My name is Dr. Isra Levy, and as a public health physician and the Chief Medical Officer and Director in the Canadian Medical Association's Office for Public Health, I am pleased to be participating in your roundtable today. With me is Mr. John Wellner, Director, Health Policy at our sister organization the Ontario Medical Association.
CEPA is, of course, a key piece of Environmental Legislation, but we at the CMA see it to be primarily about health.
Similarly, Canada's doctors see the topic of today's hearings, "Measuring CEPA's Success" in terms of the impacts on our medical practices and, more particularly, on our patients. To us the measurement of success that matters is good health in our patients. And unfortunately I must tell you that we still see the negative impacts of environmental degradation on our vulnerable patients every day.
We are pleased to participate in this review of CEPA, because for us, the measure of health benefits and health outcomes, over the short or long-term that stem from reduced exposure to environmental contaminants is an important measure of our health as a nation.
The Canadian Medical Association, first founded in 1867, currently represents more than 63,000 physicians across the country. Our mission includes advocating for the highest standard of health and care for all Canadians and we are committed to activities that will result in healthy public policy. The environment, as a determinant of health, is a major concern for the general public as well as health care providers.
And health outcomes are directly linked to the physical environment in many, many ways. We know from the crises in Walkerton, Collingwood, North Battleford and many First Nations communities, the devastating effects that contaminated water can have on individuals and families.
We know from the smog health studies undertaken by the OMA, Health Canada and others, about the public health crisis of polluted air in many parts of Canada. And it is a crisis. We are now in a position where science allows us to more clearly show the long-term, lifetime burden of morbidity caused by some of these pollutants; we now know that there are thousands more premature deaths caused by air pollution in Canada than has previously been appreciated.
We are learning that central Canada is not the only place that has a smog problem. The OMA has shown, through its Illness Costs of Air Pollution model, that it is plausible to think in terms of substantial costs to the health and pocketbooks of Canadians because of environmental risks across the country.
The CMA has developed many environmental policies that are pertinent to our CEPA discussion today.
* Prior to Canada's ratification of the Kyoto Protocol, the CMA urged the Prime Minister to commit to choosing a climate change strategy that satisfies Canada's international commitments while maximizing the clean air co-benefits and smog-reduction potential of any greenhouse gas reduction initiatives.
We realize that pollution prevention initiatives can have many health benefits and that pollution sources seldom emit contaminants in isolation. The smoke that you see, and often emissions that you can't see, represent a cocktail of potentially harmful substances.
* The CMA has committed to working with the federal Ministers of health and the Environment to develop national strategies to reduce the unacceptably high levels of persistent organic pollutants amongst the peoples of the Arctic coast.
* We have asked Environment Canada and Health Canada to initiate a review of the current Canadian one hour guideline for maximal exposure level to both indoor and outdoor NO2 and recommend that the federal Environment and Health Ministers commit their departments to improved health-based reporting by regularly updating the health effects information for pollutants of concern.
Let me return to the issue of measuring success though -
Doctors understand the concept that success from an intervention can be nuanced. In the case of disease, physicians know and accept that the benefit of treatment is not always cure of a patient. Sometimes we just reduce their symptoms, or slow their rate of decline.
But when treating the natural environment, so critical to human health, we suggest that you cannot accept a palliative solution. We must aim for cure. We urge you to commit to measures of success in terms of real improvement, rather than merely accepting slight curtailments in the "inevitable increase" of environmental contamination.
The issue of greenhouse gas reduction is one that illustrates this point. Just as slowing the progression of a disease can never be considered a cure, referring to an "inevitable increase" in emissions and attempting only to limit the growth of those emissions, cannot result in true success by any measure.
We have seen 'good news' press releases on environmental initiatives from various federal and provincial governments, but the news isn't always worthy of praise.
Although there have been some great environmental successes that Canadians should be proud of, the measure of overall success - on all contaminants of concern - has only been incremental at best.
For example, when policy makers speak about industrial emission reductions of any kind, they often refer to "emissions intensity" - the emissions per unit of production, rather than total, overall emissions. To be health-relevant, the only meaningful way to report emissions reductions is to present them as "net" values, rather than the all-to-common "gross" valuation. An emission reduction from a particular source is only health-relevant if we can guarantee that there is not a corresponding emissions increase at another source nearby, because it is the absolute exposure that an individual experiences that affects the risk of an adverse health effect.
This issue becomes especially tricky with regional pollutants like smog precursors, because you may have to take the whole air shed into account. For this reason, cross- jurisdictional pollution control initiatives are very important in Canada - and that means federal oversight. In fact, to our understanding, that is what CEPA does, it gives the federal government jurisdictional authority, and, dare I say, obligation to act to protect the health of Canadians.
To the CMA, and we believe to most Canadians, the real measure of success is a reduction in the illnesses associated with pollution. It is not just important how we measure this ultimate success, but how we measure our progress towards it.
Environmentally related illness is essentially the combined result of exposure and vulnerability.
We are vulnerable because we are human beings; each human being has different physical strengths and weaknesses. Some vulnerabilities to environmental influences are genetic, and some the results of pre-existing disease. There is not much that government can do about this part of the equation.
