrease in supply is fewer Canadian medical graduates, but a significant part is due to increased attrition from the physician population. One factor has been increased retirement of physicians. The annual number of physicians retiring increased by 40% between the 1985-1989 and 1990-1995 periods. Although there have been up turns in the total supply of physicians in 1997 (285) and 1998 (960), this is unlikely to be sustained, given our lower levels of output from the educational system and higher attrition. The removal of most of these positions was unfortunate because re-entry can provide for more flexibility in the system and can allow for a more rapid adjustment in the physician workforce to meet the health needs of the public. For the Committee's information, appended to the Brief is the CMA's Draft Principles for a Re-entry System in Canadian Postgraduate Medical Education. According to the CMA's projection via the Physician Resource Evaluation Template (PRET), if the current levels of enrolment and attrition patterns continue, Canada will definitely experience a physician shortage in the first decades of the next century, especially after 2011, when the baby-boomer cohort of physicians will begin to retire. There is additional evidence that Canada is experiencing a physician shortage. First, it can be demonstrated that physicians are working harder than ever. Data from the CMA Physician Resource Questionnaire survey show that the mean hours per week worked by physicians (excluding on-call) have increased from 46.9 per week in 1993 to 54.1 hours in 1999 - an increase of 15.4%. [BOX CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [BOX END] Second, population-based data suggest that it is becoming more difficult to access physician services. Tracking surveys conducted by the Angus Reid group on behalf of CMA show that in 1998, an estimated 60% of the population believed that access to specialist services has worsened in the past couple of years - up from 41% in 1996. Similarly, in 1998 27% of Canadians reported that access to services from a family physician had worsened - almost double the level of 14% that was reported in 1996. 15 An August 1999 poll conducted by Angus Reid asked Canadians to assess the availability of physicians in their own communities. Only a little over one half of Canadians (52%) feel there are enough physicians available to meet their community's needs. Furthermore, they expect the situation to worsen over the next five years. Less than one third (29%) feel that five years from now there will be enough physicians to meet the health care needs in their communities. 16 In summary, there is ample evidence that not only is Canada heading for a severe physician shortage, but that a shortage has been developing over the past few years. At the same time, it must be recognized that it takes on average six years to train a general practitioner and 8-12 years to train a specialist from the time one enters medical school. If we are to avoid what appears to be a significantly worsening crisis, planning for the future must begin immediately. The CMA therefore recommends: 5. That the federal, provincial and territorial governments adopt the guiding principle of national self-sufficiency in the production and retention of physicians to meet the medical needs of the population, including primary to highly specialized medical care, and the requirements for a critical mass for teaching and research. 6. That the federal government establish and fund a national pool of re-entry positions in postgraduate medical education. In close consultation and collaboration with the provinces and territories, the federal government could play an increasingly vital role when it comes to ensuring that Canada produces an adequate supply of physicians. Furthermore, it could play a role in giving physicians the flexibility they need should they require additional training to meet the emerging needs of Canadians. Cost containment initiatives have also led to decreased numbers of other health care providers all across the country, particularly nurses. The federal government could play a major role in funding and coordinating research across all jurisdictions in Canada on the appropriate supply, mix and distribution of the entire health workforce. Strategic planning in the short, medium and long-term would be greatly facilitated through the establishment of a national institution that could draw on existing national databases and compile research from all the centres in the jurisdictions across the land. The CMA therefore recommends: 7. That the federal government establish a National Centre for Health Workforce Research. RURAL-REMOTE ISSUES While there are physician shortages across the country, it is particularly acute in rural and remote regions of Canada. For a number of personal and professional reasons, physicians are not finding rural and remote practice as rewarding nor sustainable. In 1999, CMA conducted a survey of rural physicians who were asked to rate their level of satisfaction with rural medical practice both from a personal and professional perspective; this study was funded by Health Canada. A similar survey was previously done in 1991. 17 There has been little change in the level of satisfaction for the personal and family factors. However, the level of satisfaction with the professional factors has fallen significantly. In 1991, the proportion indicating they were very satisfied with work hours, professional backup, availability of specialty services and continuing medical education opportunities all decreased by at least 10 percentage points. Similarly, the percentage who were very satisfied with hospital services fell by more than half from 40% in 1991 to 17% in 1999. Likewise, in 1991 42% were very satisfied with their earning potential compared with 23% in 1999. ESCALATION AND DEREGULATION OF TUITION FEES The CMA remains very concerned about high, and rapidly escalating, medical school tuition fee increases across Canada. The CMA is particularly concerned about their subsequent impact on the physician workforce and the Canadian health care system. In addition to the significant impact of high tuition fees on current and potential medical students, the CMA believes that high tuition fees will have a number of consequences, they will: (1) create barriers to application to medical school and threaten the socioeconomic diversity of future health care providers serving the public; and (2) exacerbate the physician 'brain drain' to the United States so that new physicians can pay down their large and growing debts more quickly. In support of this priority matter, the CMA Board has struck a working group to develop a position paper on tuition fee escalation and deregulation; the working group is also planning a national, multiprofession stakeholder conference on this issue. In addition to the recommendation that follows, the CMA believes that governments should increase funding to medical schools to alleviate the pressures driving tuition increases, and that any further tuition increases should be regulated and reasonable. The CMA decries tuition deregulation in Canadian medical schools and recommends: 8. That the federal government enhance financial support systems, such as the Canada Student Loans Program, for medical students in advance of any future tuition increase, and ensure that these support systems are set at levels that meet the financial needs of students. BRAIN DRAIN The net loss of physicians from Canada to other countries has doubled since the beginning of the 1990s. Whereas a net loss of 223 physicians due to migration was recorded in 1991, the corresponding figure for 1997 was 432 physicians - which represents roughly the annual output of four to five medical schools. While these physicians leave for a variety of professional and personal reasons, what is particularly telling is that the figure has doubled over the course of the 1990s. [BOX CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [BOX END] For several years, the CMA has warned governments and policy makers about the impending crisis of physician shortages and their implications for the health care system. Regrettably, the calls for a more measured, responsible and deliberate approach to physician resource planning has fallen on deaf ears. There are a number of factors that contribute to physicians leaving Canada. While they would appear to be a combination of personal, professional and economic considerations, the bottom line is our brain drain is a de facto brain gain for another country - predominantly the United States. In reviewing the brain drain issue, Statistics Canada concludes that "there is significant net brain drain in the health professions. Brain gain in health is not enough to make up for brain drain to the United States." 18 This issue is very real for physicians - who are being asked to do more where colleagues are no longer practising; and to the public - who are being asked to be patient as access to the system is delayed or compromised. In the absence of timely, strategic and lasting policy measures, we are likely to continue to risk losing physicians - many of them our best and brightest - to other countries. In this regard, the CMA is of the view that the federal government has an important role to play when it comes to synchronizing policy in the areas of health care, finance and economics. One factor that may contribute to a physician's decision to leave or think about leaving Canada is our tax structure. It is important to note that Canada relies more heavily on personal income taxes than any other G-7 country. 