Skip header and navigation
CMA PolicyBase

Policies that advocate for the medical profession and Canadians


7 records – page 1 of 1.

2015 Pre-budget consultations: Federal leadership to support an aging population

https://policybase.cma.ca/en/permalink/policy11753
Date
2015-07-31
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Date
2015-07-31
Topics
Health systems, system funding and performance
Population health/ health equity/ public health
Text
Helping physicians care for patients Aider les médecins à prendre soin des patients Canada is a nation on the precipice of great change. This change will be driven primarily by the economic and social implications of the major demographic shift already underway. The added uncertainties of the global economy only emphasize the imperative for federal action and leadership. In this brief, the Canadian Medical Association (CMA) is pleased to present four recommendations to the House of Commons Standing Committee on Finance for meaningful federal action in support of a national seniors strategy; these are essential measures to prepare for an aging population. Canada's demographic and economic imperative In 2011 the first of wave of the baby boomer generation turned 65 and Canada's seniors population stood at 5 million.1 By 2036, seniors will represent up to 25% of the population.2 The impacts of Canada's aging population on economic productivity are multi-faceted. An obvious impact will be fewer workers and a smaller tax base. Finance Canada projects that the number of working-age Canadians for every senior will fall from about 5 today to 2.7 by 2030.3 The projected surge in demand for services for seniors that will coincide with slower economic growth and lower government revenue will add pressure to the budgets of provincial and territorial governments. Consider that while seniors account for about one-sixth of the population, they consume approximately half of public health spending.4 Based on current trends and approaches, seniors' care is forecast to consume almost 62% of provincial/territorial health budgets by 2036.5 The latest fiscal sustainability report of the Parliamentary Budget Officer explains that the demands of Canada's aging population will result in "steadily deteriorating finances" for the provinces and territories and they "cannot meet the challenges of population ageing under current policy."6 Theme 1: Productivity A) New federal funding to provincial/territorial governments Canada's provincial and territorial leaders are aware of the challenges ahead. This July, the premiers issued a statement calling for the federal government to increase the Canada Health Transfer to 25% of provincial and territorial health care costs to address the needs of an aging population. To support the innovation and transformation needed to address these needs, the CMA recommends that the federal government deliver additional funding on an annual basis beginning in 2016-17 to the provinces and territories by means of a demographic-based top-up to the Canada Health Transfer (Table 1). For the fiscal year 2016-17, this top-up would require $1.6 billion in federal investment. Table 1: Allocation of the federal demographic-based top-up, 2016-20 ($million)7 Jurisdiction 2016 2017 2018 2019 2020 All of Canada 1,602.1 1,663.6 1,690.6 1,690.3 1,879.0 Newfoundland and Labrador 29.7 30.5 33.6 35.3 46.1 Prince Edward Island 9.1 9.7 10.6 10.6 11.5 Nova Scotia 53.6 58.6 62.3 61.9 66.6 New Brunswick 45.9 50.7 52.2 52.0 57.2 Quebec 405.8 413.7 418.8 410.2 459.5 Ontario 652.2 677.9 692.1 679.0 731.6 Manitoba 28.6 30.6 33.5 31.1 36.6 Saskatchewan 3.5 4.9 7.3 11.9 15.4 Alberta 118.5 123.3 138.9 134.9 157.5 British Columbia 251.6 258.7 270.3 258.4 291.3 Yukon 1.4 2.6 2.1 2.4 2.5 Northwest Territories 1.4 1.6 1.7 1.7 2.1 Nunavut 0.9 0.6 0.8 0.9 1.0 B) Federal support for catastrophic drug coverage A major gap in Canada's universal health care system is the lack of universal access to prescription medications, long recognized as the unfinished business of medicare. Canada stands out as the only country with universal health care without universal pharmaceutical coverage.8 According to the Angus Reid Institute, more than one in five Canadians (23%) report that they or someone in their household did not take medication as prescribed because of the cost during the past 12 months.9 Statistics Canada's Survey of Household Spending reveals that households headed by a senior spend $724 per year on prescription medications, the highest among all age groups and over 60% more than the average household.10 Another recent study found that 7% of Canadian seniors reported skipping medication or not filling a prescription because of the cost.11 In addition to the very real harms to individuals, lack of coverage contributes to the inefficient use of Canada's scarce health resources. While there are sparse economic data in Canada on this issue, earlier research indicated that this inefficiency, which includes preventable hospital visits and admissions, represents an added cost of between $1 billion and $9 billion annually.12 As an immediate measure to support the health of Canadians and the productivity of the health care sector, the CMA recommends that the federal government establish a new funding program for catastrophic coverage of prescription medication. The program would cover prescription medication costs above $1,500 or 3% of gross household income on an annual basis. Research commissioned by the CMA estimates this would cost $1.48 billion in 2016-17 (Table 2). This would be a positive step toward comprehensive, universal prescription drug coverage. Table 2: Projected cost of federal contribution to cover catastrophic prescription medication costs, by age cohort, 2016-2020 ($ million)13 Age cohort 2016 2017 2018 2019 2020 Share of total cost Under 35 years 107.0 107.6 108.2 108.8 109.3 7% 35 to 44 years 167.4 169.8 172.7 175.7 178.4 11% 45 to 54 years 274.2 270.2 270.2 265.7 262.8 18% 55 to 64 years 362.5 370.7 378.6 384.6 388.2 25% 65 to 74 years 292.1 304.0 315.8 328.4 341.9 21% 75 years + 286.3 292.0 299.0 306.6 314.4 20% All Ages 1,480.4 1,497.2 1,514.2 1,531.2 1,548.1 100% Theme 2: Infrastructure and communities All jurisdictions across Canada are facing shortages in the continuing care sector. Despite the increased availability of home care, research commissioned for the CMA indicates that demand for continuing care facilities will surge as the demographic shift progresses.14 In 2012, it was reported that wait times for access to a long-term care facility in Canada ranged from 27 to over 230 days. It is estimated that 85% of "alternate level of care" patients in hospitals (i.e., patients who do not require hospital-level care) are in these beds because of the lack of availability of long-term care. Due to the significant difference in the cost of hospital care (approximately $846 per day) versus long-term care ($126 per day), the CMA estimates that the shortages in the long-term care sector represent an increased cost of $2.3 billion. Despite the recognized need for infrastructure investment in the continuing care sector, to date, this sector has been excluded from the Building Canada Plan. The CMA recommends that the federal government amend the criteria of the Building Canada Plan to include capital investment in continuing care infrastructure, including retrofit and renovation. Based on previous estimates, the CMA recommends that $540 million be allocated for 2016-17 (Table 3). Table 3: Estimated cost to address forecasted shortage in long-term care beds, 2016-20 ($ million)15 Forecasted shortage in long-term care beds Estimated cost to address shortage Federal share to address shortage in long-term care beds (based on 1/3 contribution) 2016 6,028 1,621.5 540.5 2017 6,604 1,776.5 592.2 2018 8,015 2,156.0 718.7 2019 8,656 2,328.5 776.2 2020 8,910 2,396.8 798.9 Total 38,213 10,279.3 3,426.4 Theme 3: Jobs As previously mentioned, Canada's aging population will produce significant changes in the labour force. There will be fewer Canadian workers, each with a greater likelihood of having caregiving responsibilities for family and friends. According to the report of the federal Employer Panel for Caregivers, Canadian employers "were surprised and concerned that it already affects 35% of the Canadian workforce."16 This report highlights key findings of the 2012 General Social Survey: 1.6 million caregivers took leave from work; nearly 600,000 reduced their work hours; 160,000 turned down paid employment; and, 390,000 quit their jobs to provide care. It is estimated that informal caregiving represents $1.3 billion in lost workforce productivity. These costs will only increase as Canada's demographic shift progresses. In parallel to the increasing informal caregiving demands on Canadian workers, Canada's aging population will also increase the demand for personal care workers and geriatric competencies across all health and social care professions.17 Theme 4: Taxation The above section focused on the economic costs of caregiving on the workforce. The focus of this section will be on the economic value caregivers provide while they take on an increased economic burden. Statistics Canada's latest research indicates that 8.1 million Canadians are informal caregivers, 39% of whom primarily care for a parent.18 The Conference Board of Canada reports that in 2007 informal caregivers contributed over 1.5 billion hours of home care - more than 10 times the number of paid hours in the same year.19 The economic contribution of informal caregivers was estimated to be about $25 billion in 2009.20 This same study estimated that informal caregivers incurred over $80 million in out-of-pocket expenses related to caregiving in 2009. Despite their tremendous value and important role, only a small fraction of caregivers caring for a parent received any form of government support.21 Only 5% of caregivers providing care to parents reported receiving financial assistance while 28% reported needing more assistance than they received.22 As a first step to providing increased support for Canada's family caregivers, the CMA recommends that the federal government amend the Caregiver and Family Caregiver Tax Credits to make them refundable. This would provide an increased amount of financial support for family caregivers. It is estimated that this measure will cost $90.8 million in 2016-17.23 Conclusion The CMA recognizes that in the face of ongoing economic uncertainty the federal government may face pressures to avoid new spending initiatives. The CMA strongly encourages the federal government to adopt the four recommendations outlined in this submission rather than further delay making a meaningful contribution to meeting the future care needs of Canada's aging population. The CMA would welcome the opportunity to provide further information and its rationale for each recommendation. 1 Statistics Canada. Generations in Canada. Cat. No. 98-311-X2011003. Ottawa: Statistics Canada; 2012. Available: www12.statcan.gc.ca/census-recensement/2011/as-sa/98-311-x/98-311-x2011003_2-eng.pdf 2 Statistics Canada. Canada year book 2012, seniors. Available: www.statcan.gc.ca/pub/11-402-x/2012000/chap/seniors-aines/seniors-aines-eng.htm 3 Finance Canada. Economic and fiscal implications of Canada's aging population. Ottawa: Finance Canada; 2012. Available: www.fin.gc.ca/pub/eficap-rebvpc/eficap-rebvpc-eng.pdf 4 Canadian Institute for Health Information. National health expenditure trends, 1975 to 2014. Ottawa: The Institute; 2014. Available: www.cihi.ca/web/resource/en/nhex_2014_report_en.pdf 5 Calculation by the Canadian Medical Association, based on Statistics Canada's M1 population projection and the Canadian Institute for Health Information age-sex profile of provincial-territorial health spending. 6 Office of the Parliamentary Budget Officer. Fiscal sustainability report 2015. Ottawa: The Office; 2015. Available: www.pbo-dpb.gc.ca/files/files/FSR_2015_EN.pdf 7 Conference Board of Canada. Research commissioned for the CMA, July 2015. 8 Morgan SG, Martin D, Gagnon MA, Mintzes B, Daw JR, Lexchin J. Pharmacare 2020: The future of drug coverage in Canada. Vancouver: Pharmaceutical Policy Research Collaboration, University of British Columbia; 2015. Available: http://pharmacare2020.ca/assets/pdf/The_Future_of_Drug_Coverage_in_Canada.pdf 9 Angus Reid Institute. Prescription drug access and affordability an issue for nearly a quarter of Canadian households. Available: http://angusreid.org/wp-content/uploads/2015/07/2015.07.09-Pharma.pdf 10 Statistics Canada. Survey of household spending. Ottawa: Statistics Canada; 2013. 11 Canadian Institute for Health Information. How Canada compares: results From The Commonwealth Fund 2014 International Health Policy Survey of Older Adults. Available: www.cihi.ca/en/health-system-performance/performance-reporting/international/commonwealth-survey-2014 12 British Columbia Pharmacy Association. Clinical service proposal: medication adherence services. Vancouver: The Association; 2013. Available: www.bcpharmacy.ca/uploads/Medication_Adherence.pdf 13 Supra at note 7. 14 Conference Board of Canada. Research commissioned for the CMA, January 2013. 15 Ibid. 16 Government of Canada. Report from the Employer Panel for Caregivers: when work and caregiving collide, how employers can support their employees who are caregivers. Available: www.esdc.gc.ca/eng/seniors/reports/cec.shtml 17 Stall S, Cummings G, Sullivan T. Caring for Canada's seniors will take our entire health care workforce. Available: http://healthydebate.ca/2013/09/topic/community-long-term-care/non-md-geriatrics 18 Statistics Canada. Family caregivers: What are the consequences? Available: www.statcan.gc.ca/pub/75-006-x/2013001/article/11858-eng.htm 19 Conference Board of Canada. Home and community care in Canada: an economic footprint. Ottawa: The Board; 2012. Available: http://www.conferenceboard.ca/cashc/research/2012/homecommunitycare.aspx 20 Hollander MJ, Liu G, Chappeel NL. Who cares and how much? The imputed economic contribution to the Canadian health care system of middle aged and older unpaid caregivers providing care to the elderly. Healthc Q. 2009;12(2):42-59. 21 Supra at note 16. 22 Ibid. 23 Supra at note 7.
Documents
Less detail