19 While this is important, what is more of concern is how Canada's marginal tax structure compares to that of the United States. While it is understood that Canada has taken a fundamentally different approach with regard to the magnitude and role of the tax system in social policy, the gap between the two systems can no longer be ignored in a world of increasing globalization, economic interdependence and labour mobility. While Canada's personal income tax schedule should be reviewed, it should not come as a surprise to this Committee that other tax policies - such as the Goods and Services Tax (GST)/Harmonized Sales Tax (HST) only serve to remind physicians of the severity and inequity of the problem. GOODS AND SERVICES TAX (GST) In its 1997 report to the House of Commons the Standing Committee noted the concerns of the medical profession about the application of the GST and by 1998 indicated that this issue merits further consideration by the government. The CMA believes that it has rigorously documented its concerns and further study is not required (20) - the time has come for concerted action from the federal government to remove this tax impediment. [BOX CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [BOX END] When it comes to tax policy and the tax system in Canada, the CMA is strongly of the view that both should be administered in a fair and equitable manner. This principle-based statement has been made to the Standing Committee on a number of different occasions. While these principles are rarely in dispute, the CMA has expressed its strong concerns regarding their application - particularly in the case of the goods and services tax (GST) and the recently introduced harmonized sales tax (HST) in Atlantic Canada. By designating medical services as "tax exempt" under the Excise Tax Act, physicians are in the unenviable position of being denied the ability to claim a GST refund (i.e., input tax credits - ITCs) on the medical supplies necessary to deliver quality health care, and on the other, cannot pass the tax onto those who purchase such services. This is a critical point when one considers the raison-d'être of introducing the GST: to be an end-stage consumer-based tax, and not having a producer of a good or a service bear the full burden of the tax. Yet this tax anomaly does precisely that. As a result, physicians are "hermetically sealed" - they have no ability to claim ITCs due to the Excise Tax Act, or pass the costs to consumers due to the Canada Health Act. The CMA has never, nor is currently asking for, 'special treatment' for physicians under the Excise Tax Act. However, if physicians, as self-employed individuals are considered as small businesses for tax purposes, then it is clearly reasonable that they should have the same tax rules extended to them that apply to other small businesses. This is a fundamental issue of tax fairness. [BOX CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [BOX END] While other self-employed professionals and small businesses claim ITCs, an independent (KPMG) study has estimated that physicians have "overcontributed" in terms of unclaimed ITCs by $57.2 million per year. Furthermore, with the introduction of the HST in Atlantic Canada, KPMG has estimated that it will cost physicians an additional $4.686 million per year. By the end of this calendar year, physicians will have been unfairly taxed in excess of $500 million. As it currently applies to medical services, the GST is bad tax policy and the HST will make a bad situation much worse for physicians. There are other health care providers (e.g., dentists, physiotherapists, psychologists, chiropractors, nurses) whose services are categorized as tax exempt. However, there is an important distinction between whether the services are publicly insured or not. Health care providers who deliver services privately have the opportunity to pass along the GST costs through their fee structures. It must be remembered that physicians are in a fundamentally different position given that 99% of their professional earnings come from the government health insurance plans: under the GST and HST, "not all health care services are created equal". There are those who argue that the medical profession should negotiate the GST at the provincial/ territorial level, yet there is no province or territory that is prepared to cover the additional costs that are being downloaded onto physicians as a result of changes to federal tax policy. Nor do these governments feel they should be expected to do so. The current tax anomaly, as it affects the medical profession, was created with the introduction of the GST - and must be resolved at the federal level. The principles that underpin the fundamental issue of tax fairness outlined by Chief Justice Hall are unassailable and should be reflected in federal tax policy. Clearly, it is fairness, not special treatment that the profession is seeking. As it currently stands for medical services, the GST and HST is bad tax policy that does not reinforce good health care policy in Canada. The CMA strongly recommends: 9. That health care services funded by the provinces and territories be zero-rated. This recommendation would be accomplished by amending the Excise Tax Act as follows: (1). Section 5 part II of Schedule V to the Excise Tax Act is replaced by the following: "A supply (other than a zero-rated supply) made by a medical practitioner of a consultative, diagnostic, treatment or other health care service rendered to an individual (other than a surgical or dental service that is performed for cosmetic purposes and not for medical or reconstructive purposes)." (2). Section 9 Part II of Schedule V to the Excise Tax Act is repealed. (3). Part II of Schedule VI to the Excise Tax Act is amended by adding the following after Section 40: 41. A supply of any property or service but only if, and to the extent that, the consideration for the supply is payable or reimbursed by the government under a plan established under an Act of the legislature of the province to provide for health care services for all insured persons of the province. The CMA's recommendation fulfils at least two over-arching policy objectives: (1) it strengthens the relationship between good economic policy and good health policy in Canada; and (2) it applies the fundamental principles that underpin our taxation system (fairness, efficiency, effectiveness), in all cases. In this regard, the CMA is committed to working closely, and on an ongoing basis, with the government to develop collaborative solutions to this tax anomaly. DIFFUSION OF HEALTH TECHNOLOGIES Recently, concerns have been raised about the lack of access to necessary diagnostic and treatment technologies in Canada. Many of the technologies are essential in the early detection of cancers (e.g., breast, prostate, lung), tumours, circulatory complications (e.g., stroke, hardening of the arteries) and other illnesses. A recent study concluded that Canada is generally in the bottom third of OECD countries in availability of technology. Canada ranks 18th (of 29 OECD countries) in making available computed tomography; 19th (of 24 OECD countries) in lithotriptor availability; and 18th (of 27 OECD countries) in availability of magnetic reasonance imagers. Canada ranks favourably only in the availability of radiation equipment (5th out of 16 OECD countries). 21 [BOX CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [BOX END] Given the very real concerns that have been raised with regard to waiting lists across the country, Canadians deserve better when it comes to making available needed health technologies that can effectively diagnose and treat disease. Furthermore, it is clear that we must facilitate the diffusion of new cost-effective health technologies that are properly evaluated and meet defined standards of quality. While physicians are trained to provide quality medical care to all Canadians- they must, at the same time, have the "tools" to do so. In this context, the federal government should establish a National Health Technology Fund that would allow the provinces and territories to access funds. While the provinces and territories would be responsible for determining their respective technological priorities, the federal government would very clearly link the sources of funding with their intended uses, with full recognition for an essential investment in the health care of Canadians. The CMA recommends: 10. That the federal government establish a National Health Technology Fund to increase country-wide access to needed health technologies. The CMA is prepared to work closely with the federal government to assist in the development of objectives and deliverables of such a fund within a reasonable period of time. In so doing, the federal government would work in a strategic partnership with the provinces and territories such that monies from the fund to purchase equipment would be supported by ongoing operational resources at the site of delivery. VI. SYNCHRONIZING FEDERAL GOVERNMENT POLICY: WHERE FINANCE, ECONOMICS AND HEALTH CARE COME TOGETHER In appearing before the House of Commons Standing Committee on Finance, the CMA is well aware that policy considerations in finance and economics have an important and direct impact on the funding and delivery of health care in Canada. In the world of public policy, rarely are difficult decisions portrayed as simply being black or white. In most instances, where tough choices are made amongst a series of competing ends, they are often in varying shades of grey. While this is true when it comes to health care policy in Canada or any other discipline, it is important that it be placed in a broader context in terms of being consistent with, or reinforcing other good policy choices that have been implemented. This concept is critical to ensure that, if possible, all policy decisions are moving consistently in the same direction. In effect, synchronized in a way that the "policy whole" is greater than the sum of its individual parts. Such an approach also ensures that policy decisions taken in one sector are not countering decisions taken in other sectors. HEALTH RESEARCH IN CANADA In previous submissions to the Standing Committee on Finance, the CMA has encouraged the federal government to take the necessary steps to establish a national target and implementation plan for health research in Canada. [BOX CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [BOX END] The CMA was very encouraged with the federal government's announcement in last year's budget to set aside significant resources to develop the Canadian Institute for Health Research (CIHR). By 2001, funding for the CIHR is expected to increase to $484 million. The CMA was also pleased with the Minister's recent announcement to earmark $147 million to attract and retain health researchers in Canada. In offering a vision and structure to facilitate health research in Canada, the government should be congratulated. The CMA believes that significantly increasing funding in support of health research is of direct benefit to: (1) the health of Canadians; (2) Canada's health care system; and (3) to foster the development of health care as an industry. This is where good economic policy goes hand-in-hand with good health and health care policy in Canada. The CMA strongly supports the CIHR model and is prepared to work closely with government and others to do what is necessary to make this become a reality. Recognizing that Canada is moving into a new phase when it comes to funding and undertaking health research, the government is taking an important step to ensure our best and brightest medical scientists and health researchers are developed and remain in Canada. [BOX CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [BOX END] As a national organization representing the views of practising physicians across the country, the CMA strongly believes it has a meaningful contribution to make in moving the CIHR model forward. Specifically, in the areas of: * knowledge management (the CMA contributed greatly to stimulating clinical and health services research in Canada) * contributing to the research agenda (the CMA contributes to the research agenda in health services research, for example the Western Waiting List project funded by the Health Transition Fund) * ensuring quality peer-reviewed research (the CMA publishes the leading peer-reviewed medical journal in Canada) * research transfer (the CMA plays a leading role in developing tools to transfer research into practice - such as the Clinical Practice Guideline Database) * ethics (the CMA maintains a standing committee on ethics) * sustainability (the CMA has advocated for a strong Canadian presence in health research) While the CIHR will have a broad mandate for health research, physicians will have a key role to play in medical and health services research. The CMA looks forward to playing a more substantive role as the model moves to become reality. The CMA recommends: 11. That the federal government continue to increase funding for health research on a long-term, sustainable basis. TOBACCO CONTROL PROGRAMS Tobacco taxation policy should be used in conjunction with other strategies for promoting health public policy, such as public education programs to reduce tobacco use. The CMA continues, however, to maintain that a time-limited investment is not enough. Substantial and sustainable fund-ing is required for programs in prevention and cessation of tobacco use. 22 [BOX CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] [BOX END] A possible source for this type of program investment could be tobacco tax revenues or the tobacco surtax. The CMA believes that that the federal government should designate 0.6 cents per cigarette sold to a fund to defray the costs of tobacco interventions, including those provided by physicians with the expertise in the treatment of nicotine addiction. This would generate approximately $250 million per year to help smokers quit. 23 The CMA recommends: 12. That the federal government commit stable funding for a comprehensive tobacco control strategy; this strategy should ensure that the funds are invested in evidence-based tobacco control projects and programs, which would include programs aimed at prevention and cessation of tobacco use and protection of the public from tobacco's harmful effects. 13. That the federal government support the use of tobacco tax revenues for the purpose of developing and implementing tobacco control programs. 14. That the federal government place a high priority for funding tobacco prevention and evidence-based cessation programs for young Canadians as early as primary school age. TOBACCO TAXATION POLICY Smoking is the leading preventable cause of premature mortality in Canada. The most recent estimates suggest that more than 45,000 deaths annually in Canada are directly attributable to tobacco use. The estimated economic cost to society from tobacco use in Canada has been estimated from $11 billion to $15 billion. 24 Tobacco use directly costs the Canadian health care system $3 billion to $3.5 billion (25) annually. These estimates do not consider intangible costs such as pain and suffering. CMA is concerned that the 1994 reduction in the federal cigarette tax has had a significant effect in slowing the decline in cigarette smoking in the Canadian population, particularly in the youngest age groups - where the number of young smokers (15-19) is in the 22% to 30% range and 14% for those aged 10-14. 26 A 1997 Canada Health Monitor Survey found that smoking among girls 15-19 is at 42%. 27 A Quebec study found that smoking rates for high school students went from 19% to 38%, between 1991 and 1996. 28 The CMA congratulates the federal government's initiatives to selectively increase federal excise taxes on cigarettes and tobacco sticks. This represents the first step toward the development of a federal integrated tobacco tax strategy, and speaks to the importance of strengthening the relationship between good health policy and good tax policy in Canada. The CMA understands that tobacco tax strategies are extremely complex. Strategies need to consider the effects of tax increases on reduced consumption of tobacco products with increases in interprovincial/ territorial and international smuggling. In order to tackle this issue, the government could consider a selective tax strategy. This strategy requires continuous stepwise increases to tobacco taxes in those selective areas with lower tobacco tax (i.e., Ontario, Quebec and Atlantic Canada). The goal of selective increases in tobacco tax is to increase the price to the tobacco consumer over time (65-70% of tobacco products are sold in Ontario and Quebec). The selective stepwise tax increases will approach but may not achieve parity amongst all provinces; however, the tobacco tax will attain a level such that interprovincial/territorial smuggling would be unprofitable. The selective stepwise increases would need to be monitored so that the new tax level and US/Canadian exchange rates do not make international smuggling profitable. The selective stepwise increase in tobacco taxes can be combined with other tax strategies. The federal government should be congratulated for reducing the export exemption available on shipments in accordance with each manufacturers' historic levels, from 3% of shipments to 2.5%. However the CMA believes that the federal government should remove the exemption. The objective of implementing the export tax would be to make cross-border smuggling unprofitable. The federal government should establish a dialogue with the US federal government. Canada and the US should hold discussions regarding harmonizing US tobacco taxes with Canadian levels at the factory gate. Alternatively, Canadian tobacco tax policy should raise price levels such that they approach US tobacco prices. The CMA therefore recommends: 15. That the federal government follow a comprehensive integrated tobacco tax policy (a) To implement selective stepwise tobacco tax increases to achieve the following objectives: (1) reduce tobacco consumption, (2) minimize interprovincial/territorial smuggling of tobacco products, and (3) minimize international smuggling of tobacco products; (b) To apply the export tax on tobacco products and remove the exemption available on tobacco shipments in accordance with each manufacturers' historic levels; and (c) To enter into discussions with the US federal government to explore options regarding tobacco tax policy, raising Canadian tobacco price levels in line with or near the US border states, in order to minimize international smuggling. REGISTERED RETIREMENT SAVINGS PLANS (RRSPS) There are at least two fundamental goals of retirement savings: (1) to guarantee a basic level of retirement income for all Canadians; and (2) to assist Canadians in avoiding serious disruption of their pre-retirement standard of living upon retirement. Reviewing the demographic picture in Canada, we know that an increasing portion of society is not only aging, but is living longer. Assuming that current trends will continue and peak in the first quarter of the next century, it is important to recognize the role that private RRSP savings will play in ensuring that Canadians may continue to live in dignity well past their retirement from the labour force. In its 1996 budget statement, the federal government announced that the contribution limits of RRSPs was to be frozen at $13,500 through to 2002/03, with increases to $14,500 and $15,500 in 2003/04 and 2004/05 respectively. As well, the maximum pension contribution limit for defined benefit registered pension plans will be frozen at its current level of $1,722 per year of service through 2004/05. This is a de facto increase in tax payable. This policy runs counter to the 1983 federal government White Paper on The Tax Treatment of Retirement Savings where the House of Commons Special Committee on Pension Reform recommended that the limits on contributions to tax-assisted retirement savings plans be amended so that the same comprehensive limit would apply regardless of the retirement savings vehicle or combination of vehicles used. In short, the principle of 'pension parity' was explicitly recognized and endorsed. Since that time, in three separate papers released by the federal government (1983, 1984, 1987), the principle of pension parity would have been achieved between money-purchase (MP) plans (i.e., RRSPs) and defined-benefit (DB) plans (i.e., Registered Pension Plans) had RRSP contribution limits risen to $15,500 in 1988. As a founding member of the RRSP Alliance, the CMA, along with others has been frustrated that eleven years of careful and deliberate planning by the federal government around pension reform has not come to fruition. In fact, if the current policy remains in place it will have taken more than 17 years to implement needed reforms to achieve parity (from 1988 to 2005). While pension parity will be achieved between RRSP plans and RPP plans in 2004/05, it will have been accomplished on the backs of Canadians whose RRSP contribution levels have been frozen for far too long. As a consequence, the current policy of freezing RRSP contribution limits and RPP limits without adjusting the RRSP contribution limits to achieve pension parity serves to maintain inequities between the two plans until 2004/05. This situation is further compounded by the implementation of this policy because the RRSP/RPP plans are frozen and therefore unable to grow at the rate in the yearly maximum pensionable earnings (YMPE) Specifically, if the recommended policy of pension parity had been implemented in 1988, the growth in RRSP and RPP contribution limits could have grown in line with the yearly maximum pensionable earnings - and would be approximately $21,000 today. [TABLE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] TABLE 2 - RRSP Contribution Limits Adjusted by the Yearly Maximum Pensionable Earnings (YMPE Earnings (YMPE) Year YMPE % change RRSP Limits 1988 $27,700 $15,500 1989 $28,500 2.89 $15,948 1990 $28,900 1.40 $16,171 1991 $30,500 5.54 $17,067 1992 $32,200 5.57 $18,018 1993 $33,400 3.73 $18,690 1994 $34,400 2.99 $19,249 1995 $34,900 1.45 $19,529 1996 $35,400 1.43 $19,809 1997 $35,800 1.13 $20,032 1998 $36,900 3.07 $20,648 1999 $37,400 1.36 $20,928 YMPE Source: Revenue Canada, April 1999 [TABLE END] Each year the Department of Finance publishes revenue cost to the federal treasury of a number of policy initiatives. For RRSP contributions, the net tax expenditure (i.e., tax revenue not collected) is estimated to be $7.5 billion in 1998. The net tax expenditure associated with registered pension plans is estimated to be $6.2 billion in 1998. In this context, it is critical to understand the difference between tax avoidance and tax deferral. RRSPs allow Canadians to set aside necessary resources to provide for their retirement years. In the medium and longer-term, when RRSPs are converted to annuities, they bring increased tax revenues to government. While current contributions exceed withdrawals, this will not continue indefinitely as the baby boom generation retires at an accelerated rate. In sum, at a time when the government is reviewing the role of public benefits in society, there is a social responsibility placed on government to ensure a stable financial planning environment is in place which encourages greater self-reliance on private savings for retirement. From the standpoint of synchronizing good tax policy with good social policy, it is essential that the RRSP system be expanded such that it gives Canadians the means and incentive to prepare for retirement, while at the same time, lessening any future burden on public programs. The CMA recommends: 16. That the dollar limit of RRSPs at $13,500 increase to $15,500 for the year 2000/01. 