Bill C-12: An Act to prevent the introduction and spread of communicable disease : CMA’s Submission to the House of Commons Standing Committee on Health

https://policybase.cma.ca/en/permalink/policy1948
Last Reviewed
2012-03-03
Date
2004-11-23
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2012-03-03
Date
2004-11-23
Topics
Population health/ health equity/ public health
Text
The Canadian Medical Association (CMA) appreciates the opportunity to appear before the House of Commons Standing Committee on Health to provide our observations concerning Bill C-12, an Act to prevent the introduction and spread of communicable disease, which will repeal and replace the current Quarantine Act. Since our founding in 1867, the CMA has had a long tradition in the field of public health and infectious diseases. For example, in 1885 we worked with the federal government to prevent an outbreak of cholera in Canada, while in 1891 we began a long campaign to encourage governments to deal with tuberculosis. And fast forward to 2003 and SARS, CMA worked along with many levels of government to deal with this public health crisis. While the CMA is particularly interested in how the proposed legislation will impact the practices of our more than 58,000 members across the country, we have reviewed this legislation through the lens of what is in the best interest of patients and the public. 1) Comprehensive Approach to Public Health Our comments call for and are embedded in the broader context of a comprehensive approach to public health. They are also based on previous recommendations CMA has made to the federal government including: a) Response to the Health Protection Legislative Renewal initiative carried out by Health Canada (2004). In this submission, CMA identified the Quarantine Act as a piece of legislation the CMA believed merited urgent updating; b) Review of the World Health Organizations’ draft revised International Health Regulations (IHR), (2004); c) Submission to the Naylor Advisory Committee on SARS and Public Health (2003); d) Submission to the Senate Standing Committee on Social Affairs, Science and Technology during its study of public health issues (2003); and e) Pre-budget submission to the House of Commons Standing Committee on Finance following September 11, 2001. These submissions are all available on request, or at www.cma.ca. The CMA is pleased that Parliament has identified revision of the Quarantine Act as a priority. The Act is more than a century old and the medical community and others have long called for it to be updated. Bill C-12 is an excellent start to modernizing the previous Act; however, we believe the proposed legislation does not go far enough in remedying its deficiencies. In this submission we present eight key recommendations for your consideration, along with questions about particulars in the implementation process, which we suggest Parliament address in subsequent review of the Act and its regulations. 2) Recommendations for Consideration in Review of Bill C-12 Recommendation 1: The Act should be part of a larger, comprehensive Emergency Health Measures Plan. In our brief to the Naylor Advisory Committee, CMA recommended the enactment of a comprehensive Emergency Health Measures Act, administered by the Chief Public Health Officer of Canada. This Act would consolidate and enhance existing legislation, allowing for a more rapid national response to health emergencies, in cooperation with the provinces and territories, based on a graduated, systematic approach. We also recommended that the Emergency Health Measures Act be part of a strong commitment, by all levels of government, to a public health strategy that also included a 5-year capacity enhancement program, development of research and surveillance capability; and funding for a communications initiative to improve technical capacity for real-time communication with front-line health providers during public health emergencies. Recommendation 2: The Chief Public Health Officer of Canada must have authority to enforce the Act The proposed legislation designates the Minister of Health as the person with ultimate responsibility for enforcing the Act; it grants the Minister sweeping powers including the power to overrule a health official’s quarantine. As medical professionals we believe that public health decisions should be made primarily on the basis of the best available medical and scientific evidence, and should be independent to the greatest extent possible of other considerations. Therefore we believe that responsibility for the implementation of the Act should rest with the Public Health Agency of Canada, and with the Chief Public Health Officer of Canada, not with the Minister of Health. In the provinces and territories, Medical Officers of Health do not require approvals from their Ministers to exercise their functions as health professionals; the same should hold true at the federal level. We understand that responsibility has been placed with the Minister of Health due to a lack of existing legislation setting out the mandate, roles, responsibilities and powers of the recently created Public Health Agency of Canada, and the newly appointed Chief Public Health Officer of Canada. We are also aware that enabling legislation is currently being prepared; we urge that this legislation be enacted as soon as possible. On enactment of this enabling legislation, the powers now vested in the Minister should be ceded to the Chief Public Health Officer. Locating responsibility for administration of the Act within the Public Health Agency of Canada will also combine enforcement with other needed functions of surveillance, monitoring and linkage with international monitoring agencies. As we stressed in our previous recommendation, these must all be part of a comprehensive Canadian emergency response strategy. Recommendation 3: The Act must address interprovincial as well as international traffic. We are happy that the provisions of Bill C-12 apply to goods and travellers leaving as well as entering Canada. This was a deficiency identified in the previous Quarantine Act. However, the Act must also expressly address goods and travellers crossing provincial or territorial boundaries. Currently, there is tremendous variation in public health system capacity among provinces and territories and, more particularly, among municipalities and local authorities. Inconsistencies in provincial approaches to public health matters have resulted in significant weaknesses in the “emergency shield” between and across provinces. Unless the potential consequences of these disparities are remedied through federal legislation they must, as a priority, be remedied through federal/provincial/territorial agreements. The role of the Public Health Agency of Canada in facilitating, equalizing and monitoring the management of public health emergencies nationwide must be enshrined in the legislation that establishes the Agency. CMA also hopes that the development of a pan-Canadian Public Health Network, acknowledged in the 2004 Throne Speech, will facilitate the nationwide collaboration essential for adequate and appropriate response to health emergencies. The CMA supports those provisions in Bill C-12 that give the Minister (preferably the Chief Public Health Officer of Canada) the power to establish quarantine centres anywhere in the country. In times of threat to national health security, such bold leadership would be both warranted and expected. Recommendation 4: “Public Health Emergency” must be adequately defined. Bill C-12 contains no definition of “public health emergency” or “public health emergency of international concern.” We believe these should be defined.1 Bill C-12 includes a schedule of specific communicable diseases to which its provisions would apply. We are concerned that this Schedule may limit Canada’s capacity to respond to emergencies. The next public health emergency may be a disease we have not heard of yet; or it may be a bio-terrorist attack, or a chemical or nuclear event. The Act must enable Canada to respond to new and emerging, as well as existing, threats to health. The World Health Organizations’ draft International Health Regulations (IHR) has proposed a set of criteria for assessing emergencies; these include: * Is the event serious? * Is the event unexpected? * Is there a significant risk of international spread? The CMA urges the Canadian government to consider a hybrid approach incorporating both known disease states and criteria such as the ones used by the IHR, for assessing new diseases or other public health emergencies. Recommendation 5: The Act, or its regulations, must clarify the roles, responsibilities and training requirements of emergency response personnel. Some provisions of Bill C-12 have raised questions in our minds about the scope of practice of personnel involved in disease screening, and we would appreciate clarification on these points. For example: Screening officers, the first point of contact for travelers entering or leaving Canada, are customs officers and others designated by the Minister. Their primary role under Section 14 of the Act is to use “non-invasive” screening technology to detect travelers entering and exiting Canada with communicable disease vectors, etc. According to Section 15 (3) screening officers, who are not health professionals, will have the power to “order any reasonable measure to prevent spread of a communicable disease”. Of what might these “reasonable measures” consist? Quarantine officers, by definition in Section 5(2) are medical practitioners or other health professionals or anyone else in this “class of persons”. Since the quarantine officer’s job description includes physical assessment of travellers to determine whether they should be detained – a function that requires the expertise of a health professional - we would appreciate clarification of the phrase “in this class”. Similarly, under Section 26, the quarantine officer has the power to order the traveler “to comply with treatment”. Which officer—screening/quarantine or medical—might actually prescribe the course of treatment? This function must be specifically delegated to medical officers. Bill C-12 gives authorities the powers to restrict personal movement and temporarily impound or seize property. The CMA believes that the government should also provide adequate resources and powers to allow for tracking down apparently well people who cross borders and are subsequently diagnosed with infectious diseases. The Act or its regulations should also address factors that hinder deployment of qualified health professionals, such as portability of licensure and coverage for malpractice and disability insurance. CMA has previously called for the establishment of a Canadian Public Health Emergency Response Service that would maintain a “reserve” of public health professionals who could be deployed to areas of need during times of crisis, and which would co-ordinate the logistics of the issues above mentioned. This would improve the capacity of health professionals to be deployed quickly in times of health emergency, to locations where they are most needed. Finally, CMA suggests that the Act or its regulations provide greater detail on training requirements for screening officers, to guarantee that they are appropriately trained. Recommendation 6: Privacy and confidentiality must be respected and safeguarded. Bill C-12 grants quarantine officers and the Minister some sweeping powers to arrest and detain people without warrants, including people who have refused to comply with testing. Though on rare occasions such measures may be required to protect the public, it is recognized that potential for their abuse may exist. In addition, Bill C-12 raises questions about the degree to which personal health information might be exposed to scrutiny. We note that Section 51 authorizes a quarantine officer to “order any person to provide any information or record…the officer might reasonably require.” This provision could include patient medical records in a doctor’s office, particularly if the Bill guarantees travellers the right to request a “second opinion” which we assume could be obtained from any practicing physician in Canada. Similarly, Sections 55 and 56 appear to give the Minister authority to “collect medical information in order to carry out the purposes of this Act” and to “disclose personal information obtained under the Act” to a host of entities. The CMA believes that the power to obtain and disclose information should be explicitly constrained and circumstances under which this power could be exercised must be outlined in the Act. Recommendation 7: The role of physicians and other health care workers must be respected. The health professional sector is on the front lines of response to health emergencies, as they were during the SARS outbreak. Therefore as a first principle the new Act should recognize the importance of health professionals having the power, subject to appropriate constraints, to make vital decisions in response to health emergencies. This is a legitimate delegation of power, because of the competencies of health professionals. During the SARS outbreak of 2003, physicians and other health care providers were not only partners in containing infection; many became ill or died as well. Since health care workers expose themselves to infection as they respond to health emergencies, protocols should ensure that care and attention is paid to their safety, through measures such as ensuring ready availability of proper masks The Act or regulations should address precautions required to protect quarantine officers and other health care workers from transmission of disease or the effects of becoming ill. For example, it should address compensation for quarantine officers who lose work because they become infected in the course of their duty. We would be remiss in our review of this act if we did not pursue with this Committee the issue of compensation and indemnification programs for physicians and trainees requiring quarantine because of exposure to a communicable disease while providing medical service, or who are required to close their offices for other public health reasons, or who cannot practice in hospitals because of closure of hospitals for public health reasons. Indeed, delegates to our annual general council meeting called on the CMA to do so. A number of these physicians were caught in such situations during the turmoil of the SARS outbreak. Recommendation 8: Decision-making should be evidence-based. At times, public perception and political considerations may widely influence the assessment and management of risk. While this is probably unavoidable, CMA believes that public policy should be founded first and foremost on the highest possible quality of scientific evidence. The Act should provide the requisite mechanisms to ensure that reviews of risk are independent and unbiased. We acknowledge, however, that this principle should not be rigidly applied; “we’re waiting for the evidence” must not be used as an excuse for inaction when action is urgently required. 3) Additional Comments In addition to the above recommendations, additional concerns remain regarding implementation of the Act. In particular we note that many crucial components, such as how physical examinations are to be carried out (section 62(1), medical practitioner’s review process (section 62(d), and the protection of personal information (62(g) are left to regulations. These regulations must be developed as soon as possible. We understand that the current Act constitutes “Phase I” of a longer-term strategy to enhance Canada’s capacity to respond to public health emergencies. Though we believe that the Quarantine Act merits attention at this time, we also believe that it should be looked at with a longer-term view. For instance, as we have already recommended, it should be incorporated into the broader legislative renewal of public health in Canada, with a view to enhancing this country’s ability to respond swiftly and effectively to public health emergencies, locally and nationwide. Above all, Canada must ensure a sustained and substantial commitment of resources to its public health emergency response program. Without this, the best-written laws will be inadequate. The Canadian Medical Association commends the Government of Canada for bringing this bill forward, and looks forward to working with the Government, and the Public Health Agency of Canada, to help keep Canadians safe in the event of a public health emergency. End Notes 1 A public health emergency has been defined by the US Model State Emergency Powers Act (http://www.publichealthlaw.net accessed July 7, 2003) as an occurrence or imminent threat of an illness or health condition of a temporary nature that is believed to be caused by: * the appearance of a novel or previously controlled or eradicated infectious agent or biological toxin; * a bioterrorist event; * a natural disaster * a chemical event or accidental release; or * a nuclear event or accident and that poses a high probability of any of the following harms: * a large number of deaths in the affected population; * a large number of serious or long-term disabilities in the affected population; or * widespread exposure to an infectious or toxic agent that poses a significant risk of substantial future harm to a large number of people in the affected population.
Documents
Less detail

Canadian Medical Association submission on Bill C-462 Disability Tax Credit Promoters Restrictions Act.

https://policybase.cma.ca/en/permalink/policy11542
Date
2015-05-22
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Date
2015-05-22
Topics
Population health/ health equity/ public health
Text
The Canadian Medical Association (CMA) is pleased to present this brief to the House of Commons Standing Committee on Finance regarding Bill C-462 Disability Tax Credit Promoters Restrictions Act. The Canadian Medical Association represents 78,000 physicians in Canada; its mission is to serve and unite the physicians of Canada and to be the national advocate, in partnership with the people of Canada, for the highest standards of health and health care. The CMA is pleased that the House of Commons has made Bill C-462 a priority. This bill is an important step toward addressing the unintended consequences that have emerged from the Disability Tax Credit since 2005. Part 2: Issues to be addressed In 2005, the Disability Tax Credit was expanded to allow individuals to back-file for up to 10 years. While this was a welcome tax measure for individuals with disabilities, the CMA has been urging the Canada Revenue Agency to address the numerous unintended consequences that have emerged. Central among these has been the emergence of a “cottage industry” of third-party companies engaged in a number of over-reaching tactics. The practices of these companies have included aggressive promotional activities to seek and encourage individuals to file the Disability Tax Credit. The primary driver behind these tactics is profit; some companies are charging fees of up to 40 per cent of an individual’s refund when the tax credit is approved. Further to targeting a vulnerable population, these activities have yielded an increase in the quantity of Disability Tax Credit forms in physician offices and contributed to red tape in the health sector. In some cases, third parties have placed physicians in an adversarial position with their patients. We are pleased that this bill attempts to address the concerns we have raised. The CMA supports Bill C-462 as a necessary measure to address the issues that have emerged since the changes to the Disability Tax Credit in 2005. However, to avoid additional unintended consequences, the CMA recommends that the Finance Committee address three issues prior to advancing Bill C-462. First, as currently written, Bill C-462 proposes to apply the same requirements to physicians as to third-party companies if physicians apply a fee for form completion, a typical practice for uninsured physician services. Such fees are subject to guidelines and oversight by provincial and territorial medical regulatory colleges (see Appendix 1: CMA Policy on Third Party Forms: The Physician Role). The CMA recommends that the Finance Committee: Amend the definition of “promoters” under section 2 to exclude “a health care practitioner duly licensed under the applicable regulatory authority who provides health care and treatment.” . If the committee imports the term “person” from the Income Tax Act, then the applicable section of Bill C-462 should be amended to specify that, for the purposes of the act, “Person does not include a health care practitioner duly licensed under the applicable regulatory authority who provides health care and treatment.” Second, the CMA is concerned that one of the reasons individuals may be engaging the services of third-party companies is a lack of awareness of the purpose and benefits of the Disability Tax Credit. Additional efforts are required to ensure that the Disability Tax Credit form (Form T2201) be more informative and user-friendly for patients. Form T2201 should explain more clearly to patients the reason behind the tax credit, and explicitly indicate there is no need to use third-party companies to submit the claim to the CRA. The CMA recommends that the Finance Committee: . Recommend that the Canada Revenue Agency undertake additional efforts to ensure that the Disability Tax Credit form is more informative, accessible and user-friendly for patients. Finally, the CMA recommends that a privacy assessment be undertaken before the bill moves forward in the legislative process. It appears that, as written, Bill C-462 would authorize the inter-departmental sharing of personal information. The CMA raises this issue for consideration because protecting the privacy of patient information is a key duty of a physician under the CMA Code of Ethics. Part 3: Closing The CMA encourages the Finance Committee to address these issues to ensure that Bill C-462 resolves existing problems with the Disability Tax Credit while not introducing new ones. The CMA appreciates the opportunity to provide input to the Finance Committee’s study of this bill and, with the amendments outlined herein, supports its passage. Summary of Recommendations Recommendation 1 The definition of “promoters” under section 2 of Bill C-462 should be amended to exclude “a health care practitioner duly licensed under the applicable regulatory authority who provides health care and treatment.” Recommendation 2 If the Committee imports the definition of “persons” from the Income Tax Act, the applicable section of Bill C-462 should be amended to specify that, for the purposes of the act, “Person does not include a health care practitioner duly licensed under the applicable regulatory authority who provides health care and treatment.” Recommendation 3 The Canada Revenue Agency should undertake additional efforts to ensure that the Disability Tax Credit form is informative, accessible and user-friendly. Recommendation 4 Prior to advancing in the legislative process, Bill C-462 should undergo a privacy assessment.
Documents
Less detail