17. That the federal government explore mechanisms to increase RRSP contribution limits in the future given the delay in achieving pension parity, since 1988. Under current federal tax legislation, 20% of the cost of an RRSP, RRIF or Registered Pension Plan's investments can be made in 'foreign property'. The rest is invested in 'Canadian' investments. If the 20% foreign content limit is exceeded at the end of a month, the RRSP pays a penalty of 1% of the amount of the excess. In its December 1999 pre-budget consultation, the Standing Committee on Finance made the following recommendation (p. 58): "The Committee recommends that the 20% Foreign Property Rule be increased in 2% increments to 30% over a five year period. This diversification will allow Canadians to achieve higher returns on their retirement savings and reduce their exposure to risk, which will benefit all Canadians when they retire." A study by Ernst and Young demonstrated that Canadian investors have experienced substantially better investment returns over the past 20 years with higher foreign content limits. As well, the Conference Board of Canada concluded that lifting the foreign content limit to 30% would have a neutral effect on Canada's economy. The CMA strongly supports the Standing Committee's position that there is sufficient evidence to indicate that Canadians would benefit from an increase in the Foreign Property Rule, from 20% to 30%. The CMA therefore recommends: 18. That the 20% Foreign Property Rule for deferred income plans such as Registered Retirement Savings Plans and Registered Retirement Income Funds be increased in 2% annual increments to 30% over a five year period, effective the year 2000. As part of the process to revitalize and sustain our economy, greater expectations are being placed on the private sector to create long-term employment opportunities. While this suggests that there is a need to re-examine the current balance between public and private sector job creation, the government nonetheless has an important responsibility in fostering an environment that will accelerate job creation. In this context, the CMA strongly believes that current RRSPs should be viewed as an asset rather than a liability. With proper mechanisms in place, the RRSP pool of capital funds can play an integral role in bringing together venture capital and small and medium-size business and entrepreneurs. The CMA would encourage the federal government to explore current regulatory impediments to bring together capital with small and medium-size businesses. The CMA recommends: 19. That the federal government explores the regulatory changes necessary to allow easier access to RRSP funds for investment in small and medium-size businesses. Currently, if an individual declares bankruptcy, creditors are able to launch a claim against their RRSP or RRIF assets. As a consequence, for self-employed Canadians who depend on RRSPs for retirement income, their quality of life in retirement is at risk. In contrast, if employees declare bankruptcy, creditors are unable to lay claim on their pensionable earnings. This is an inequitable situation that would be remedied if RRSPs were creditor-proofed. The CMA recommends: 20. That the federal government undertake the necessary steps to creditor-proof RRSPs and RRIFs. ENDNOTES: 1. It is important to keep in mind that in addition to the CHST, a separate accounting procedure was established through what is called a CHST Supplement. The Supplement, which totals $3.5 billion, was charged to the 1998 federal government public accounts, but is allocated over a three-year period (i.e., $2.0 billion, $1.0 billion, and $0.5 billion). However, at any point in time, a province or territory can take its portion of the $3.5 billion. 2. The $2.5 billion dollars to be reinvested represents the amount of federal cash that was removed with the introduction of the Canada Health and Social Transfer (CHST) beginning in April 1996 through to 1998. The amount is calculated on the basis of the recent historical federal cash allocation (approximately 41%) under EPF and CAP (now the CHST) to health care as a proportion of the $6.0 billion required to restore the CHST cash floor to $18.5 billion (1995/96 level). 3. The data sources for Figure 1 are: (1) CHST: Canadian Medical Association, Looking Toward Tomorrow, September 1998, p. 4.; (2) Historical national cash transfer to health from Established Programs Financing Reports, Federal-Provincial Relations Division, Department of Finance; (3) Population Statistics: Statistics Canada Catalogue no. 91-213; (4) CPI annual % change: Source for 1990-96 is Canadian Economic Observer, cat. No. 11-210-XPB, Historical Statistical Supplement 1996/97, p. 45. For 1996, 1997 and 1998 the source is Canadian Economic Observer, cat. No. 11-010-XPB, April 1999. For 1999 and 2000 the source is Royal Bank of Canada Econoscope, May 1999, p.14. For 2001, 2002 and 2003 CPI % change is assumed to stay constant at the 2000 level of 1.3%. 4. Thomson A. Federal Support for Health Care. Health Action Lobby. June 1991, p. 13. 5. Statistics Canada, Population Projections for Canada, Provinces and Territories, Medium Growth Scenario, 1993-2016, December, 1994 (Catalogue #91-520). 6. Health Canada. National Health Expenditures in Canada, 1975-1994. January 1996. 7. 1998 Report of the Auditor General of Canada, Chapter 6, Population Aging and Information for Parliament: Understanding the Choices, April. WWW: http://www.oag-bvg.gc.ca/domino/reports.nsf/html/9860xe12.html, available on 06/09/99 at 17:38:37. 8. Maintaining Prosperity in an Ageing Society. Organization for Economic Cooperation and Development, Paris, 1998. 9. The Fiscal Monitor, Department of Finance. August 1999. Current Analysis, The Royal Bank of Canada, August 1999. The Bank estimates that the fiscal dividend will reach $25.9 billion in 2004/05, and $41.2 billion in 2007/08. 10. Facing the Future - Challenges and Choices for A New Era. Report of the Standing Committee on Finance, December 1998, p. 30-31. 11. Green JP, MacBride-King J. Corporate Health Care Costs in Canada and the U.S.: Does Canada's Medicare System Make a Difference? Conference Board of Canada, 1999. Purchase B. Health Care and Competitiveness. School of Policy Studies, Queen's University, 1996. KPMG. The Competitive Alternative: A Comparison of Business Costs in Canada and the United States, 1996. Amanor-Boadu, Martin LJ. Canada's Social Programs, Tax System and the Competitiveness of the Agri-Food Sector, Guelph, Agri-Food Competitiveness Council, 1994. 12. Green JP, MacBride-King J. Corporate Health Care Costs in Canada and the U.S.: Does Canada's Medicare System Make a Difference? Conference Board of Canada, 1999. 13. KPMG. The Competitive Alternative: A Comparison of Business Costs in Canada and the United States, 1996. 14. Baillie C. Health Care in Canada: Preserving a Competitive Advantage, Speech to the Vancouver Board of Trade, April, 1999. 15. National Angus Reid Poll, 1998. 16. National Angus Reid Poll, 1999. 17. Canadian Medical Association. The 1991 Survey of Physicians in Rural Medical Practice, 1991. Canadian Medical Association. Survey on Rural Medical Practice in Canada, 1999. 18. Presentation by Statistics Canada Officials to the Standing Committee on Industry, May 1999. 19. Business Council on National Issues: Creating Opportunity, Building Prosperity. October 1998, p. 6. 21. KPMG, Review of the Goods and Services Tax on Canadian Physicians, June 12, 1992. KPMG, Review of the Impact of a Provincial Value Added Tax on Physicians in New Brunswick, Nova Scotia and Newfoundland, August 12, 1996. 21. Harriman D, McArthur W, Zelder M. The Availability of Medical Technology in Canada: An International Comparative Study. The Fraser Institute. August 1999. 22. In California, between 1988 and 1993, when the state was carrying on an aggressive public anti-smoking campaign, tobacco consumption declined by over 25%. Goldman LK, Glantz SA. Evaluation of Antismoking Advertising Campaigns. JAMA 1988; 279: 772-777. 23 In 1998, 45.613 billion cigarettes were sold in Canada. Statistics Canada, Catalogue #32-022, December, 1998. In 1997/98, total tobacco revenues were $2.04 billion, Public Accounts, Volume II, Part 1, Excise Tax Revue. The rationale for 0.6 cents per cigarette is based on a total amount of 25 cents per pack, of which the federal and provincial/territorial governments would contribute on an equal basis (i.e., 12 cents each). Recently, California passed Proposition 99 which added 25 cents to each pack of cigarettes. 24. Health Canada, Economic Costs Due to Smoking (Information Sheet). Ottawa: Health Canada, November 1996. 25. Health Canada, Economic Costs Due to Smoking (Information Sheet). Ottawa: Health Canada, November 1996. 26. Health Canada, Youth Smoking Behaviour and Attitudes (Information Sheet). Ottawa: Health Canada, November 1996. 27. Canada Health Monitor, Highlights Report, Survey #15. Price Waterhouse, January-February 1997. 28. Editorial. Raise Tobacco Taxes. The Gazette [Montreal] 1997 Sept 23. Sect B:2.