CMA & CNA Letter on the Future Mandate of the Health Care Innovation Working Group (the Council of the Federation)

https://policybase.cma.ca/en/permalink/policy11477
Date
2015-01-22
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
  1 document  
Policy Type
Parliamentary submission
Date
2015-01-22
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Text
Re: Future Mandate of the Health Care Innovation Working Group (the Council of the Federation) Dear Premiers: On behalf of the Canadian Nurses Association (CNA) and the Canadian Medical Association (CMA), I am writing in advance of the meeting of the Council of the Federation later this month regarding the future mandate of the Health Care Innovation Working Group with respect to seniors care. The CNA and CMA welcomed the Council of the Federation's prioritization of seniors care as an area of focus of the Health Care Innovation Working Group. Already, seniors and their families in communities across Canada face significant challenges accessing social supports and health services. These challenges will only intensify as the demographic shift progresses. Based on current trends and approaches, the proportion of provincial/territorial health spending associated with seniors care is forecast to grow by over 15% to almost 62% of health budgets by 2036. Recognizing the significant pressure this will present for health care systems and provincial/territorial budgets moving forward, it is critical that the Council of the Federation maintain its prioritization of seniors care and meeting the needs of an aging population. As such, we respectfully encourage you in your capacity as Co-Chairs of the Health Care Innovation Working Group to ensure the future mandate of the working group on seniors care be included as part of the agenda at the January 30, 2015 meeting of the Council of the Federation. The CNA and CMA are actively engaged on this issue and welcome the opportunity to meet with each of you to discuss how we may collaborate to ensure improved health outcomes for seniors, now and in the future. Sincerely, Christopher S. Simpson, MD, FRCPC, FACC, FHRS CMA President Karima Velji, RN, PhD, CHE CNA President
Documents
Less detail

Health Protection and a Canadian Public Health Strategy: A Comprehensive Approach To Public Health: Submission to Health Canada