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Response to Health Canada’s Discussion Papers on “Proposed New Labelling Requirements for Tobacco Products” and “Options for Tobacco Promotion Regulations”

https://policybase.cma.ca/en/permalink/policy1982
Last Reviewed
2018-03-03
Date
1999-03-12
Topics
Health care and patient safety
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2018-03-03
Date
1999-03-12
Topics
Health care and patient safety
Population health/ health equity/ public health
Text
I. Introduction This document presents the position of the Canadian Medical Association (CMA)on the discussion papers “Proposed New Labelling Requirements for Tobacco Products” and “Options for Tobacco Promotion Regulations”, which were released by Health Canada on January 18, 1999. The document assesses the proposals outlined in the two papers and places them in the context of CMA’s comprehensive policy on tobacco control. The CMA is the national voice of Canadian physicians. Our mission is to provide leadership for physicians and to promote the highest standard of health and health care for Canadians. On behalf of its 45,000 members and the Canadian public, CMA performs a wide variety of functions, including advocating health promotion and disease and injury prevention policies and strategies. It is in this capacity that we present this brief, the most recent of many statements on tobacco which CMA has made since it issued its first public warning on tobacco’s hazards in 1954. We have spoken out strongly and consistently for more than forty years because physicians have first-hand experience of the havoc that tobacco plays with the lives of Canadians. Tobacco kills 45,000 people a year in this country1 - more than traffic accidents, murders, suicides, drug abuse and AIDS combined. Because many people with tobacco-related diseases do not die of them, this number greatly underestimates the actual burden of suffering caused by tobacco in Canada. This burden of disease comes with a high price tag. Health Canada estimates that tobacco costs the Canadian health care system $3.5 billion a year in direct health care expenses. This does not include the cost of the disability, lost productivity and human pain and suffering caused by tobacco, which has been estimated at between $8 and 11 billion annually.2 It is for these reasons that the CMA has consistently recommended tough legislative and regulatory measures to control tobacco use. Since the Supreme Court of Canada struck down portions of the Tobacco Products Control Act in 1995, we have advocated strong replacement legislation. We supported Bill C-71, the Tobacco Act, and welcomed its enactment in 1997; since then we have repeatedly expressed our opposition to suggested amendments that would weaken the Act. CMA now commends Health Canada on its proposal to augment the Tobacco Act with regulations to mandate strong health warnings on packages of tobacco products, and on initiating discussion on regulations to control tobacco advertising and promotion. The following discusses in detail Health Canada’s specific suggestions. II. “Option for Tobacco Promotion Regulations” Before discussing specific options it should be said that the CMA advocates the prohibition of all forms of tobacco promotion in Canada. This includes advertisements in broadcast and print media, the sale of accessories and tobacco products displaying brand names, logos or colours, and advertising at point of sale. Accordingly we view the options described in the paper as compromises rather than ideal solutions, and our recommendations should be considered from this viewpoint. a) Tobacco Products, (Sections 3.1 (a) to 3.1 (f)) The CMA recommends a total ban on advertising and promotion of tobacco products at point of sale. The eye-catching “power walls” of cigarettes that one sees in corner stores could be considered a form of advertising. CMA therefore recommends the most restrictive option proposed in the paper, i.e. that tobacco products not be displayed above counter-tops. There should be no exemption from this restriction for any store. b) Accessories and Nontobacco Products (Section 3.1 (g) to 3.1 (k)) CMA’s recommended ban on tobacco advertising extends to a ban on the sale of accessories and nontobacco products carrying tobacco brand elements. We are aware that the Tobacco Act permits the use of tobacco brand elements on nontobacco products; however, we recommend that regulations restrict their use to the greatest extent possible. c) Service (Section 3.1 (l)) We assume that this provision is intended to control in-store advertising for events sponsored by tobacco companies. CMA has publicly opposed all advertising related to such events. We note that this advertising will be removed from stores altogether by 2003, under the provisions of Bill C-42. d) Availability Signs (Sections 3.1(m) - 3.1(p)) The CMA questions the need for availability signs; however, if they are permitted, Health Canada’s regulations must ensure that they not be used as advertising. For example, the number of signs that a location can display should be limited; the text on signs should be in plain black and white font; and the content should be restricted as described in Section 3.1(p). e) Advertising (Section 3.2) Again, CMA reminds Health Canada that it opposes tobacco advertising in all forms and would prefer a total ban to the options proposed in this section. However, since the Tobacco Act permits a limited amount of advertising, we recommend that Health Canada act on its stated intent to restrict this advertising’s attractiveness to young people and its potential to reach them. Accordingly we recommend the following: * that all advertisements for tobacco products, accessories or nontobacco products displaying tobacco product brand elements carry prominent health warning messages as proposed; * that advertisements be “text-only” without illustrations or decorative fonts; * that if it is impossible to keep brand elements off advertisements, they occupy as small a space as possible; * that advertisements be print-only and restricted to adult-circulation publications, as mandated in the Tobacco Act; * that the size of advertising signs be restricted; and * that the above recommendations also apply to advertising signs in places where young persons are not permitted. The Tobacco Act allows advertising in such places with the proviso that it not be “lifestyle” related. However, the concept of "lifestyle" advertising is vague and open to broad interpretation; as such, it is difficult to police and could be easily ignored or circumvented. Therefore CMA believes that a comprehensive ban on advertising is preferable to a partial one. f) Tobacco Product Packaging (Section 3.3) Packaging is an important part of the marketing of any product, and tobacco is no exception. Cigarette packages should not serve as an advertising tool and inducement to purchase. Plain packaging would reduce the attractiveness of cigarette boxes to consumers; accordingly CMA recommends that tobacco products be sold in plain packages. We are pleased to see standardized plain packaging presented as an option in this section, and we recommend that this option be adopted. III. “Proposed New Labelling Requirements for Tobacco Products” As Health Canada’s own research indicates, package labelling is a health education tool that can reach a large number of people for minimal cost; we believe that health warning labels have contributed to raising public awareness of the dangers of smoking and the toxic content of tobacco. Accordingly, CMA supports in principle the proposals in this paper. In addition to our support for plain packaging, CMA recommends that packages of tobacco products: * Contain health warnings prominently displayed; * Display messages that are as simple and direct as possible; this applies not only to health warnings but to all proposed messages, e.g. those reminding of the ban on sales to minors; * Use messages that are supported by scientific data and focus on the health effects of tobacco rather than social norms or emotional appeals. In particular, CMA recommends eliminating the message, “Smoking is a weakness, not a strength.” We believe that this message unfairly blames the victim for an activity that is in fact an addiction, not a weakness; * Display a list of toxic ingredients and additives; and * Provide information on treatment for tobacco addiction, for example, information on nicotine replacement, advice to smokers to consult their physicians if they are ready to stop smoking, and information about available cessation programs. Packages might also include inserts containing additional information on product content and health risks. This information should also be based on scientific evidence focusing on the medical consequences of tobacco use. However, the use of inserts should be carefully evaluated in light of its possible impact on the environment. The labelling requirements proposed in this paper are consistent with the spirit of CMA’s policy. We commend Health Canada for taking these steps, and for mandating health warnings not only on cigarettes but on all tobacco products. IV. The Larger Context It is important to emphasize that CMA does not consider the proposed regulations, or any other single initiative, a “miracle cure” for Canada’s tobacco problem. Just as there are a variety of reasons why children take up the smoking habit, so it will take a variety of initiatives, working in combination, to effectively fight tobacco. We urge the government of Canada to augment its proposed regulations on labelling and promotion by: * Providing support for smoking cessation services for those who are addicted to tobacco. CMA has been involved with three of its provincial divisions in the “Mobilizing Physicians for Clinical Tobacco Intervention (MP-CTI)” project, whose purpose is to help physicians counsel their patients on how to stop smoking. Evidence shows that even brief counseling by a health professional increases the quit rate, particularly when combined with the “patch” or other