https://policybase.cma.ca/en/permalink/policy1958
Last Reviewed
2011-03-05
Date
2004-04-12
Topics
Population health/ health equity/ public health
  2 documents  
Policy Type
Parliamentary submission
Last Reviewed
2011-03-05
Date
2004-04-12
Topics
Population health/ health equity/ public health
Text
This submission is the response of the Canadian Medical Association to Health Canada's request for feedback on its detailed "Health Protection Legislative Renewal" legislative proposal released in June 2003. Our submission calls for and is embedded in the broader context of a comprehensive approach to public health. The Canadian Medical Association is committed to working with others to realize the vision of a comprehensive, robust public health strategy as a vital component of Canada's health care system. This strategy should rest upon three pillars: * Emergency Response Empowering rapid and effective response to health emergencies, e.g. communicable disease outbreaks, water contamination, bio-terrorist attacks. * Health Protection: Ensuring that Canadians are protected from health risks in their daily environment; for example, risks associated with the use of health or consumer products, or with the potential spread of infectious disease. * Health Promotion and Disease Prevention Instituting programs to encourage healthy behaviour and advocating for public policy and fiscal policy that supports health. Though these three pillars have different foci and different legislative instruments, they must all be part of a strategy to enhance public health and public health service delivery in Canada. With specific reference to health protection, CMA believes that legislation should rest on the following principles: a) Commitment to the primacy of health and safety. b) Commitment to evidence-based decision making. c) A thorough risk-analysis procedure based on the relative risk of products or services. d) Support for informed patient decision-making. e) Accountability vested in the Government of Canada. f) A comprehensive, effective post-marketing surveillance system. g) Enforcement through effective, meaningful penalties for noncompliance. h) Flexibility to quickly and efficiently accommodate new technologies. i) Openness and transparency. j) Encouragement of collaboration and co-operation with other stakeholders, while respecting existing jurisdictions and legislative mechanisms. Recommendations A Canadian Public Health Strategy 1) That the federal government ensure that legislative and administrative measures related to public health complement one another in function and are connected through communications and co-ordination mechanisms. The Drug Review Process 2) That the federal government implement a timely and efficient drug review process to reduce review times to the fastest level consistent with ensuring improved health outcomes and the safety of the drug supply. 3) That the federal government consider co-operative agreements for drug review with comparable agencies in Europe, the United States and Australia, while retaining final authority as to whether a new product should be allowed on the Canadian market. 4) That the drug review and approval process be open and transparent, providing updates on review status and the opportunity for stakeholder input. 5) That Health Canada apply a priority review process to "breakthrough" drugs, i.e. those that demonstrate a substantial improvement over products already on the market. Patient Safety and Post-Marketing Surveillance 6) That Health Canada work in partnership with stakeholders including CMA and other national medical and health professional associations, to develop a rigourous post-marketing surveillance system to monitor the ongoing safety of marketed drugs. 7) That government accelerate activities to establish the Patient Safety Institute using a systems approach to support a culture of safety. 8) That all stakeholders join in supporting and encouraging outcome-based research to ascertain best practices in prescribing. 9) That the federal government invest in measures such as electronic communications networks, to increase physicians' capacity to report medication incidents and to improve the timeliness of adverse event reporting. Drug Information and Advertising 10) That all stakeholders work to ensure that Canadians have ready access to a source of comprehensive, reliable information on health products and their uses, and that governments fund development and dissemination of validated information to physicians and to the public. 11) That the legislation define "promotion" and "advertising" so as to clearly distinguish them from unbiased health information, and from counselling by health professionals. 12) That the current safeguards against deception be strengthened in order to * Forbid fraudulent or misleading health claims in advertisements, on labels or in any other promotional or descriptive material pertaining to the product; * ensure pre-clearance and ongoing review of all health claims by an objective agency; * provide meaningful penalties for infraction. 13) That Health Canada maintain the current ban on advertising health products for treatment, prevention and cure of conditions or disease states to be identified in a regulatory schedule or administrative list; the inclusion of conditions in this list should be determined through a set of criteria that are written into the Act or regulations. 14) That the existing ban on direct to consumer advertising of prescription drugs be maintained and enforced to the full extent of the law, and that the loophole that currently permits advertising the name, price and quantity of a prescription drug be closed. 15) That all stakeholders, including medical associations and industry groups, work together toward effective regulation of drug promotion to health practitioners. Safeguarding the Privacy of Health Information 16) That the Health Protection Act respect the provisions of the Charter of Rights and Freedoms, the Federal Privacy Act and the Personal Information Protection and Electronic Documents Act (PIPEDA). 17) That the privacy provisions in the Health Protection Act meet the legislative test outlined in Section 3.6 of CMA's Health Information Privacy Code. Other Issues 18) That the Health Protection Act give Health Canada a clear mandate to develop guidance documents to address health and safety issues raised by new technologies. 19) That Natural Health Products be regulated on a strict framework that ensures their safety, quality and efficacy as well as the provision of complete and unbiased information to the public. 20) That the Act provide Health Canada with a clear mandate to collaborate with provincial/territorial and local governments across Canada in reviewing legislation governing all aspects of drinking water from source to consumption to ensure that comprehensive programs are in place and being properly implemented. 21) That Health Canada urgently review the Quarantine Act and modernize its provisions. 1. Introduction This submission is the response of the Canadian Medical Association (CMA) to Health Canada's request for feedback on its detailed "Health Protection Legislative Renewal" legislative proposal released in June 2003. Our submission calls for and is embedded in the broader context of a comprehensive approach to public health. It also includes recommendations dealing with selected specific issues raised in the proposal, particularly those that have a potential major impact on physicians and other health professionals, and on the practice of medicine. The Canadian Medical Association supports the government's efforts to update and revitalize health protection legislation. Physicians are committed to working with others to realize the vision of a comprehensive, robust public health strategy as a vital component of Canada's health care system, in order to realize Canada's potential as a healthy nation. Recent headlines illustrate the diversity of public health challenges facing Canadians: * The spread of avian flu across Asia, and the reappearance of SARS in China; * Reports linking the use of Selective Serotonin Reutake Inhibitor antidepressants to increased suicide and other behavioural disorders in children and adolescents, which led to a public warning against their use in this population; * The rapidly rising rates of obesity in Canada and other developed countries. To deal with these problems and others, a comprehensive public health strategy is required. This strategy should rest upon three pillars: emergency response, health protection and health promotion (Figure 1). Each of these pillars is discussed in greater detail in the following section. 2. Three Pillars of a Canadian Public Health Strategy a) Pillar #1: Emergency Response The 2003 SARS outbreak shone a merciless light on the difficulties that Canada's stretched public health system can encounter when it needs to respond to health emergencies. The 21st century has brought a disturbing array of new public health risks (such as avian flu) and old risks revisited (such as contamination of water supplies). A comprehensive public health strategy should be able address these risks by: * Empowering rapid and effective response to health emergencies, e.g. communicable disease outbreaks, water contamination, bio-terrorist attacks. * Supporting health surveillance, screening and research, to identify potential health risks. [FIGURE CONTENT DOES NOT DISPLAY PROPERLY. SEE PDF FOR PROPER DISPLAY] Figure 1. The Three Pillars of Public Health [FIGURE END] CMA Position: CMA's 2003 submission to the National Advisory Committee on SARS and Public Health (the Executive Summary is attached as Appendix I) recommended a number of measures to strengthen Canada's capacity to respond to health emergencies. These included: * The enactment of a Canada Emergency Health Measures Act to allow for a more rapid national response to emergencies that pose an acute and imminent threat to human health and safety in Canada. * The creation of an independent Canada Public Health Agency, headed by a Chief Public Health Officer of Canada who would work with provinces and territories to develop and implement a pan-Canadian public health action plan. * Enhancements to the current system of disease surveillance and response, so that it remains privacy sensitive and ensures a two-way flow of information between public health experts and front-line clinicians. In 2004 CMA reiterated these recommendations to the Honourable Carolyn Bennett, Minister of State for Public Health, in response to her request for consultation on a Canada Public Health Agency. b) Pillar #2: Health Protection The Health Protection function ensures that Canadians are protected from health risks in their daily environment; for example, risks associated with the use of health or consumer products, or with the potential spread of infectious disease. Specific health protection functions include: * Ensuring that Canadians have access to the right pharmaceutical drugs, which have been proven safe and efficacious, at the right times, for the right prices. Our policy in this area is further discussed in our 2003 submission to the House Standing Committee on Health's review of prescription drugs, an executive summary of which is attached (Appendix II). * Monitoring Canada's pharmaceutical drug supply to ensure its safety, effectiveness and continued availability. * Ensuring the safety of natural health products, medical devices, hazardous products and other consumer products. This should include the regulation of toxic substances, including tobacco. * Regulating health claims for consumer products. * Monitoring the advertising and promotion of health products to the public. * Administering quarantine procedures. * Developing regulatory frameworks to ensure the safety and effectiveness of new technologies such as gene therapy and genetically modified foods. CMA Position: The principles that CMA believes should guide review of health protection legislation are discussed in Section 3. c) Pillar #3: Health Promotion and Disease Prevention For more than 30 years the federal government has incorporated the promotion of health, as well as the treatment of disease, into its mandate. Activities undertaken in pursuit of this function include: * Programs to encourage healthy behaviours, e.g. physical activity strategies. * Advocating for or implementing public policy that supports health e.g. bans on tobacco advertising and sponsorship, and fiscal policies, such as high tobacco taxes. * Research strategies to increase our understanding of the determinants of health. CMA Position: The CMA has called on the federal government to commit to the goal of establishing Canada as the top country in the world with regard to the health status of its citizens. Canada remains one of the few countries in the industrialized world without a clear statement of national health goals, targets and strategies. All levels of government should enable the Health Council of Canada to monitor and report on defined health goals and priorities. In addition, the CMA has developed policies and statements urging action on specific health promotion issues including: obesity control; injury prevention; physical activity; tobacco control; mental health; and many others. Though these three pillars have different foci and different legislative instruments, they must all be part of a comprehensive legislative agenda and strategy to renew and enhance public health and public health service delivery in Canada. Addressing issues under one pillar without reference to the other pillars or to a comprehensive public health framework and strategy fails to address the overall public health needs of Canadians. Recommendation 1. That the federal government ensure that legislative and administrative measures related to public health complement one another in function and are connected through communications and co-ordination mechanisms. 3. A Policy Framework for Health Protection Legislation This submission is a response to a legislative proposal regarding health protection; consequently the rest of this document will focus on the second of the three pillars described above, the "health protection" pillar. This section discusses the overall policy framework that the CMA believes should govern health protection in Canada. The CMA holds that health protection legislation should rest on the following principles: i) Primacy of Health and Safety. Legislation should commit to protection of public health and safety as its primary objective. ii) Core Values. Legislation should recognize the core values of Canadians, such as privacy of health and personal information, freedom of choice, and protection of vulnerable citizens, and be sensitive to cultural, gender, socio-economic and other factors where relevant. Where there is a conflict between Principle (i) and other values, this conflict and the grounds on which to resolve it should be explicitly stated. iii) Evidence-based Decision Making. Legislation should reflect a commitment to scientific, evidence-based decision making. It should provide for the requisite mechanisms to ensure that reviews of risk are independent and unbiased. iv) The Risk Assessment Process. Legislation should reflect a thorough risk-analysis procedure including risk assessment and evaluation. The pre-approval scrutiny to which a product1 is subjected should be based on its relative risk: regulatory requirements should be greater for products with greater risk and lower for those with less risk. Risk assessment should take into account risk to the community as well as to individuals. While the risk assessment process should be science-based, it should also recognize that public perception might influence the management and communication of risk. In areas of risk uncertainty, application of the precautionary principle could be considered on a case-by-case basis. v) General Safety Requirement. The CMA supports the proposal to include in the legislation a General Safety Requirement that would make it illegal for anyone to manufacture, promote or market a product that may present an undue risk to health, under reasonably foreseeable conditions of use. However, this overall requirement should not be used as a substitute for enacting regulations to cover specific products if evidence indicates that such regulations are necessary to protect public health. Nor should it be used as a rationale for relaxing regulatory regimes currently in place. vi) Support for Informed Patient Decision-Making. Legislation should ensure that Canadians have access to reliable, evidence-based information to support them in making decisions regarding their own health, and should ensure that the information they receive is not misleading or deceptive. vii) Accountability. Legislation should ensure that there is clear accountability for decision-making, and that this is vested in the Government of Canada. viii) Surveillance. Legislation should ensure comprehensive, effective post-marketing surveillance of drugs and other health products. This should be co-coordinated with surveillance and research programs governed by related public health acts such as the proposed Canada Emergency Health Measures Act. ix) Enforcement. Legislation should provide and enforce effective, meaningful penalties for noncompliance. x) Flexibility. Legislation should allow for flexibility in product approval, consistent with Principle i, in order to quickly and efficiently accommodate emerging issues (such as new technologies) developed in Canada and internationally. xi) Openness and Transparency. Legislation should operate transparently, incorporating ongoing, two-way communication with stakeholders, including health professionals and the public. xii) Working with Others. Legislation should encourage collaboration and co-operation with other federal departments, with provinces and territories, and with non-governmental and international organizations. At the same time it should respect existing jurisdictions and existing legislative and administrative mechanisms. 4. Impact of Health Protection Legislation on Medical Practice Physicians, along with other health professionals, play an important role in maintaining high health standards and communicating appropriate health information to Canadians. Some of the proposals included in the legislative proposal could have a significant positive or negative impact on medical practice. These include: a) The Drug Review Process Stakeholders have repeatedly drawn attention to the slowness and secrecy of Canada's drug approval process. Between 1996 and 1998 Canadian approval times (median 518 days) were significantly longer than Sweden (median 371 days), the UK (median 308 days) and the United States (median 369 days). These have not improved significantly even after Health Canada implemented a cost-recovery approach to funding drug reviews. In addition, the review process may not distinguish genuinely new and innovative "breakthrough" drugs from imitations of products already on the market. The legislative proposal discusses possible means of modernizing the drug review process, including co-operative agreements with comparable drug review agencies in other jurisdictions, and establishment of a mechanism for public comments. The CMA approves both these suggestions. To ensure that Canadians have access to the right drugs for their conditions as quickly as is consistent with safety, the CMA recommends: Recommendations 2. That the federal government implement a timely and efficient drug review process to reduce review times to the fastest level consistent with ensuring improved health outcomes and the safety of the drug supply. 3. That the federal government consider co-operative agreements for drug review with comparable agencies in Europe, the United States and Australia, while retaining final authority as to whether a new product should be allowed on the Canadian market. 4. That the drug review and approval process be open and transparent, providing updates on review status and the opportunity for stakeholder input. 5. That Health Canada apply a priority review process to "breakthrough" drugs, i.e. those that demonstrate a substantial improvement over products already on the market. b) Patient Safety and Post-marketing surveillance Recent reports have drawn public attention to the need for a rigourous, well-resourced post-marketing surveillance system to monitor the ongoing safety of marketed drugs and other health products in Canada. CMA strongly recommends that Health Canada work in partnership with stakeholders to develop such a system. The system should be non-punitive, supporting a "culture of safety" rather than one of blame, and should respect the privacy of patients and physicians. In this context the CMA supports the establishment of the Patient Safety Institute. In developing its post-marketing surveillance capacity, Health Canada should ensure that sufficient resources are in place to enable the system to: * Facilitate the reporting of adverse reactions by health professionals and others. The CMA supports activities that encourage the voluntary reporting of adverse reactions by physicians and others. For example, to facilitate timely and comprehensive reporting, forms should be easily accessible and the reporting process should be computerized, simple and transparent. * Collect and analyze data and produce information that health care professionals and policy makers can use in decision-making at the population level. With appropriate privacy safeguards, this information could also be used for a number of research purposes, e.g. monitoring the importation and use of drugs not yet licensed in Canada; ascertaining best practices in prescribing. * Communicate this information back to the provider in real time. The importance of real-time two-way communication with front-line practitioners and institutions cannot be overstated. The CMA has repeatedly called for sustained and substantial investment in a Health Communications and Coordination Initiative to improve the technical capacity of front-line health providers to communicate in real time with one another and with the rest of the health care system. This is a critical endeavour and should be undertaken immediately, using funds established for health surveillance in the March 2004 Federal Budget, and implemented within the next 6 months. This network could form the cornerstone of an adverse drug reaction reporting system. Recommendations: 6. That Health Canada work in partnership with stakeholders including CMA and other national medical and other health professional associations, to develop a rigourous post-marketing surveillance system to monitor the ongoing safety of marketed drugs. 7. That government accelerate activities to establish the Patient Safety Institute using a systems approach to support a culture of safety. 8. That all stakeholders join in supporting and encouraging outcome-based research to ascertain best practices in prescribing. 