nicotine replacement therapies.3 MP-CTI has provided physicians and other health professionals with motivation to make smoking cessation counseling a part of their routine and with tools to enhance their counseling practices. The CMA believes that the government should support MP-CTI and other programs that encourage evidence-based practices in health care. * Continuing to increase consumer and manufacturer tobacco taxes, raising them as high as is compatible with discouraging smuggling. In our 1998 pre-budget brief to the Standing Committee on Finance we recommended that the government gradually increase tobacco taxes, and we supported the tobacco tax increase implemented in February 1998.4 * Providing funding to ensure that Canada maintains strong, sustained and effective programs to discourage children from smoking. In 1997 the Liberal Party promised to commit $100 million over five years for tobacco control programs, including $50 million for public education5. We would like to see this amount committed as a minimum, and preferably increased. The CMA also continues to support the concept of a levy on tobacco products to fund programs to discourage tobacco use, and we urge the government to take action soon in this regard. Tobacco is the number one cause of preventable disease and death in Canada. The CMA urges the Government of Canada to deal with it as strongly as the burden it imposes on this country warrants. V. References 1. Ellison LF, Mao Y, Gibbons L Projected smoking-attributable mortality in Canada, 1991 2000. Chron Dis Can 1995; 16: 84 - 89. 2. Health Canada. Economic Costs due to Smoking (Information Sheet). Health Canada, November 1996. 3. Agency for Health Care Policy and Research. Smoking Cessation (Clinical Practice Guideline Number 18). U.S. Department of Health and Human Services, 1996. 4. Canadian Medical Association. Canadians’ Access to Quality Health Care: a System in Crisis. Brief submitted to the House of Commons Standing Committee on Finance, August 1998. 5. Liberal party. Securing our Future. Liberal Party of Canada, 1997.
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Proposed Amendments to the Criminal Code of Canada (Impaired Driving) : Response to Issue Paper of the Standing Committee on Justice and Human Rights

https://policybase.cma.ca/en/permalink/policy1983
Last Reviewed
2018-03-03
Date
1999-03-05
Topics
Health care and patient safety
Population health/ health equity/ public health
  2 documents  
Policy Type
Parliamentary submission
Last Reviewed
2018-03-03
Date
1999-03-05
Topics
Health care and patient safety
Population health/ health equity/ public health
Text
The CMA believes that comprehensive long-term efforts that incorporate both deterrent legislation and public awareness and education constitute the most effective policy in attempting to reduce the number of lives lost and injuries suffered in crashes involving impaired drivers. The CMA supports a multidimensional approach to the issue. The CMA therefore recommends the following: * developing awareness campaigns and education programs, particularly at the high school level where the pattern of alcohol misuse is often established; * retaining the curative treatment provision found in Section 255(5) of the Criminal Code; * providing comprehensive treatment suited to the needs of the individual person. Those repeatedly convicted of impaired driving should be considered for mandatory assessment; * seizing or impounding the driver’s vehicle for the length of the license suspension if an individual is charged with impaired driving while his or her licence is suspended because of a previous impaired driving conviction; * lowering the legal BAC limit to 50 mg%; and * creating probationary licence systems for new drivers that would make it an offence to drive a motor vehicle during this probationary period with any measurable alcohol in the body. I. Introduction The Canadian Medical Association is the national voice of Canadian physicians. Our mission is to provide leadership for physicians and to promote the highest standard of health and health care for Canadians. The CMA is a voluntary professional organization representing the majority of Canada's physicians and comprising 12 provincial and territorial divisions and 43 affiliated medical organizations. On behalf of its 45,000 members and the Canadian public, CMA performs a wide variety of functions, including advocating health promotion and disease and accident prevention policies and strategies. It is in this capacity that we present our position on proposed amendments to the Criminal Code sections on impaired driving. The CMA welcomes this opportunity to comment on the issue of drinking and driving and the safety of our public roadways. The injuries and deaths resulting from impaired driving present a major public health concern. Physicians see the consequences of impaired driving in their practices. In 1996, 3,420 persons were killed in motor vehicle crashes. Alcohol was involved in 39.7% of those fatalitiesi. In CMA policy documents and publications like the Physicians’ Guide to Driver Examination, the CMA has advocated for measures to reduce injury and death resulting from drinking and driving. The CMA has previously endorsed legislation aimed at reducing the incidence of drinking and driving, including the use of the breathalyser test, more severe penalties for those convicted and the taking of a mandatory blood sample if the individual is unable to provide a breath sampleii. Several of CMA’s provincial and territorial divisions have also issued policy statements on impaired driving (Appendix 1). II. Multidimensional Approach From 1987 to 96, there was a general decline in the percentage of fatally injured drivers who had been drinkingiii. In 1996, of tested drivers fatally injured in motor vehicle crashes, 41.6% had been drinking (with a Blood Alcohol Content (BAC) over 1 mg%>) while 34.9% were legally impaired (BAC >80 mg%)iv. CMA believes that to reduce the number of fatalities and injuries even further, a comprehensive, multidimensional approach encompassing the expertise, resources and experience of health professionals and all levels of government is required. This approach encompasses: (1) public education, (2) medical assessment and treatment interventions and (3) legislation. 1. Public Education Drinking and driving must be viewed as socially unacceptable behaviour and until this change in attitude occurs, the judicial system cannot be completely effective in controlling the drinking and driving patterns of individuals. Education and information programs which increase society’s awareness of the consequences of using alcohol in combination with driving are integral parts of any attempt to reduce injuries and fatalities. The CMA supports and recommends the development of awareness campaigns and education programs, particularly at the high school level where the pattern of alcohol misuse is often established. 2. Medical Assessment and Treatment Interventions CMA shares the belief of specialists in the field of addiction medicine that punishment in the form of incarceration will not solve the problem of impaired drivingv. Rather, in addition to public education campaigns and criminal law sanctions, government must create and fund appropriate assessment and treatment interventions. Impaired drivers may be occasional users of alcohol. They may also suffer from the disease of Substance Dependence. In the case of alcohol, this disease is commonly known as alcoholism. There are several assessment tools and screening tests to diagnose chronic alcoholismvi. The term “Hard Core” drinking driver has also been coined to describe impaired drivers who repeatedly drive after drinking, often with a high BAC of 150 mg% or more. They are also resistant to change despite previous actions, treatment or education effortsvii. Although roadside surveys have revealed a general decrease in the overall level of drinking-driving in Canada, drivers with very high levels of BAC (over 150 mg%) seemed immune to this trendviii. “Hard Core” drinking drivers are most likely suffering from substance dependence or alcoholism, a condition requiring significant treatment interventionix. Physicians, in their educational capacity, can assist in establishing programs in the community aimed at the recognition of the early signs of alcohol abuse or dependency. These programs should recognize the chronic, relapsing nature of alcohol addiction as a disease. There is also good evidence that physician interactions like the Alcohol Risk Assessment and Intervention program developed by the College of Family Physicians of Canada can have a positive impact on the behaviours of moderate drinkersx. Another tool to aid physicians in the assessment of patients who drive impaired is the CMA publication, The Physicians’ Guide to Driver Examination. The Physicians’ Guide to Driver Examination is a collection of guidelines and expert opinions designed to help physicians assess their patients’ medical fitness to drive. The Physicians’ Guide discusses the impact of a variety of medical conditions on driving, including alcohol use, abuse and dependency. The Physicians’ Guide underlines the fact that alcohol-induced impairment is the single greatest contributor to fatal motor vehicle accidents in Canadaxi. The Physicians Guide to Driver Examination takes a strong stance on the status of drivers with chronic alcohol problems. It recommends that a chronic alcohol abuser should not be allowed to drive any type of motor vehicle until the patient has been assessed and received treatment. The Physicians' Guide to Driver Examination is currently under revision with an anticipated distribution date in the fall of 1999 for the sixth edition. (a) Discharge for Curative Treatment The Standing Committee on Justice and Human Rights has asked whether it is appropriate under Section 255(5) of the Criminal Code to allow the courts to discharge an impaired driver who is in need of “curative treatment” by placing that person on probation with a condition that he or she attends such treatment. Section 255(5) of the Criminal Code reads: Notwithstanding subsection 736(1), a court may, instead of convicting a person of an offence committed under section 253, after hearing medical or other evidence, if it considers that the person is in need of curative treatment in relation to his consumption of alcohol or drugs and that it would not be contrary to the public interest, by order direct that the person be discharged under section 730 on the conditions prescribed in a probation order, including a condition respecting the person’s attendance for curative treatment in relation to his consumption of alcohol or drugs. The CMA believes that Section 255(5) should remain within the Criminal Code. Section 255(5) is an important recognition within the punitive framework of the Criminal Code of the necessary medical and rehabilitative elements at stake in the issue of impaired driving. CMA believes that there are sufficient safeguards within the wording of Section 255(5) to conclude that it does not invite misuse. There are several hurdles to meet in Section 255(5) before the court may award curative treatment. First, the court hears “medical or other evidence”. In essence, the granting of the curative treatment order is not merely dependent on the pleas of the impaired driver. Second, the court must be satisfied that the discharge is not contrary to the public interest. In determining what is in the public interest, the courts look to the accused’s motivation and good faith, whether he or she was already subject to a driving prohibition, the risk of recidivism, previous convictions for impaired driving, prior curative discharges and the circumstances of the offence, including consideration of whether the accused was involved in an accident which caused death, bodily harm or significant property damagexii. Finally, it is highly unlikely that the “curative treatment” at issue in Section 255(5) would be involuntary or enforced against the wishes of the accused because his or her motivation or good will in pursuing treatment as an alternative to conviction is a key factor in the court’s decisionxiii. The CMA recommends retaining the curative treatment provision found in Section 255(5) of the Criminal Code. (b) Assessment and Rehabilitation Rehabilitation can occur through education and treatment programs designed for impaired drivers. The CMA believes it is important to provide comprehensive treatment suited to the needs of the individual person. The CMA recognizes that as an exception to the general rule that medical interventions should be voluntary, individuals repeatedly convicted of the offence of impaired driving should be considered for mandatory assessment. This mandatory assessment, followed by medical recommendations for appropriate treatment, would not only benefit those with a chronic alcohol problem but could also help to reduce the incidence of drunk driving incidents attributable to repeat offenders. Physicians have the training, knowledge and expertise to assist in developing alcohol assessment, treatment and rehabilitation programs. Currently, nine jurisdictions have some form of mandatory assessment and rehabilitation programsxiv. The CMA recommends providing comprehensive treatment suited to the needs of the individual person. Those repeatedly convicted of impaired driving should be considered for mandatory assessment. 3. Legislation (a) Impoundment On the issue of whether the current penalties provide sufficient deterrence, the CMA is in general agreement with the impoundment measures currently found in eight provincial and territorial jurisdictionsxv. CMA would encourage jurisdictions that do not have these impoundment programs to consider enacting them. Since 1989, the CMA has recommended that if an individual is charged with impaired driving while his or her licence is suspended because of a previous impaired driving conviction, the suspended driver’s vehicle should be seized or impounded for the length of the license suspension. (b) Blood Alcohol Content (BAC) In response to the question of whether the legal BAC limit should be lowered from 80 mg%, since 1988 the CMA has supported 50 mg% as the general legal limit. Studies suggest that a BAC limit of 50 mg% could translate into a 6% to 18% reduction in total motor vehicle fatalities or 185 to 555 fewer fatalities per year in Canadaxvi. A lower limit would recognize the significant detrimental effects on driving-related skills that occur below the current legal BACxvii. Finally, the CMA notes that many jurisdictions have 50 mg% as the limit for impairmentxviii. The CMA recommends lowering the legal BAC limit to 50 mg%. The CMA has also supported the 1987 recommendation of the former Standing Committee of National Health and Welfare on Alcohol and Drug Abuse in Canada that the provinces establish a probationary or graduated licence system for new drivers that would make it an offence to drive a motor vehicle during this probationary period with any measurable alcohol in the body. Several studies have remarked on the significant reduction in casualty collisions when there is a 0 BAC limit for novice drivers xix. The CMA notes that several provinces have instituted such a graduated licensing systemxx. The CMA supports probationary licence systems for new drivers that would make it an offence to drive a motor vehicle during this probationary period with any measurable alcohol in the body. (c) Police Powers On the issue of police powers to demand breath, blood or saliva samples for alcohol and/or blood testing, the CMA reiterates its earlier support for mandatory blood alcohol testing as outlined in the Criminal Code. At the request of CMA, physicians and other health care workers who take blood samples under this law are specifically protected from criminal and/or civil litigation, but it is not an offense for these health care workers to refuse to take a blood samplexxi. III. Conclusion The CMA believes that comprehensive long-term efforts that incorporate both deterrent legislation and public awareness and education campaigns constitute the most effective policy in attempting to reduce the number of lives lost and injuries suffered in crashes involving impaired drivers. It is prefererable to use countermeasures that prevent the occurrence of motor vehicle crashes involving impaired drivers rather than those that deal with the offender after the fact. The multifaceted nature of the issue of impaired driving requires multidimensional countermeasures as part of a comprehensive policy involving all levels of government, private organizations, communities and individuals. The CMA urges all Canadians to support such efforts to reduce the prevalence of drinking and driving. IV. Appendix 1 A List of Some Policy Statements and Resolutions on Impaired Driving from CMA Provincial and Territorial Divisions: * Alberta Medical Association, 1983: That the AMA recommend to the Government of Alberta that it take whatever steps are necessary to ensure that there are adequate penalties for impaired driving and that such penalties are well enforced. * New Brunswick Medical Society: February, 1988.“Statement on Driving Impairment” October, 1992. “NBMS Position Statement on Alcohol” * Northwest Territories Medical Association: Endorsed June, 1998. “Strategy to Reduce Impaired Driving in the Northwest Territories: Interagency Working Group on Impaired Driving. June, 1996.” * Ontario Medical Association: November, 1994. “An OMA Position Paper on Drinking and Driving”. V. Endnotes i.Traffic Injury Research Foundation (TIRF) (1998).Strategy to Reduce Impaired Driving 2001: STRID 2001 Monitoring Report: Progress in 1996 and 1997. Ottawa: Traffic Injury Research Foundation at 25, 28. ii.Canadian Medical Association (1989). Substance Abuse and Driving: A CMA Review. Ottawa: Canadian Medical Association at 3. 3. Mayhew, D.R., S.W. Brown and H.M. Simpson. (1998) Alcohol Use Among Drivers and Pedestrians Fatally Injured in Motor Vehicle Accidents: Canada, 1996. Ottawa: Traffic Injury Research Foundation at 19. iv.Ibid at 13-14. v. Hajela, Raju CD, MD, MPH, CCFP, CASAM, FASAM, President of the Canadian Society of Addiction Medicine. Letter to CMA dated January 13, 1999. vi.American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, DSM-IV. Washington, D.C.: American Psychiatric Press. vii. Beirness, D.J., H.M. Simpson, and D.R. Mayhew (1998). Programs and policies for reducing alcohol-related motor vehicle deaths and injuries. Contemporary Drug Problems 25/Fall 1998. See also the Century Council (1998) National Hardcore Drunk Driver Project. http://www.dwidata.org. viii. Beirness, D.J., Mayhew, D.R., Simpson, H.M. and Stewart, D.E. (1995) Roadside surveys in Canada: 1974-1993. In Kloeden, C.N. and McLean, A.J. (eds). Alcohol, Drugs and Traffic Safety-T’95.Adelaide, Australia:NHMRC Road Accident Research Unit, University of Adelaide, pp. 179-184 as cited in Mann, Robert E., Scott Macdonald, Gina Stoduto, Abdul Shaikh and Susan Bondy (1998) Assessing the Potential Impact of Lowering the Blood Alcohol Limit to 50 MG % in Canada. Ottawa: Transport Canada, TP 13321 E at 14-15. ix. Hajela, note 5 at 2. x. Brison, Robert J., MD (1997). The Accidental Patient. Canadian Medical Association Journal, 157 (12) 1661-1662. xi. Canadian Medical Association (1991).Physicians' Guide to Driver Examination. Ottawa: Canadian Medical Association at 51. xii. R v. Storr (1995), 14 M.V.R. (3d) 34 (Alta. C.A.). xiii. Ibid. xiv.Traffic Injury Research Foundation (TIRF), note 1 at 12. xv.Ibid. xvi. Mann et al., note 8 at 54. xvii. Moskowitz, H. and Robinson, C.D. (1988). Effects of Low Doses of Alcohol on Driving Skills: A Review of the Evidence. Washington, DC: National Highway Traffic Safety Administration, DOT-HS-800-599 as cited in Mann, et al., note 8 at page 12-13. xviii.Mann et al., note 8 at 24. xix.Hingson, R., Heeren, T. and Winter, M. (1994) Lower legal blood alcohol limits for young drivers. Public Health Reports, 109, 738-744 as cited in Mann et al., note 8 at 36. xx.Mann et al., note 8 at 29. xxi.Canadian Medical Association, note 2 at 3.