9. That the federal government invest in measures such as electronic communications networks, to increase physicians' capacity to report medication incidents and improve the timeliness of adverse event reporting. c) Drug Information and Advertising CMA believes that the public has a right to unbiased, accurate information on drugs and other therapeutic products. This information should be provided in accordance with CMA's "Principles for Providing Information about Prescription Drugs to Consumers" (Appendix III). Brand-specific product advertising is a less than optimal way of providing this information, and should be carefully monitored to discourage fraudulent or misleading claims. In particular, direct to consumer advertising of prescription drugs should not be permitted in Canada. Physicians and their associations are willing to work with Health Canada and other stakeholders in developing and disseminating accurate, unbiased information to the public and to health professionals about drugs and other health products. Recommendations: 10. That all stakeholders work to ensure that Canadians have ready access to a source of comprehensive, reliable information on health products and their uses, and that governments fund development and dissemination of validated information to physicians and to the public. 11. That the legislation define "promotion" and "advertising" so as to clearly distinguish them from unbiased health information, and from counselling by health professionals. 12. That the current safeguards against deception in advertising be strengthened in order to * Forbid fraudulent or misleading health claims in advertisements, on labels or in any other promotional or descriptive material pertaining to the product; * Ensure pre-clearance and ongoing review of all health claims by an objective agency; * Provide meaningful penalties for infraction. 13. That Health Canada maintain the current ban on advertising health products for treatment, prevention and cure of conditions or disease states to be identified in a regulatory schedule or administrative list; the inclusion of conditions in this list should be determined through a set of criteria that are written into the Act or regulations. 14. That the existing ban on direct to consumer advertising of prescription drugs be maintained and enforced to the full extent of the law, and that the loophole that currently permits advertising the name, price and quantity of a prescription drug be closed. 15. That all stakeholders, including medical associations and industry groups, work together toward effective regulation of drug promotion to health practitioners. d) Safeguarding the privacy of health information Patients must be able to feel assured that anything they tell their physicians will remain confidential, imparted to others only to the extent necessary to ensure optimal care. Accordingly, the privacy and confidentiality of patient-specific and physician-specific information should be safeguarded to the fullest extent possible. New technologies, e.g. electronic health records, have made the transfer of information simpler and more efficient. They have also made it more vulnerable to infringements on a patient's right to privacy. Several important pieces of legislation to safeguard privacy have already been enacted. In addition, the CMA has developed a Privacy Code (Appendix IV) that discusses confidentiality issues specific to health information. Section 3.6 of this Code contains a legislative test to which all proposed legislation, including the Health Protection Act, should be submitted. Recommendations 16. That the Health Protection Act respect the provisions of the Charter of Rights and Freedoms, the Federal Privacy Act and the Personal Information Protection and Electronic Documents Act (PIPEDA). 17. That the privacy provisions in the Health Protection Act meet the legislative test outlined in Section 3.6 of CMA's Health Information Privacy Code. e) Other Issues The legislative proposal discusses giving Health Canada the power to develop guidelines or regulatory frameworks for specific circumstances, e.g. for new products and technologies such as genetically modified foods; or for situations in which the health of the public may otherwise be at risk, such as contamination of drinking water. In addition, the proposal discusses the possibility of modernizing existing laws that have become outdated. The CMA supports the direction of these proposals. The Quarantine Act, for example, is a piece of legislation the CMA believe merits urgent updating; new legislation should incorporate quarantine provisions for possible vectors leaving as well as entering Canada, and for inter-provincial as well as international traffic. With regard to specific issues not addressed elsewhere in this submission, the CMA recommends: Recommendations 18. That the Health Protection Act give Health Canada a clear mandate to develop guidance documents to address health and safety issues raised by new technologies. 19. That Natural Health Products be regulated on a strict framework that ensures their safety, quality and efficacy as well as the provision of complete and unbiased information to the public. 20. That the Act provide Health Canada with a clear mandate to collaborate with provincial/ territorial and local governments across Canada in reviewing legislation governing all aspects of drinking water from source to consumption to ensure that comprehensive programs are in place and being properly implemented. 21. That Health Canada urgently review the Quarantine Act and modernize its provisions. 5. Conclusion Health protection is one of three pillars of an effective public health system, along with rapid and effective emergency response, and programs and policies to maintain health and prevent disease. The CMA is pleased to have been able to advise governments on all of these pillars, in order to establish the health of Canadians on a strong foundation. We look forward to continued consultation with Health Canada on the proposed Health Protection Act, both on its overall framework and on specific issues of concern to the medical profession. We trust that the result will be strong legislation, founded on fair and enduring principles, to safeguard the health and security of Canadians. APPENDIX I Answering the Wake-up Call: CMA's Public Health Action Plan CMA Submission to Naylor Advisory Committee on SARS and Public Health (Executive Summary) The public health system in Canada lies at the heart of our community values. It is the quintessential "public good" and is central to the continued good health of our population. When the public health system is working well, few are even aware that it is at work! Only when something goes terribly wrong - like the Walkerton tragedy or when we are faced with a new threat like SARS - is the integral, ongoing role of public health really recognized. The Canadian Medical Association (CMA) has been warning that our public health system is stretched to capacity in dealing with everyday demands, let alone responding to the latest crises. Canada's physicians have repeatedly called for governments to enhance public health capacity and strengthen the public health infrastructure throughout Canada. Our public health system is the first - and often the only - line of defence against emerging and ongoing infectious and noninfectious threats to the health of Canadians. But we are only as strong as the weakest link in the emergency response chain of survival. As most health threats know no boundaries, our public health armaments must be in a constant state of "battle readiness." In today's climate of SARS, West Nile Virus, mad cow disease and monkey pox, even the thought that the public health system may be stretched beyond capacity strikes fear into the hearts of Canadians. Physicians have always been an integral part of the public health system serving as medical officers of health, community health specialists and other related roles. Indeed public health cannot successfully fulfill its mandate without the cooperation and commitment of front-line clinicians. In this submission, we reflect on the lessons to be learned from our recent experience with SARS and reflect on the longer-term needs of the public health system as a whole. The objectives of the pan-Canadian Public Health Action Plan proposed by the CMA are, first to realize a clearer alignment of authority and accountability in times of extraordinary health emergencies; and, second, to enhance the system's capacity to respond to public health threats across the country (see recommendations, below). To achieve these twin objectives, three broad strategies are presented for immediate attention. They are legislative reform; capacity enhancement; and research, surveillance and communications. Legislative reform (see recommendations 1-3) The country's response to SARS has brought into stark relief the urgent need for national leadership and coordination of public health activity across the country, especially during a health crisis. The apparent reluctance to act quickly to institute screening at airports, the delay in unifying the practice community for a concerted response and the appalling communications confusion worked against optimum handling of the outbreak - despite the best efforts of health care professionals. This is a wake-up call that highlights the need for comprehensive legislative reform to clarify the roles of governments with respect to the management of public health threats. A renewed and enhanced national commitment to public health should be anchored in new federal legislation to be negotiated with the provinces and territories. Specifically, the CMA recommends an Emergency Health Measures Act, to deal with emergent situations in tandem with the creation of a Canadian public health agency headed by a Chief Public Health Officer of Canada. Capacity enhancement (see recommendations 4-7) The SARS crisis has demonstrated the diminished capacity within the public health system. The Greater Toronto Area (GTA), with one of Canada's most sophisticated public and acute health systems, has not been able to manage the SARS crisis adequately and carry on other health programs. The acute care system virtually ground to a halt in dealing with SARS. There was little or no surge capacity in Canada's largest city. We should be grateful that SARS did not first strike a smaller centre in a far less-advantaged region of Canada. A critical element of the public health system is its workforce and the health professionals within the acute care system, such as hospital-based infectious disease specialists and emergency physicians who are the front-line interface. Let there be no doubt that the ongoing efforts of the GTA front-line providers are nothing short of heroic. However, the lack of coordinated contingency planning of hospital and community-based disease control efforts was striking. The overall shortage of critical care professionals and the inability of governments to quickly deploy the required professionals to areas of need contributed to the enormous strain on the public and health care system. Considering the importance of the public health system and its clearly limited capacity to protect and promote the health of Canadians, it is incomprehensible that we do not know how much is actually spent on the system. It is imperative that public health expenditures and capacity, in terms of both physical and human resources, be tracked and reported publicly. The CMA recommends a $1-billion, 5-year capacity-enhancement program to be coordinated with and through the new Canadian public health agency. Research, surveillance and communications (see recommendations 8-10) Canada's ability to respond to public health threats and acute events, such as SARS, and to maintain its effective public health planning and program development depends on sound research, surveillance and rapid, real-time communications. A concerted pan-Canadian effort is required to take full advantage of our capacity for interdisciplinary research on public health, including infectious disease prevention and control measures. New-millennium challenges require moving beyond old-millennium responses. Enhanced surveillance is an overdue and integral part of public health, performing an essential function in early detection and response to threats of infectious diseases. Mandatory national reporting of identified diseases by all provinces and territories is critical for national and international surveillance. During times of crisis, rapid communication to the public, public health staff and front-line clinicians is of critical importance, but in many jurisdictions impossible. We tested our systems during the SARS outbreak and they came up short. The CMA recommends a one-time federal investment to enhance technical capacity to allow for real-time communication. Conclusion The CMA believes that its proposed three-pronged strategy, as set out in the attached recommendations, will go a long way toward addressing shortfalls of the Canadian public health system. Action now will help to ensure that Canadians can once again be confident that they are protected from any future threat of new infectious diseases. Action now will help Canada regain its position as a leader in public health. We wish the advisory committee well in its deliberations and offer the CMA's assistance at any time in clarifying the strategies set out in our submission. Recommendations to the National Advisory Committee on SARS and Public Health Legislative reform ($20 million / 5 years*) 1. The enactment of a Canada Emergency Health Measures Act that would consolidate and enhance existing legislation, allowing for a more rapid national response, in cooperation with the provinces and territories, based on a graduated, systematic approach, to health emergencies that pose an acute and imminent threat to human health and safety across Canada. 2. The creation of a Canadian Office for Disease Surveillance and Control (CODSC) as the lead Canadian agency in public health, operating at arm's length from government. 3. The appointment of a Chief Public Health Officer of Canada to act as the lead scientific voice for public health in Canada; to head the Canadian Office for Disease Surveillance and Control; and to work with provinces and territories to develop and implement a pan-Canadian public health action plan. Capacity enhancement ( $1.2 billion / 5 years*) 4. The creation of a Canadian Centre of Excellence for Public Health, under the auspices of the CODSC, to invest in multidisciplinary training programs in public health, establish and disseminate best practices among public health professionals. 5. The establishment of a Canadian Public Health Emergency Response Service, under the auspices of the CODSC, to provide for the rapid deployment of human resources (e.g., emergency pan-Canadian locum programs) during health emergencies. 6. Tracking and public reporting of public health expenditures and capacity (both physical and human resources) by the Canadian Institute for Health Information and Statistics Canada, on behalf of the proposed Canadian Office for Disease Surveillance and Control. 7. Federal government funding in the amount of $1 Billion over 5 years to build adequate and consistent surge capacity across Canada and improve coordination among federal, provincial/territorial and municipal authorities to fulfill essential public health functions. Research, surveillance and communications ($310 million / 5 years*) 8. An immediate, sequestered grant of $200 million over 5 years to the Canadian Institutes of Health Research to initiate an enhanced conjoint program of research with the Institute of Population and Public Health and the Institute of Infection and Immunity that will expand capacity for interdisciplinary research on public health, including infectious disease prevention and control measures. 9. The mandatory reporting by provinces and territories of identified infectious diseases to the newly established Chief Public Health Officer of Canada to enable appropriate communications, analyses and intervention. 10. The one-time infusion of $100 million, with an additional $2 million a year, for a "REAL" (rapid, effective, accessible and linked) Health Communication and Coordination Initiative to improve technical capacity to communicate with front line public health providers in real time during health emergencies. APPENDIX II The Right Drugs, at the Right Times, for the Right Prices: Toward a Prescription Drug Policy for Canada CMA Submission to House of Commons Standing Committee on Health Every year, three hundred million prescriptions - about 10 for every man, woman and child - are filled in Canada. Prescription drugs have benefited both the health of Canadians, and the health care system itself; they have meant dramatically improved quality of life for many Canadians, and have saved the country a great deal in hospitalization, social benefits and other expenses. However, it could be questioned whether all of Canada's prescription drug use is appropriate; patients may be receiving too few medications, too many medications or suboptimal medications for their conditions. In addition, prescription drugs carry a price tag of their own. Since 1975, expenditures on prescription medication have risen faster than any other category in the health sector in Canada, and more is now spent on prescription drugs than on physician services. Governments, health care providers, drug manufacturers and the public must constantly strive to ensure that Canadians receive optimal and appropriate prescription drug therapy: the right drugs, at the right times, for the right prices. A considered, coherent, comprehensive, "made in Canada" approach to prescription drug policy should: * Put the health of the patient first; * Promote and enhance quality prescribing; * Respect, sustain and enhance the therapeutic relationship between patients and health professionals; * Promote patient compliance with drug therapy; * Respect the principles of patient confidentiality and the privacy of patient and prescriber information. Prescription drug policy in Canada should address: Access: to * efficacious new drugs within an appropriate time; * coverage for medically necessary drugs for catastrophic care; * generic drugs at reasonable prices; * a patient/physician consultation as part of the prescribing process; * continued research and development capacity in Canada. Information for health care providers and the public that is balanced and accurate. Safety: through mechanisms for the systematic monitoring of prescription drugs and their effects. Canada's doctors are committed to working with others to ensure that Canadians receive the right drugs, at the right times, for the right prices. Summary of CMA Recommendations: 1. That the federal government implement a timely and efficient drug review process to reduce review times to a level at or better than that in other OECD countries. 2. That the pharmaceutical industry give priority to research and development on drugs and delivery mechanisms that demonstrate a substantial improvement over products already on the market. 3. That Health Canada apply a priority review process to all drugs that demonstrate a substantial improvement over products already on the market. 4. That governments and insurance providers conduct research to identify the current gaps in prescription drug coverage for all Canadians, and develop policy options for providing this coverage, including consideration of the roles of public and private payers. 5. That the federal government monitor and, if necessary, regulate the export of prescription medications to ensure their continued availability to Canadians. 6. That prescribing of medication be done within the context of the therapeutic relationship which exists between the patient and the physician. 7. That brand-specific direct to consumer prescription drug advertising (DTCA) not be permitted in Canada, 8. That the federal government enforce the existing restrictions on DTCA found in the Food and Drug Act to the full extent of the law. 9. That the federal government develop and fund a comprehensive program to provide accurate, unbiased prescription drug information to patients. 10. That all stakeholders join in supporting and encouraging outcome-based research to ascertain best practices in prescribing. 11. That government accelerate activities to establish the Patient Safety Institute using a systems approach to support a culture of safety. 12. That a post-marketing surveillance system be implemented to monitor the ongoing safety of marketed drugs. APPENDIX III CMA POLICY Principles for Providing Information about Prescription Drugs to Consumers Approved by the CMA Board of Directors, March 2003 Since the late 1990's expenditures on direct to consumer advertising (DTCA) of prescription drugs in the United States have increased many-fold. Though U.S.-style DTCA is not legal in Canada 2 , it reaches Canadians through cross-border transmission of print and broadcast media, and through the Internet. It is believed to have affected drug sales and patient behaviour in Canada. Other therapeutic products, such as vaccines and diagnostic tests, are also being marketed directly to the public. Proponents of DTCA argue that they are providing consumers with much-needed information on drugs and the conditions they treat. Others argue that the underlying intent of such advertising is to increase revenue or market share, and that it therefore cannot be interpreted as unbiased information. The CMA believes that consumers have a right to accurate information on prescription medications and other therapeutic interventions, to enable them to make informed decisions about their own health. This information is especially necessary as more and more Canadians live with chronic conditions, and as we anticipate the availability of new products that may accompany the "biological revolution", e.g. gene therapies. The CMA recommends a review of current mechanisms, including mass media communications, for providing this information to the public. CMA believes that consumer information on prescription drugs should be provided according to the following principles. 3 Principle #1: The Goal is Good Health The ultimate measure of the effectiveness of consumer drug information should be its impact on the health and well-being of Canadians and the quality of health care. Principle #2: Ready Access Canadians should have ready access to credible, high-quality information about prescription drugs. The primary purpose of this information should be education; sales of drugs must not be a concern to the originator. Principle #3: Patient Involvement Consumer drug information should help Canadians make informed decisions regarding management of their health, and facilitate informed discussion with their physicians and other health professionals. CMA encourages Canadians to become educated about their own health and health care, and to appraise health information critically. Principle #4: Evidence-Based Content Consumer drug information should be evidence based, using generally accepted prescribing guidelines as a source where available. Principle #5: Appropriate Information Consumer drug information should be based as much as possible on drug classes and use of generic names; if discussing brand-name drugs the discussion should not be limited to a single specific brand, and brand names should always be preceded by generic names. It should provide information on the following: * indications for use of the drug * contraindications * side effects * relative cost. In addition, consumer drug information should discuss the drug in the context of overall management of the condition for which it is indicated (for example, information about other therapies, lifestyle management and coping strategies). Principle #6: Objectivity of Information Sources Consumer drug information should be provided in such a way as to minimize the impact of vested commercial interests on the information content. Possible sources include health care providers, or independent research agencies. Pharmaceutical manufacturers and patient or consumer groups can be valuable partners in this process but must not be the sole providers of information. Federal and provincial/territorial governments should provide appropriate sustaining support for the development and maintenance of up-to-date consumer drug information. Principle #7: Endorsement/ Accreditation Consumer drug information should be endorsed or accredited by a reputable and unbiased body. Information that is provided to the public through mass media channels should be pre-cleared by an independent board. Principle #8: Monitoring and Revision Consumer drug information should be continually monitored to ensure that it correctly reflects current evidence, and updated when research findings dictate. Principle #9: Physicians as Partners Consumer drug information should support and encourage open patient-physician communication, so that the resulting plan of care, including drug therapy, is mutually satisfactory. Physicians play a vital role in working with patients and other health-care providers to achieve optimal drug therapy, not only through writing prescriptions but through discussing proposed drugs and their use in the context of the overall management of the patient's condition. In addition, physicians and other health care providers, and their associations, can play a valuable part in disseminating drug and other health information to the public. Principle #10: Research and Evaluation Ongoing research should be conducted into the impact of drug information and DTCA on the health care system, with particular emphasis on its effect on appropriateness of prescribing, and on health outcomes. APPENDIX VI CMA POLICY HEALTH INFORMATION PRIVACY CODE This Code articulates principles for protecting the privacy of patients, the confidentiality and security of their health information and the trust and integrity of the therapeutic relationship. Its provisions are more exacting than those currently in place in the Canadian health care system. Although a patchwork of laws across Canada permit or require health information collection, use, disclosure and access without patient consent, or even knowledge, this Code would require that all of these laws and any proposed laws be reviewed for consistency with its provisions. Moreover, existing practices and initiatives concerning health information collection, use, disclosure and access, including health information systems or networks, may be contrary to patient expectations and the physician's duty of confidentiality. These practices and initiatives must also be reviewed for consistency with this Code. Many laws, practices and initiatives may not withstand the kind of scrutiny deemed necessary and reasonable for the protection of privacy and the trust and integrity of the therapeutic relationship. CMA issues this Code in recognition that its implementation raises numerous issues and challenges, and that the changes it envisions will require time and the expenditure of resources. CMA appreciates that, given the complexity of the health care system, agreement and cooperation among a wide range of users and collectors of health information will be essential to the successful implementation of this Code. In view of these challenges, CMA issues this Code to the Canadian health care community at this time as an ideal to strive for, to guide and coordinate the efforts that need to be made to protect the privacy of patients, the confidentiality and security of their health information and the trust and integrity of the therapeutic relationship. Moreover, this Code is issued in the understanding that those to whom it applies will not be able to achieve full compliance with its provisions until such time as numerous implementation issues have been clarified and resolved through cooperation and the coordinated efforts of many different stakeholders. Consequently, companion implementation documents are being developed that provide for a gradual implementation of the Code's provisions over a five-year span and outline work that needs to be done to achieve the ideal it envisions. Section A: Scope This Health Information Privacy Code ("Code") has been produced by physicians to protect the privacy of their patients, the confidentiality and security of their health information and the trust and integrity of the therapeutic relationship. This Code is based on the Canadian Standards Association's Model Code for the Protection of Personal Information ("CSA Code") as a sectoral code of the CSA Code. This Code provides instruction and guidance respecting health information collection, use, disclosure and access. 1. This Code describes the minimum requirements to protect the privacy of patients and the security and confidentiality of their health information. 2. This Code has been developed by physicians in their capacity as clinicians and in recognition of their principal obligation to patients. 3. This Code recognizes the potential benefits of the use of health information for secondary purposes, including teaching, research and system planning, and contains provisions to permit such use under clearly defined terms and conditions. 4. This Code has been developed as a sectoral code of the Canadian Standards Association's Model Code for the Protection of Personal Information and consequently adopts the minimum standards contained in the CSA Code and augments them to meet the special circumstances of health information. 5. The development of this Code has been 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? 6. The Code applies to all health information and to all individuals, groups or organizations that collect, use, disclose or access such information. Its objective is to instruct in the development and implementation of policies, practices, health information systems or networks and legislation. 7. The principles that make up this Code are interrelated. Health information custodians adopting this Code shall adhere to these principles as a whole. 8. Health information custodians must subscribe to the principles contained in this Code and agree to uphold them, but may tailor this Code by modifying or adding principles provided the changes afford no less protection to the privacy of patients and the confidentiality and security of their health information. 9. Statements containing "shall" or "must" indicate requirements that must be met by any health information custodian who wishes to adopt this Code and be recognized for having done so. The use of "should" indicates a recommendation or aspiration. Section B: Definitions The following definitions apply in this Code: "Access" means the ability to acquire or possess health information in any information format. "Accountability" means having clearly defined and understood responsibilities in connection with health information, agreeing to accept those responsibilities and being subject to appropriate sanctions for failing to fulfil accepted responsibilities. "Authorized" means that which occurs with patient consent or within the provisions of this Code and applies to purposes, collection, use and disclosure of, or access to, health information. "Authorized user" is someone permitted to collect, use, disclose or access health information under the provisions of this Code, who is properly instructed on his or her limits and responsibilities, and who can be held accountable for his or her compliance. "Collection" means 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. "Confide" and "confided" mean the revelation of information by a patient within the therapeutic context. "Confidentiality" and "confidential" mean that health information that is confided by a patient is to be kept secret and not disclosed or made accessible to others unless authorized by patient consent. A breach of confidentiality occurs whenever a health professional discloses or makes health information available to others without or inconsistent with the patient's 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. 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. 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. "Disclosure" means the provision of health information to a third party for any reason, or making health information available for a third party to collect. It includes any transfer or migration of health information from one provider or user to another. "Duty of confidentiality" means the duty of physicians and other health professionals in a fiduciary relationship with patients to ensure that health information is kept secret and not disclosed or made accessible to others unless authorized by patient consent. "Emergency situations" mean those instances when health care must be provided to preserve life or prevent severe harm to a patient who is unable, owing to the circumstances, to be cognizant of the context and whose surrogate is not immediately available to make decisions on the patient's behalf. "Fiduciary duty" means the obligation to act with the utmost good faith for the benefit of another. "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. "Health information custodian" means any organization or institution that has custody, care or control of health information, and includes hospitals, regional boards, governments, corporations and solo or group medical practices. "Information format" means any form containing or recording health information, including: (a) a form that identifies or could identify a specific patient, either directly or indirectly; (b) a form that removes the link between the patient and information about him or her and which could, either directly or indirectly, be manipulated to reconnect the link between the patient and information about him or her ("deidentified-relinkable"); (c) a form that removes the link between the patient and information about him or her with the intent of preventing any reconnection of the link between the patient and information about him or her in accordance with recognized standards ("anonymous"); or (d) the composite form produced when health information is linked to any information about the patient from any other source, whether or not it is also health information. "Integrity of health information" means the preservation of its content throughout storage, use, transfer and retrieval so that there is confidence that the information has not been tampered with or modified other than as authorized. "Health professional" is any person having a fiduciary duty to patients who is registered and entitled by provincial or territorial law to practise or provide health care in that province or territory. "Knowledge" means the patient's awareness of what can or must happen with the health information he or she confides or permits to be collected. "Linkage" is the joining together of health information with information from any other source or database, in whatever form. When health information is linked to any other information, the composite is also health information. "Nonconsensual" collection, use, disclosure or access, whether justified or not, occurs without a patient's consent and contravenes the patient's right of privacy. "Patient" means the person about whom health information is collected and, for the purposes of this Code, may also mean a surrogate or guardian acting on behalf of this person. "Physician" means a person who is registered and entitled under the laws of a province or territory to practise medicine in that province or territory. "Primary" means that which occurs for the therapeutic benefit of a particular patient. Secondary means not directly related to the therapeutic benefit of the particular patient from whom the information has originated. "Purpose" means an end or aim for which health information is collected, used, disclosed or accessed. A description of purpose can be general enough to incorporate a range of like information uses provided that the generic description is sufficiently narrow and limited so as to communicate to the ordinary person a clear understanding of the potential information uses that could reasonably be expected to be relevant to their consent. The primary therapeutic purpose is the delivery of health care to a particular patient with respect to a particular and immediate health need or problem. It encompasses consultation with and referral to other providers on a need-to-know basis. A primary longitudinal purpose concerns developing composite health information about a particular patient, such as a detailed medical history, beyond direct application to any particular and immediate health need or problem, in order to enhance ongoing care to that person. Secondary legislated purposes have been subjected to the legislative test specified in this Code and have subsequently been written in law. Secondary nonlegislated purposes are any other purposes, such as education or research not governed by legislation, that meet the provisions of this Code and the secondary nonlegislative test provided by this Code. "Provider" means a health professional or institution that delivers health care services or products in the therapeutic context. "Right of privacy" includes a patient's right to determine with whom he or she will share information and to know of and exercise control over use, disclosure and access concerning any information collected about him or her; it entails the right of consent. Nonconsensual collection, use, disclosure or access violates the right of privacy, even if it is justified. "Security" means reasonable precautions, including physical and technical protocols, to protect health information from unauthorized collection, use, disclosure and access, and to ensure that the integrity of the information is properly safeguarded. A breach of security occurs whenever health information is collected, used, disclosed or accessed other than as authorized, or its integrity compromised. "Sensitivity" of health information refers 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. "Therapeutic context" means a setting in which information is confided by or collected from, about or on behalf of a patient who: (a) is in a therapeutic relationship with or under the care of a physician or health professional; (b) is resident in or seeking health care within a facility or institution whose principal purpose is the provision of health care, including physicians' offices, hospitals and other health care facilities; (c) confides information within a fiduciary relationship to a health care professional and with the belief that the health care professional will maintain its confidentiality, subject to very limited exceptions; or (d) confides information in the belief that it is necessary for the safe, timely and effective delivery of health care. "Transparency and openness" are the characteristics of policies, procedures and practices that seek to ensure that patients know what can or must happen with the health information they confide or permit to be collected, used, accessed or disclosed. "Use of health information" means any processing of health information including storage, retention, retrieval, manipulation, connection or linkage to other sources of information in any format. Section C: Principles Principle 1: The Right of Privacy The right of privacy is fundamental in a free and democratic society. It includes a patient's right to determine with whom he or she will share information and to know of and exercise control over use, disclosure and access concerning any information collected about him or her. The right of privacy and consent are essential to the trust and integrity of the patient-physician relationship. Nonconsensual collection, use, access or disclosure violates the patient's right of privacy. The right of privacy is important and worthy of protection, not just for the good of individuals in society but also for the good of society as a whole. 1.1 Canadians are entitled to expect and enjoy fundamental privacy rights and guarantees, which include: (a) physical, bodily and psychological integrity and privacy; (b) privacy of personal information; (c) freedom from surveillance; (d) privacy of personal communications; and (e) privacy of personal space. 1.2 The basic duties owed to others to ensure that their privacy rights are adequately respected include: (a) the duty to ensure consent; (b) the duty to take all the steps necessary to respect adequately others' privacy rights or, if their rights must be infringed, to interfere with privacy as little as possible; (c) the duty to be accountable; (d) the duty to be transparent; and (e) the duty to build privacy protection features into technological systems and designs. 1.3 The specific duties related to the protection of the patient's right of privacy in health information include: (a) the duty to hold health care information in trust; (b) the duty to limit information collection to what is necessary and justifiable for the benefit of the patient; (c) the duty to ensure that patients are informed by reasonable means about purposes for collection, use, disclosure or access at or before the time of collection, including the potential for such to occur nonconsensually; (d) the duty to ensure that the information is accurately recorded; (e) the duty to ensure consent by reasonable means, except in limited circumstances where the right of privacy and of consent are justifiably infringed by some compelling right, good or duty; (f) the duty to ensure that the right of privacy and the right to consent are infringed no more than is necessary by the compelling right, good or duty; (g) the duty to use and disclose health information only as consistent with the purposes identified at or before the time it was collected; (h) the duty to keep health information only for as long as necessary to fulfil identified purposes; (i) the duty not to disadvantage people because they elect to exercise their right of privacy; and (j) the duty of physicians and other health professionals to hold information in confidence. 1.4 Although the patient's interests and concerns about health information may vary depending on the sensitivity of the information, the right of privacy extends to all health information in whatever format. Principle 2: Special Nature of Health Information Governing principles and rules for health information must recognize the patient's right of privacy in health information, its highly sensitive nature, the circumstances of vulnerability and trust under which it is confided or collected, and the fiduciary duties of health professionals in relation to this information. The patient-physician relationship as defined by trust and a professional promise of confidentiality is a societal good worthy of protection. 2.1 Principles and rules governing health information must recognize: (a) its high level of sensitivity and protect the patient's right of privacy accordingly; (b) that the principal purpose for confiding and collecting this information is to benefit the patient; (c) that in the therapeutic context patients may be vulnerable and under duress, and must not be subjected to manipulation, coercion or exploitation; (d) that patients confide information to physicians and other health professionals under a very special trust, and that physicians and other health professionals have fiduciary duties to patients, including a duty to hold information in confidence. 2.2 Principles and rules governing health information must ensure that physicians and other health professionals can discharge their fiduciary duties and therefore shall take into account that: (a) patients may be in a situation of vulnerability owing to infirmity or incapacity, urgent need, lack of knowledge and power, or simply because they have needs and have to rely or depend upon providers to meet those needs; (b) patients confide information that is ordinarily considered by them to be private because they have certain needs that require the care of a provider and believe the information is required by the provider to help meet those needs; (c) were it not for those needs, and the expectation that the provider can help patients meet them, the occasion for the collection of the health information would not exist and the information would remain private; (d) were it not for the reputation of health professionals for trustworthiness and the expectation that information disclosed to them will be held in confidence, patients would be less willing to confide health information fully and truthfully in the therapeutic context; and (e) to the extent that provisions for health information inhibit patients from confiding health information fully and truthfully, their health care will be adversely affected. Principle 3: Constraints on Purposes and Limitation on Collection, Use, Disclosure and Access The principal purpose for the collection of health information is to benefit the patient who confides or permits information to be collected for a therapeutic purpose. Secondary purposes for the use of the information shall not be pursued if they inhibit patients from confiding information for the primary purpose, exploit patients' vulnerability, compromise the ability of physicians to discharge their fiduciary duties to patients or borrow on the trust patients invest in physicians for the primary therapeutic purpose. Collection, use, disclosure or access for secondary purposes shall be restricted to what is necessary for those purposes and shall not impede the confiding or collection of information for primary purposes. Nonconsensual access to and collection, use or disclosure of health information is a violation of a patient's right of privacy, compromises the physician's duty of confidentiality and is potentially disruptive of the trust and integrity of the therapeutic relationship. Therefore, it must only occur in very limited circumstances - namely emergency situations, in accordance with legislation that meets the requirements of this Code, or in response to a court decision or order. Even consensual collection, use, disclosure or access may erode the right of privacy and the trust and integrity of the therapeutic relationship. Therefore, it must only occur with due consideration of possible negative impacts and with measures designed to maximize privacy protection. 