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CMA Patient Safety Policy Framework (Update 2010)

https://policybase.cma.ca/en/permalink/policy9747
Last Reviewed
2018-03-03
Date
2010-02-27
Topics
Health care and patient safety
  1 document  
Policy Type
Policy document
Last Reviewed
2018-03-03
Date
2010-02-27
Replaces
CMA Patient Safety Policy Framework (2001)
Topics
Health care and patient safety
Text
CMA PATIENT SAFETY POLICY FRAMEWORK (Update 2010) BACKGROUND The CMA’s mission is to promote the highest standard of health and health care for Canadians. This means, among other things, ensuring that the health care system is safe for patients and providers and effective in achieving good health outcomes for individuals and society. Unfortunately, studies published in recent years have raised concern that health care is not as safe as it could be; data collected by researchers in various countries has shown that there are unacceptably high levels of preventable adverse events, as high as 16% in one study of adverse events associated with hospital admissions. A study conducted by G. R. Baker, P.G. Norton et al, “The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada” showed an adverse event rate of 7.5 per 100 hospital admissions. (1) This suggests that of the nearly 2.5 million hospital admissions yearly in Canada, approximately 185,000 are associated with an adverse event and 70,000 of those possibly preventable. These studies have focused attention on health care error and adverse events, but patient safety requires that participants in the health care system are constantly aware of the risks present in the system, and that risks are addressed proactively - preferably before an adverse event occurs. If a preventable adverse event does occur, it provides an opportunity to learn about and correct sources of error. The CMA considers that a national patient safety strategy, aimed at building a culture of safety, is a priority. This Policy Framework has been developed to provide a clear statement of the CMA’s views on the principles that should underpin a patient safety strategy and to ensure clear support and direction for CMA members and staff involved in patient safety initiatives. PRINCIPLES The Health Care System Outcomes Errors and adverse events are inevitable in any complex system and more complex systems are more prone to errors. Nevertheless, studies have demonstrated an unacceptably high level of preventable adverse events associated with management of health care. 1. Patient safety initiatives should aim to improve health outcomes for patients by minimizing the rate of preventable adverse events and improving the management of events when they occur. Quality 2. Patient safety is one aspect of quality health care; activities relating to patient safety should result in a net increase in the quality of health care. Systemic factors 3. Patient safety initiatives should recognize that error and adverse events occur because of qualities of the system within which individuals operate. A primary concern of initiatives should be to prevent future errors by addressing the system rather than blaming and punishing individuals. Accountability The Canadian public has a reasonable expectation that health care will not result in avoidable injury. 4. Patient safety initiatives should support the accountability of the health sector, including providers, funders and regulators, to patients and the wider public for the safety of health care. Participants in Health Care Patients as partners 5. Patient safety initiatives should promote the role of patients as partners in the provision of safe care, including the prevention and management of adverse events. 6. Patient safety initiatives should encourage and anticipate the full and appropriate disclosure to patients of relevant information that is material to their health and healthcare, including information about adverse events or effects. Professional responsibility and support With a very few exceptions, health care is delivered by competent, caring professionals who are striving to achieve a good outcome for patients. 7. Patient safety initiatives should recognize the responsibility of professionals for achieving and maintaining the standard of their own practice. 8. Patient safety initiatives, while responding appropriately to adverse events, should be sensitive to the professional role and personal well being of individual physicians and other health care providers. Learning and Collaboration 9. Patient safety initiatives should promote and reflect teamwork, communication and collaboration at all levels. 10. Patient safety initiatives should support learning from one’s own experience and the sharing of knowledge so that it is possible to learn from the experience of others. Legal and Regulatory Environment 11. Patient Safety initiatives should promote a legal and regulatory environment that supports open communication and effective management of adverse events. 12. The protection afforded to the opinions expressed within quality assurance committees must be upheld Evidence Base and Evaluation Patient safety initiatives should be based on sound evidence. Patient safety initiatives should contain provision for appropriate evaluation. Patient safety initiatives should contain provision for broad dissemination of findings. PATIENT SAFETY INITIATIVE AREAS Building a culture of safety in Canadian health care will require the collaboration of many different groups and organizations. The CMA can play a leadership role within this larger group and within its own constituency of over 70,000 physicians. In some instances, it will be the CMA’s role to advocate for initiatives that can be delivered only by another provider or through a consortium; in other instances, CMA can assume sole responsibility for taking action. The CMA has identified that, as priorities, it will support: Advocacy for changes to legislation and regulation that would remove disincentives for health care providers to share information about adverse events. Raising awareness of patient safety and changing attitudes towards risk, error and adverse events within the health care community. Developing and providing resources such as clinical practice guidelines and information technology systems that have been shown to standardize practice and reduce adverse events. Reporting systems that collect and aggregate data on risks so that good practices can be developed and shared. Education and training for health care professionals and managers to provide them with the conceptual and practical tools to introduce change into their practice and organizations. Advocacy for, and development of, an agenda for patient safety research in Canada. The involvement of government at all levels in supporting and committing resources to initiatives for improved patient safety. GLOSSARY Adverse event – any unintended injury or complication that is caused by health care management rather than the patient’s disease and that leads to prolonged hospital stay, morbidity or mortality. Adverse events do not necessarily result from error, for example a toxic reaction to a drug in a patient without apparent risk factors for the reaction. Error – the failure of a planned action to be completed as intended (“error of execution”) or the use of a wrong plan to achieve an aim (“error of planning”). An error may not result in an adverse event if the error does not result in harm or is intercepted. Risk – the chance of injury or loss as defined as a measure of the probability and severity of an adverse effect to health, property, the environment or other things of value. (1) G. Ross Baker, Peter G. Norton, Virginia Flintoft, Régis Blais, Adalsteinn Brown, Jafna Cox, Ed Etchells, William A. Ghali, Philip Hébert, Sumit R. Majumdar, Maeve O'Beirne, Luz Palacios-Derflingher, Robert J. Reid, Sam Sheps, and Robyn Tamblyn. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada Can. Med. Assoc. J., May 2004; 170: 1678 - 1686.
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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
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