3.1 Provided that the principles contained in this Code are adhered to, and in particular that the principles related to patient consent are rigorously applied, health information may be collected, used, disclosed or accessed for the following purposes: (a) Primary purposes: (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. (b) Secondary purposes: (i) Secondary legislated purpose refers to health information collection, use, disclosure or access required or permitted by legislation or regulation that meets the provisions of this Code and the legislative test provided by this Code. (ii) Secondary nonlegislated purpose is any other purpose, such as education or research not governed by legislation, that meets the provisions of this Code and the secondary nonlegislative test provided by this Code. 3.2 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. 3.3 Health information collection, use, disclosure or access for any secondary purposes shall be as minimal as necessary in recognition of the need to protect the patient's right of privacy in the therapeutic context. 3.4 Health information collection, use, disclosure or access without patient consent shall only occur in the limited circumstances provided by this clause. Nonconsensual health information collection, use, disclosure or access, including the conversion of health information from one information format to another, is a violation of a patient's right of privacy, may compromise the physician's duty of confidentiality, and is potentially disruptive of the trust and integrity of the therapeutic relationship. Therefore, it must only occur under strict conditions and in these very limited circumstances: (a) when permitted or required by legislation or regulation that meets the requirements of this Code; or (b) when ordered or decided by a court of law. 3.5 Any existing or proposed secondary purpose for health information collection, use, disclosure or access, including health information systems or networks, shall be subjected to a patient privacy impact analysis that shall include an evaluation of: (a) the likely impact of the proposed measures on the right of privacy of patients; (b) the likely impact of the proposed measures on the relationship between patients and their physicians, and in particular on the duty of confidentiality and the trust within this relationship; (c) the likely impact of the proposed measures on the willingness of patients to disclose health information; (d) the likely impact of the proposed measures on the ability of patients to receive health care; and (e) compelling evidence to demonstrate broad public support for the proposed measures. 3.6 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; (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 this 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. 3.7 Any proposed or existing secondary nonlegislated purpose shall be subjected to the following nonlegislative test: (a) Before a health information custodian uses health information in its custody for secondary nonlegislated purposes, or before it releases or makes health information accessible to an external third party for secondary nonlegislated purposes, it must demonstrate or require the third party to demonstrate that: (i) a patient privacy impact assessment has been conducted, the analysis has been made public, the results have been duly considered and uses for that purpose will not be pursued if there is an adverse effect on privacy; (ii) collection of health information by persons beyond the therapeutic context will not exploit or compromise the trust of the patient-physician relationship; (iii) patients are not likely to be inhibited from confiding information for primary purposes; (iv) the ability of physicians to discharge their fiduciary duties to patients will not be compromised; (v) patient vulnerability will not be exploited; (vi) collection will be restricted to what is necessary for the identified purpose(s) and will not intrude upon primary purposes; (vii) patients will be fully informed of the purpose(s) and patient consent will be clearly voluntary; (viii) patient privacy will be intruded upon to the most limited degree possible in light of the purpose(s) consented to; (ix) linkage of health information will be restricted and consented to by the patient; (x) unless clear and compelling reasons exist, - all reasonable steps will be taken to make health information anonymous; - if it has been demonstrated that making health information anonymous will render it inadequate for legitimate uses, then the information will be collected and stored in a deidentified-relinkable format; (xi) any third party to whom health information is released has adopted this Code or has equivalent provisions in place; and (xii) the purpose(s) will not be applied retroactively to existing health information unless patient consent is given. 3.8 Health information shall not be collected by means that are unlawful, unfair or exploit the patient's vulnerability, nor shall any of the patient's beliefs or potentially false expectations about subsequent collection, use, disclosure or access be exploited. 3.9 Courts of law should respect the provisions of this Code when issuing orders or decisions. 3.10 Health information shall be retained only as long as it is necessary to fulfil authorized purposes. Once the authorized purposes are fulfilled it shall be securely destroyed, unless some issue or decision related to the patient and pertinent to the patient's health information is pending. Principle 4: Knowledge and Specification of Purpose, Collection, Use, Disclosure and Access In the therapeutic context, health information is confided by or collected from patients under the patient's presumption that it is necessary to meet his or her therapeutic needs. 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. It is not acceptable to withhold such knowledge from patients deliberately out of concern that knowledge could inhibit them from confiding important information fully and truthfully. 4.1 A health information custodian must have documentation that lists all purposes for which it uses or discloses the health information it collects, including to whom it permits access to what information, in what format and whether consent is required. 4.2 Within the therapeutic context health information is confided or provided by patients in the knowledge or with the belief that it is necessary to achieve therapeutic purposes. Patients must be explicitly informed about any other purposes. 4.3 Health information must not be used for purposes not identified to the patient at or before the time it is confided or collected, unless patient consent is subsequently sought and obtained. 4.4 Patients must either have or be provided by reasonable means with knowledge about what can or must happen with their health information. The degree of detail or specificity of this knowledge is what could be presumed germane to the decision of a reasonable person in the circumstances of the patient. 4.5. Unless a particular patient has given indication to the contrary, the conveyance of generic information is a reasonable means of providing knowledge. When the preferences of a particular patient for being informed are known or can be reasonably inferred given his or her circumstances, the provision of knowledge should as much as possible be tailored to these known preferences. 4.6 The goal of providing knowledge to patients is to ensure that before they confide information or permit information to be collected they actually understand what can or must subsequently happen with their information, particularly without their consent. Principle 5: Consent The patient's ability to decide with whom he or she will share information is crucial for the protection of the right of privacy and for the preservation of trust in the therapeutic context. Only the patient's consent to health information collection, use, disclosure and access for the primary therapeutic purpose can be inferred. Except for the very limited nonconsensual purposes addressed in this Code, any other collection, use, disclosure or access requires express consent. Nonconsensual collection, use, disclosure or access infringes the right of privacy and compromises the trust of the fiduciary relationship. To satisfy the requirement that consent be informed, the patient must have, or by reasonable means be provided with, knowledge about the potential for subsequent nonconsensual collection, use, disclosure or access before he or she confides any information. 5.1 Except for the very limited conditions set out in 3.4 concerning nonconsensual collection, use, disclosure or access, consent is required for health information collection, use, disclosure or access for any purpose. 5.2 For the purposes of this Code, consent for health information collection, use, disclosure or access in emergency situations is deemed to have been given to the extent necessary to allay the emergency as consistent with legal principles governing emergency medical care. The protection accorded this information shall be consistent with the provisions of this Code. 5.3 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. 5.4 Interpretation of "need-to-know" shall be guided by consideration of what the reasonable person in similar circumstances would expect, or otherwise authorize by his or her consent. If expectations are unclear or ambiguous, care should be taken to ascertain those expectations and to make the flow of information among providers in the therapeutic context consistent with those expectations. 5.5 Consent to collection, use, disclosure and access for longitudinal primary purposes must be express unless the provider has good reason to infer consent. 5.6 For the purposes of this Code, disclosure of health information to the patient's relatives or significant others is recognized as assisting in primary purposes. Consent to this disclosure must be express unless the provider has good reason to imply patient consent. 5.7 Consent can only be inferred in the case of primary purposes, and for primary purposes alone; collection, use, disclosure or access thus authorized must be limited either to the known expectations of a particular patient or to what the reasonable person in similar circumstances would likely believe necessary to receive health care. 5.8 Implied consent does not deprive the patient of the right to refuse consent or the right to challenge the provider's finding of implied consent. 5.9 Patient consent for secondary nonlegislated purposes shall be express, voluntary and fully informed. 5.10 Where express consent is required, patients must be informed of their right to refuse consent. It is not acceptable to compromise care deliberately as a consequence of the patient's refusal to provide express consent or to exploit any fear the patient might have that this could occur. 5.11 Consent shall not be obtained by coercion, deception or manipulation. Failure to inform the patient by reasonable means of relevant information pertinent to consent invalidates this consent. 5.12 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. Principle 6: Individual Access Patients have the right of access to their health information. In rare and limited circumstances, health information may be withheld from a patient 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 a denial of access. 6.1 The patient is entitled to know about, and subject to 6.5 to have access to, any information about himself or herself under the custody of the health information custodian. 6.2 Patients should be informed that they have the right to access their health information, to read it and to have copies of it. 6.3 Patients who wish to access their information should be given the opportunity to do so with explanation from a health professional who is knowledgeable about this information and capable of interpreting it for the patient. 6.4 Patients must be able to receive copies of their health information at a reasonable cost that does not exceed the cost of providing the information. 6.5 Providers may, in rare and limited circumstances, withhold health information from a patient 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 is on the provider to justify a denial of access. 6.6 Patients are entitled to know who has gained access to their health information and for what purposes. Principle 7: Accurate Recording of Information Accurate recording is important to protect the patient's right of privacy and to meet the purposes for its collection, use, disclosure or access. 7.1 Health information shall be recorded as accurately as possible, and shall be as complete and current as necessary for authorized purposes. 7.2. 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. 7.3 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. 7.4 Whenever possible, health information should be recorded in a form that allows for authorized secondary purposes consented to by the patient. Any standardization of recording requirements relevant to subsequent secondary purposes shall not impede recording of information for primary purposes. Principle 8: Security Security safeguards must be in place to ensure that only authorized collection, use, disclosure or access occurs. Such safeguards must also assure the integrity of the available information. 8.1 Health information, regardless of the information format, shall be protected by security safeguards to ensure compliance with the provisions of this Code. 8.2 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. 8.3 Security safeguards shall impede as little as possible health information collection, use, access and disclosure for primary purposes. 8.4 A health information custodian shall ensure that persons are able to collect, use, disclose or access health information in its control only as authorized. Persons thus authorized must have a clear understanding of the authority, parameters, purposes and responsibilities of their access, and of the consequences of failing to fulfil their responsibilities. 8.5 An authorized person's access to health information, including persons or groups external to the health information custodian, shall be limited to only the information needed for the authorized purpose(s), in the least intrusive format. 8.6 Security safeguards shall include both physical and human resource safeguards to prevent unauthorized health information collection, use, disclosure and access. Physical security measures include such safeguards as locked filing cabinets, restricted access to certain offices or areas, and the use of passwords, encryption and lock-boxes. Human resource security measures include security clearances, sanctions, training and contracts. 8.7. Health information custodians must protect health information in their custody so as to ensure its integrity and have assurance that the integrity of information received from other health information custodians has been similarly safeguarded. 8.8 Security safeguards should incorporate identification, authentication, information integrity/availability and non-repudiation, as appropriate. Principle 9: Accountability Accountability is owed first and foremost to the patient. Health information custodians must have in place policies and procedures that recognize this principal accountability and health professionals' duty of confidentiality to the patient. Anyone a health information custodian authorizes to have access to health information must be capable of being held accountable for his or her actions. In addition, health information custodians must designate a qualified person responsible and accountable for monitoring and ensuring internal compliance with this Code. 9.1 Health information custodians are responsible for the security of health information they collect, use, disclose or permit access to. 9.2 Health information custodians must ensure that persons, including administrative and technical support staff, receive authorization to access health information only as necessary to fulfil authorized purposes. 9.3 A health information custodian must ensure that anyone permitted to have access to health information has clearly defined and understood responsibilities in connection with health information, agrees to accept those responsibilities, and is subject to appropriate sanctions for failing to fulfil the accepted responsibilities. 9.4 Health information custodians must designate a qualified person responsible and accountable for monitoring and ensuring internal compliance with this Code. The designated accountable person shall have the autonomy, authority, and resources necessary to ensure the health information custodian's adherence to the Code. In the case of small private practices, practitioners may designate themselves. 9.5 Policies and procedures to ensure compliance with this Code must consider the special, direct accountability of health professionals to their patients. The high level of trust vested in health professionals is crucial to the initial confiding of health information for the therapeutic purpose. 9.6 Health information custodians must ensure that third parties privy to health information have adopted this Code or are bound by equivalent provisions. Provided that this has been determined before health information is disclosed or made accessible, health information custodians are not accountable for the actions of third parties or for what subsequently happens to the information. 9.7 Although it is the responsibility of the health information custodian to ensure that patients are appropriately informed, secondary users whose information requirements impose a burden upon the health information custodian are responsible for covering their share of any related costs or resource requirements (e.g., preparation of brochures). Health information custodians may reasonably require secondary users to cover their own costs as a condition of making health information available to them as authorized. Principle 10: Transparency and Openness Policies, procedures and practices relating to health information must be transparent so that patients can clearly understand the extent and circumstances of health information collection, use, disclosure and access. They must be explicit enough that patients are adequately informed and able to acquire knowledge germane to their confiding of information, and must be open to scrutiny and challenge. 10.1 Health information custodians must have transparent, explicit and open policies, procedures and practices, tailored to their practice setting, that seek to ensure that patients are provided with information about what can or must happen with their health information without their consent. 10.2 Policies, procedures and practices shall be as explicit as necessary to ensure that patients are aware of any considerations that could be relevant to deciding what information they elect to freely confide or consent to be collected, used, disclosed or accessed. Nothing must be left implicit that, if made explicit, could reasonably be expected to alter a patient's decision to freely confide information. Information about nonconsensual collection, use, disclosure and access must be made explicit. 10.3 Patients should be able to discuss the health information custodian's policies, procedures and practices concerning health information with a knowledgeable person and have specific questions about their own health information answered in a timely fashion. 10.4 A health information custodian's policies, procedures and practices shall ensure that patients can understand what might, can or must happen to their health information, that consent is sought as required by this Code and that nothing is left implicit or unknown to patients that if known or made explicit could reasonably be expected to alter a patient's decision to freely confide information. 10.5 Patients shall be able to challenge the health information custodian's compliance with the provisions of this Code by addressing their concerns to the designated accountable person. 10.6 Procedures shall be in place to receive and respond to complaints or inquiries about policies, procedures and practices relating to health information collection, use, disclosure and access. The complaint process must be easily accessible and simple to use. 10.7 Patients who make inquiries or lodge complaints shall be informed of the existence of relevant complaint mechanisms. 10.8 All complaints shall be investigated. If a complaint is found to be justified, appropriate remedial measures shall be taken such as amending policies, procedures or practices. Section D: Health Information Policies Health information custodians must have in place and implement policies, procedures and practices that give effect to the principles of this Code. 1.1 Health information policies, procedures and practices should be tailored to the specific health care setting of the custodian and shall address and provide for: (a) complying with and giving effect to the principles of this Code; (b) protecting the security of health information; (c) ensuring the accurate recording and integrity of health information; (d) documentation of all purposes for which the health information custodian uses or discloses the health information it collects, including to whom it permits access to what information, in what format and whether consent is required; (e) documentation of what health information may be linked to other pieces of information; (f) documentation of what health information is made available to third parties; (g) allowing access only to authorized users in the appropriate format and for the limited purposes for which they are authorized; (h) identification of the person who is accountable for the policies, procedures and practices and to whom complaints or inquiries can be made; (i) receiving and responding to complaints and inquiries; (j) ensuring that persons who collect, use, disclose or access health information can be held accountable and are under an enforceable duty to keep information secure; (k) ensuring that persons who work for or in the health institution know and receive sufficient training about this Code and related institutional policies, procedures and practices to ensure accountability; (l) the means of gaining access to one's own health information held by the health institution; (m) making available information that a particular patient specifically requests or reasonably can be presumed to wish to know; (n) ensuring that patients have, or by reasonable means are provided with, knowledge about their health information and that consent is sought and obtained as appropriate; and (o) specification of minimum and maximum retention periods and rules for the succession, transfer and destruction of health information. 1.2 The health information custodian's policies must be readily available to patients and should include information about practices and procedures. 1 Though this submission uses the word "product" in this context, it is understood that services, e.g. therapeutic procedures, may also be covered by the Health Protection Act. 2 DTCA is not legal in Canada, except for notification of price, quantity and the name of the drug. However, "information-seeking" advertisements for prescription drugs, which may provide the name of the drug without mentioning its indications, or announce that treatments are available for specific indications without mentioning drugs by name, have appeared in Canadian mass media. 3 Though the paper applies primarily to prescription drug information, its principles are also applicable to health information in general.
Documents
Less detail

Obesity in Canada: Causes, Consequences and the Way Forward

https://policybase.cma.ca/en/permalink/policy11540
Date
2015-06-02
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Date
2015-06-02
Topics
Population health/ health equity/ public health
Text
The Canadian Medical Association (CMA) would like to thank the Standing Senate Committee on Social Affairs, Science and Technology for the opportunity to provide our views on the causes and consequences of obesity in Canada, and our recommendations for a way forward. Canada’s physicians have repeatedly expressed their concern about the increasing prevalence of obesity and overweight in this country. Over the past ten years, responding to these expressions of concern, the CMA has developed a number of policy statements, briefs to government, and discussion papers on the issue, which articulate our recommendations for addressing this serious problem. In this brief, we will focus our recommendations on two remedies that we believe should be part of the way forward: the implementation of public policy that supports Canadians in making healthy food choices; and the provision of reliable, user-friendly information to health professionals and to the public. 2) Obesity in Canada: Causes and Consequences More than half (62%) of Canadian adults are overweight according to the 2013 Canadian Health Measures Survey. A quarter of Canadian adults can be classed as obese (BMI = 30); this is double the obesity rate in 1979.1 The rise in obesity is most pronounced among Canada’s heaviest people; since 1985, the prevalence of extreme obesity (BMI=40) rose from 0.3% to 1.6%, a more than five-fold increase.2 One in ten Canadian children is obese;3 obesity in children and youth has more than doubled since the late 1970s. Prevalence of overweight and obesity is higher among some segments of the Canadian population, particularly Aboriginal peoples and people of lower socio-economic status. 1 Statistics Canada. Body composition of adults, 2012 to 2013. Accessed at http://www.statcan.gc.ca/pub/82-625-x/2014001/article/14104-eng.htm. This survey used actual measurement which is considered more accurate than self-report. 2 Twells LK, Gregory DM, Reddigan J, Midodzi WK. Current and predicted prevalence of obesity in Canada: a trend analysis. CMAJ Open, March 3, 2014. Accessed at http://cmajopen.ca/content/2/1/E18.full 3 Statistics Canada. Body mass index of children and youth, 2012 to 2013. Accessed at http://www.statcan.gc.ca/pub/82-625-x/2014001/article/14105-eng.htm 4 Canadian Diabetes Association. http://www.diabetes.ca/diabetes-and-you/kids-teens-diabetes/children-type-2-diabetes Obesity is of particular concern to Canada’s physicians because it increases a person’s risk of developing a number of serious health problems: high blood pressure, high blood cholesterol, heart disease and stroke, type 2 diabetes, osteoarthritis, lower back pain and other musculoskeletal disorders, and many types of cancer. Type 2 diabetes, once found only in adults, is now being seen in children4. Health advocates are concerned that because of obesity, today’s generation of children will have a shorter life expectancy than their parents. In addition to poor physical health, obese people are at greater risk than people with normal weights of suffering from mental health problems such as low self-esteem, depression and anxiety. The stigma attached to obesity is high; obese people are at high risk of being bullied, ostracized socially, and discriminated against in the workplace. Some turn to food to relieve stress or as an escape from their unhappy lives, thereby perpetuating a vicious cycle of unhealthy eating and poor mental health.5 5 Canadian Obesity Network. Obesity and mental illness: addressing a double epidemic. Accessed at http://www.obesitynetwork.ca/de.aspx?id=322 6 Public Health Agency of Canada. Obesity in Canada: Health and economic implications. Accessed at http://www.phac-aspc.gc.ca/hp-ps/hl-mvs/oic-oac/econo-eng.php 7 From the CMA background paper on processed food and health. Original citation: Cohen D a. Obesity and the built environment: changes in environmental cues cause energy imbalances. Int J Obes (Lond). 2008;32 Suppl 7:S137–42. doi:10.1038/ijo.2008.250. The Public Health Agency of Canada estimates that obesity-related health conditions cost Canada $4.6 billion dollars in 2008, both in direct costs (such as hospitals and health professional services) and indirect ones (e.g. disability claims, psychological damage and lost productivity).6 Other estimates have been even higher. The causes of obesity are multifarious and highly complex. There is no one, simple cause. In some cases human biology is responsible, because certain people have a genetic predisposition toward gaining weight. But for the most part, obesity can be attributed to environmental circumstances that contribute to Canadians consuming more calories than they burn through physical activity. These circumstances include: . The widespread consumption of pre-packaged and processed foods. In the US it is estimated that the percentage of food spending that goes toward foods prepared away from home went up from 24% in 1966 to 42% in 2006.7 Processed foods are more likely than fresh foods to be high in trans fats, sodium, sugar and other ingredients that are risk factors for obesity-related diseases. They are available widely, in fast-food outlets, grocery stores and vending machines, and their manufacturers often promote them heavily. In addition, they are generally lower in price than fresh fruits, vegetables or meats, which may be beyond the means of many low-income Canadians. . Change in physical activity patterns. Many adults spend their days at sedentary desk jobs, and if they engage in physical activity, they often devote specific time to it (say, an hour at the gym) rather than incorporating it into their daily lives. Where children might once have gone outdoors to play after school, today they are more likely to sit in front of a computer or television set. The conventional wisdom about addressing obesity is that it is the individual’s responsibility to lose weight through diet and exercise, and to keep it off. However, achieving and maintaining a healthy weight is a complex process, and can be frustratingly hard to manage. For many Canadians, obesity is a lifelong condition, and the environmental conditions discussed above discourage healthy behaviour. Despite an abundance of diet information and advice (of varying quality and accuracy), most people who lose weight eventually put it on again. Pharmaceutical weight loss drugs are available but are not always recommended because of their side effects8. More aggressive treatments such as surgery are recommended mainly for severely obese people with health complications. 8 Canadian Task Force on Preventive Health Care. Recommendations for prevention of weight gain and use of behavioural and pharmacologic interventions to manage overweight and obesity in adults in primary care. CMAJ 187:3 (February 17, 2015): 184-195. 3) The Way Forward Just as obesity sparks challenges in our populations and has no single cause, so there is no single way forward that will fully address it. CMA believes that the way forward actually involves a number of separate paths moving in the same direction. Two of these paths are discussed in the following sections. a) Implementing Public Policy That Helps Canadians Make Healthy Food Choices Public policy can be a powerful tool to help reduce risks to public health. In the case of tobacco control, measures such as bans on tobacco advertising and on smoking in public places contributed to the decline in smoking in Canada by making it easier for individuals to choose to be smoke-free. In the same way, CMA believes the federal government should implement policies and regulations to help create a supportive environment for people wanting to achieve and maintain a healthy weight. In particular, CMA recommends that the Committee give consideration to the following measures: i) Improving Access to healthy food Recommendation: that the Government of Canada support community-based initiatives aimed at reducing Canadians’ barriers to accessing healthy, nutritious food. If Canadians are to be encouraged to make healthy food choices, then healthy foods should be readily available to them at affordable prices. Unfortunately, for many Canadians, this is not the case. In some neighborhoods, often lower-income neighbourhoods, fast food outlets outnumber grocery stores. Many variety stores, restaurants, schools and workplace cafeterias offer a larger selection of processed foods than of fresh fruits, vegetables and meat. For some Canadians, financial barriers limit their capacity to make healthy individual choices. As a rule, fresh food tends to be more expensive than processed “fast food”. The difficulty is compounded in Canada’s remoter areas and in the North, where fresh produce must be transported from far away, and what little is available is very high priced. Programs to improve access to healthy food exist at all levels of government. The federal Northern Food Program, designed to offset the cost of transporting fresh food to remote areas, has been in existence for several years, though it has been criticized as ineffective9. At the community level, not-for-profit and municipal agencies have collaborated on programs such as the Good Food Markets in Ottawa, which offer fresh, affordable foods in low-income areas.10 9 Woo A. “Critics slam Canada’s northern food program.” The Globe and Mail, November 4, 2014. Accessed at http://www.theglobeandmail.com/news/critics-slam-canadas-northern-food-program/article21451386/ 10 Canadian Public Health Association. “Ottawa Public Health partners with community Groups to Increase access to healthy foods.” Accessed at http://www.cpha.ca/en/programs/social-determinants/frontlinehealth/stories/ottawa.aspx 11 “Restricting Marketing of Unhealthy Foods and Beverages to Children and Youth in Canada” a policy paper endorsed by CMA and other health and scientific organizations. Other measures to improve access to healthy food could include: ensuring that every Canadian is within reach of a grocery store; regulating the number and location of fast-food outlets; and increasing the availability of nutritious foods and restricting that of processed foods in workplaces, schools and recreational facilities. ii) Controls on Marketing of Processed Foods. Industry marketing of fast food and processed food, including beverages, is ubiquitous – in television, on the radio, on the Internet, and at point-of-purchase displays and event sponsorships. Unfortunately, many of the advertised foods are high in calories and low in nutrients. Food advertising is aimed at Canadians of all ages, but children, particularly those under the age of 13, have been found to be especially vulnerable to it. Research has shown that the advertising of food and beverages to children influences their food and beverage preferences, purchase requests and consumption patterns.11 At present, Canada relies on voluntary industry codes to govern advertising and marketing practices. However, health groups are skeptical of the effectiveness of such codes, and of manufacturers’ commitment to them. The CMA believes that for maximum efficacy, regulatory measures are required to minimize the negative effect of food marketing on health. Recommendation: That governments ban the advertising and promotion of high-calorie, nutrient poor foods to children 13 years of age or younger. Food advertisements often include claims as to the product’s nutrition content and health benefits. Unfortunately, such advertising may be misleading; a product labelled “lower fat” may still have a relatively high fat content, or contain high levels of other potentially unhealthy ingredients such as sugar and sodium. In general, brand-specific advertising is a less than optimal way to provide health information to consumers. Therefore, CMA believes that the federal government should review and regulate the health claims that manufacturers can make for their products, to ensure that these claims are based on the best available scientific evidence and that they are accurately communicated to consumers. Recommendation: that the Government of Canada set rigorous standards for the advertising of health claims for food, and strengthen provisions against deceptive advertising in the Food and Drug Act. iii) Enhancing Nutrition Labelling Governments at all levels, as well as health organizations, currently provide a variety of programs, educational materials and guidelines to the public. The CMA encourages these initiatives and encourages all levels of government to continue to make overweight and obesity a public health education priority. Food labels are an important means of health education, providing guidance to shoppers at the point of purchase to help them inform their food choices. Health Canada has made important contributions to public education, through a number of programs including its “Nutrition Facts” package labels. The labels are continually being revised and updated, as research reveals new information about nutrition and about effective means of conveying health messages to the public. As part of its revision process, CMA believes that Health Canada should consider enhancing health messages on the front as well as the back of food packages. Recommendation: that the Government of Canada implement, and set rigorous standards for, front-of-package food labelling. The CMA encourages the federal government to build upon the current package labelling system, making labels as user-friendly as possible and helping Canadians to interpret the information they provide. Colour-coded, brief-summary labels, such as the “red-light, green-light” system used in Britain, are intended to provide consumers with an “at a glance” assessment of a food’s nutritional value. While the system has its critics, it has the benefit of being easy to notice and interpret. The CMA has also recommended that food packages and retail displays contain warnings about the health risks associated with an excessive consumption of calorie-high, nutrient poor food and beverages. b) Information and Support for Physicians and other Health Professionals For many patients, obesity is a lifelong condition which, like other chronic health conditions, can be managed medically but rarely fully cured. Increasingly, it is being recognized that effective obesity management requires more than short-term weight loss diets; it involves identifying and addressing both the root causes of a patient’s weight gain (physical, psychological or socio-economic) and the barriers the patient experiences in maintaining healthy weight. 12 According to the Canadian Obesity Network, primary care interventions should be evaluated not by how many pounds the patient loses but by improvements in the patient’s health and well-being. 12 Canadian Obesity Network: 5As Guiding Principles. Accessed at http://www.obesitynetwork.ca/5As_core_principles 13 “Weight loss surgeries leap in Canada, study says.” CBC News, May 22, 2014. Accessed at http://www.cbc.ca/news/health/weight-loss-surgeries-leap-in-canada-study-says-1.2651066 Physicians, working with dietitians, nurses, physiotherapists, mental health care providers and other health professionals, have an important role in providing care and support to people who are trying to maintain a healthy weight. Physicians can provide nutrition advice to patients as part of the routine medical examination. In addition, since primary care physicians are generally the patient’s first point of contact with the health care system, they often see patients at “teachable moments” when, because of an associated health condition such as diabetes, they are motivated to change unhealthy behaviours. Physicians can also provide patients with resources to help them live healthy lives. For instance, in British Columbia, physicians are prescribing exercise on specially-designed prescription pads, distributing free pedometers, and hosting free walking events for their patients and the public. In the Edmonton area, Primary Care Networks are prescribing free access passes or a free month of access at local municipal recreation facilities. The tertiary health care sector also has an important role to play in addressing obesity, since there is a growing number of severely obese patients who are at high risk of serious health problems and may require specialized treatment, possibly bariatric surgery. According to a study by the Canadian Institute for Health Information, the number of bariatric surgeries performed in Canada has jumped four-fold since 2006-07. The study notes that though the health care system has made great strides in meeting the demand,13 access to bariatric surgery varies from one region of Canada to another. Governments have an important role to play in ensuring equitable access to bariatric surgery for patients for whom it is clinically indicated. Recommendation: That the federal government work with provincial/territorial governments and with researchers, medical educators and others to continually develop and disseminate up-to-date, evidence-based clinical knowledge and practice tools, to help physicians and other health professionals manage overweight and obesity in their patients. Clinical guidelines, based on the best current scientific evidence, are available to help health professionals work with their patients to achieve and maintain healthy weights. The Canadian Obesity Network has developed a “5As of Obesity Management” program for primary care. The Canadian Task Force on Preventive Health Care also develops and frequently updates recommendations for primary caregivers on how to manage overweight and obesity in practice. The Task Force’s most recent recommendations were published in the Canadian Medical Association Journal early in 2015. Clinical practice guidelines should be distributed widely and continually updated, and governments could play an important role in supporting the revision and dissemination process. Thanks to ongoing research our knowledge of the extent and causes of obesity, and the effectiveness of existing programs in addressing it, is continually growing and developing. CMA encourages an ongoing commitment to research, and believes that the Government of Canada has an important role to play in supporting it. Results of this research should be communicated to health professionals and the public as quickly and widely as possible, so that it can be rapidly incorporated into clinical practice. Recommendation: That the federal government support, and help to disseminate, evidence-based research on obesity in Canada and on the evaluation of strategies to address it. 3) Conclusion Obesity and overweight are serious health problems in Canada, and as such are of great concern to the country’s physicians and to the Canadian Medical Association. The causes, CMA believes, are rooted mainly in changes in our environment and their effect on our eating and physical activity habits. The consequences are extremely serious, both for individual Canadians’ health and for the sustainability of Canada’s health care system. CMA believes that the way forward requires a number of different interventions, on many levels. These should include providing and continually updating research and practice information for health professionals; and implementing policies that support Canadians as they pursue the goal of maintaining healthy weights. Once again, CMA commends the Senate of Canada on conducting this study. We hope it will help encourage productive and meaningful change in the way Canadians view obesity, and assist in creating a social environment that supports healthy eating and healthy weight.
Documents
Less detail

Toward a National Strategy on Mental Illness and Mental Health : CMA Presentation to the Senate Standing Committee on Social Affairs, Science and Technology

https://policybase.cma.ca/en/permalink/policy2008
Last Reviewed
2011-03-05
Date
2004-03-31
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Last Reviewed
2011-03-05
Date
2004-03-31
Topics
Population health/ health equity/ public health
Text
Thank you, honourable Senators, for the opportunity to speak on the critical need to address mental health and mental illness in Canada. In my remarks today I want to talk briefly about the dimensions of the issues, the instruments available to government to address them, and the CMA’s specific thoughts and recommendations on moving forward. Dimensions of the problem As the members of this committee know, the economic toll exacted by mental health disorders, including stress and distress topped 14 billion dollars in 1998. The human cost, however, extends far beyond dollars and cents. Estimates show that about one in five Canadians — close to six million people — will be affected by mental illness at some point in their life. This problem climbs still higher if one includes the serious problem of addiction to illicit drugs, alcohol, prescription drugs and the increasingly serious emerging problem of gambling addiction. Yet our society and health care system remains woefully inadequate in promoting mental health and in delivering care and treatment where and when needed. These systemic shortcomings have been exacerbated by the twin barriers of stigma and discrimination. These barriers have a detrimental effect on recovery from mental illness and addictions by hindering access to services, treatment and acceptance in the community. This is especially unfortunate because effective treatment exists for most mental illnesses and addictions. Poor mental health affects all aspects of a person’s life and requires a collaborative approach. Family physicians, psychiatrists, psychologists, social workers, nurses and other counselors can be involved in one patient’s mental health care. While family physicians can deal with a number of mental illnesses, most are not trained in the complicated medical management of severe mental illness. Many family physicians’ offices are also not sufficiently resourced to deal with family counseling, or related issues such as housing, educational and occupational problems often associated with mental illness. As a family physician myself I should be assured that, when a patient’s mental health care requires additional expertise, the appropriate resources are available for my patients and their families. Physicians are striving to ensure that the care is provided by the appropriate caregiver at the appropriate time. For example the Shared Mental Health Care initiative of the College of Family Physicians of Canada and the Canadian Psychiatric Association is designed to lead to better outcomes for patients. I know the committee will hear more about this initiative from the Canadian Psychiatric Association. I mention it now simply as a reminder that progress is being made and even more could be gained with the establishment of a national strategy to address mental illness and mental health. Canada is the only G8 nation without such a national strategy. This oversight has contributed significantly to fragmented mental health services, chronic problems such as lengthy waiting lists for children’s mental health services and dire health human resource shortages. Case in point, there are no child psychiatrists in the northern territories, where such care is so desperately needed. Planning to correct the problem The fragmented state of mental health services in Canada did not develop overnight and it would be overly simplistic to say problems can be solved immediately. However, it is important to understand that there are means available to the federal government to better meet its obligations with respect to surveillance, prevention of mental illness and promotion of mental health. The way forward has been clearly described by the Canadian Alliance for Mental Illness and Mental Health, and the October 2002 National Summit on Mental Health and Mental Illness hosted by the CMA, and the Canadian Psychological and Psychiatric Associations. This gathering helped define the form that a national strategy should take. Participants recommended a focus on national mental health goals, a policy framework that includes research, surveillance, education, mental health promotion and a health resources plan, adequate and sustained funding; and an accountability mechanism. In addition to a national strategy, the CMA believes it is also important to recognize the deleterious effect of the exclusion of a “hospital or institution primarily for the mentally disordered” from the application of the Canada Health Act. Simply put, how are we to overcome stigma and discrimination if we validate these sentiments in our federal legislation? The CMA firmly believes that the development of a national strategy and action plan on mental health and mental illness is the single most important step that can be taken on this issue. The plan also requires support, wheels if you will, to overcome the inertia that has foiled attempts thus far. Those wheels come in the form of five specific actions that are listed at the back of the presentation. But, to summarize, they would include: * Amending the Canada Health Act to include psychiatric hospitals. * Adjusting the Canada Health Transfer to provide for these additional insured services. * Re-establishing an adequately-resourced federal organizational unit focused on Mental Illness and Mental Health and addictions. * The review of federal health policies and programs to ensure that mental illness is on par in terms of benefits with other chronic diseases and disabilities. * An effective national public awareness strategy to reduce the stigma associated with mental illnesses and addictions in Canadian society. Looking inward While my remarks have focused on the broad status of mental health initiatives in Canada, the mental health status of Canadian health care providers is also of concern to the CMA. In recent years, evidence has shown that physician stress and dissatisfaction is rising and morale is low. The CMA’s 2003 Physician Resource Questionnaire found that 45.7% of physicians are in an advanced state of burnout. Physicians, particularly women physicians, appear to be at a higher risk of suicide than the general population. The CMA has been involved in a number of activities to address this situation, including last year’s launch of the Centre for Physician Health and Well-Being. The Centre functions as a clearinghouse and coordinating body to support research and provide trusted information to physicians, physicians in training and their families. A first activity of the Centre was to provide, through partnership with the CIHR’s Institute of Neurosciences, Mental Health and Addiction, $100,000 in physician health research funding. This funding is currently supporting two research projects. One will develop a guide of common indicators for Canadian physician health programs. This will generate a national profile of the physicians who use the programs, the services provided, and their outcomes. The second will study the psychodynamics of physicians’ work to allow for a better understanding of the dynamics of problems such as stress, burnout, addiction and violence in the workplace. These efforts must be bolstered - other health providers are also impacted by mental illness and need support. The health care provider community needs help in terms of the reduction of stigma, access to resources and supportive environments. Conclusion I know some of what I have said today will have been familiar to members of the committee given the impressive list of roundtables, witness testimony and submissions you have reviewed already as part of your study on mental health. I only hope my comments will be of help in your important efforts and lead to real progress on addressing the largely unmet mental health and mental illness needs in Canada. Recommendations for Action CMA Submission to the Senate Social Affairs, Science and Technology 1. That the federal government make the legislative and/or regulatory amendments necessary to ensure that psychiatric hospital services are subject to the five program criteria of the Canada Health Act. 2. That, in conjunction with legislative and/or regulatory changes, funding to the provinces/territories through the Canada Health Transfer be adjusted to provide for federal cost sharing in both one-time investment and ongoing cost of these additional insured services. 3. That the federal government re-establishes an adequately resourced organizational unit focused on Mental Illness and Mental Health and addictions within Health Canada or the new Canadian Agency for Public Health. This new unit will coordinate mental health and mental illness program planning, policy coordination and delivery of mental health services in areas of federal jurisdiction. The unit would also work with provinces and territories, and the Canada Health Council to enact the National Action Plan endorsed at the National Summit on Mental Illness and Mental Health. Specific responsibilities would include fostering research through federal bodies such as the Canadian Institute for Health Research (CIHR), and disseminating best practices in the provision of mental health programs and services in Canada. 4. That the federal government review federal policies such as disability policy, tax policy, income support policy to ensure that mental illness is on par in terms of benefits with other chronic diseases and disabilities. 5. That the federal government work with the provinces and territories and the Canadian Alliance on Mental Illness and Mental Health to develop an effective national public awareness strategy to reduce the stigma associated with mental illnesses and addictions in Canadian society.
Documents
Less detail

7 records – page 1 of 1.