Our exposure, on the other hand is related to the air we breathe, water we drink and food we eat. This is where CEPA comes in. This is where your role is critical, and where the measures of success will be the most important.
Proxy measures for the health outcomes that matter must be relevant from a health perspective. Health-based success can only be measured by quantifiable reductions in the exposure levels of contaminants in our air, water and foods.
Canada has historically relied only on guidelines for contaminants of concern, memoranda of understanding with polluters and voluntary goals and targets. Our American neighbours prefer legally binding standards, strict emission monitoring, and pollution attainment designations. While there may be some benefit to the Canadian approach, we are clearly behind in this area. In many parts of the U.S., counties try desperately to avoid "non-attainment" designations based on the ambient air pollution target levels. If they are designated to be a non-attainment zone they risk loss of federal infrastructure transfer payments.
In Canada, we have Canada-Wide smog Standards for 2010 - but of course these are non-binding, have no penalties for non-attainment, provide loopholes for any jurisdictions claiming cross-border pollution influences and allow provinces to opt-out with a mere three months notice. We must be more forceful. Indeed sufficient evidence exists on the health effects of a wide-range of CEPA-Toxic substances (smog precursors, for example) to justify more forceful action to reduce exposures. And there are many more chemicals of concern, for which all the evidence may perhaps not yet be in, but which require a precautionary approach in order to prevent potential human harm.
So, although the presentation of environmental information (e.g., ambient pollution levels in a State of the Environment report, or a health-based Air Quality Index) is beneficial and may provide information that enables Canadians to reduce their exposures, ultimately this is not enough.
The CMA believes that although enhanced environmental monitoring or pollutant exposure studies are important to our understanding of some contaminants, such studies in and of themselves will not improve the health of our patients. The true measure of success would go beyond reporting the danger, to actually reducing the danger. The CMA believes that is the purpose of CEPA.
We look forward to working with you to improve CEPA and ensure that the measures of CEPA's success will benefit the health of our patients across Canada.
Canadian Medical Association Ottawa, June 12, 2006
While my remarks today will focus on the recognition of foreign credentials, mainly with reference to the medical profession with which I am most familiar, I want to emphasize that this is just one element of assuring a sustainable health workforce in Canada as my colleagues will be amplifying in greater detail.
I want to impress upon Members of the Committee that the CMA does not test, credential, license or discipline physicians, nor is it empowered to act on complaints made by patients - this is the purview of the provincial/territorial licensing bodies. We are not directly involved in provincial or territorial benefit negotiations for physicians - this is the responsibility of our provincial/territorial Divisions. Nor do we control medical school enrolment or conduct clinical research.
What we do, is carry out research and advocacy on short, medium and long term health and health care issues to ensure we can meet the current and emergent needs of Canadians.
CONTRIBUTIONS OF INTERNATIONAL MEDICAL GRADUATES TO CANADA
I would like to begin by dispelling the popular myth that Canada is a "closed shop" to persons with international medical credentials. In fact Canada has always relied on International Medical Graduates to make up a significant proportion of the medical workforce; this proportion has remained fairly steady at about one in four physicians for the past few decades.
(Currently 23%). Our best estimate is that some 400 IMGs are newly licensed to practice in Canada each year. In fact, the College of Physicians and Surgeons of Ontario, has for the past two years licensed more IMGs that Ontario medical graduates.
A corollary of this myth is that IMGs are unable to access the postgraduate medical training system to complete any supplementary training they might need. In the Fall 2005, of the some 7,800 postgraduate trainees in Canada just over 900 or 12% were IMGs. Many more are participating in special assessment/supervised practice programs in the community.
The fact of the matter is that Canada has historically trained fewer physicians than we need to meet our population needs. This can be clearly demonstrated by looking at relative opportunity to enter medical school. In the most recent year (2005/2006) Canada had 7.1 first year medical school places per 100,000 population. This level is just over one-half of that of the United Kingdom, with its 12.9 places per 100,000 population. While the United States has the same ratio of medical school places per 100,000 population as Canada - it has 1.5 first year postgraduate places per medical graduate and relies on bringing large numbers of IMGs in to fill these places and supplement production in this manner.
Not only is Canadian undergraduate medical education capacity inadequate, but postgraduate medical training capacity is similarly insufficient to meet the demands of training Canadian medical graduates, providing training to IMGs, and permitting Canadians to retrain in specialties. In 2006 of the 932 IMGs registered in the second iteration run by the Canadian Resident Matching Service, just 111 or 12% were successful in obtaining a training position. There is clearly a backlog of IMGs who are eligible to receive the supplementary training they need to become eligible for licensure to practice in Canada should sufficient capacity be available.
For those who are not eligible, opportunities should be provided to achieve credentials in other health professions such as physician assistants or paramedics. A recent pilot project in Ontario was funded to allow IMGs to qualify and work as physician assistants in supervised practice settings.
Against this backdrop, it is no small wonder that Canada ranks 26th out of 29 OECD countries in the ratio of physicians per 1,000 population. For the past decade Canada's ratio has stood at 2.1 physicians per 1,000 population - one-third below the OECD average of 3.0 in 2003.
Over the years, medicine has worked hard to promote national standards for medical education and the practice of medicine in Canada.
Since 1912 the Medical Council of Canada (MCC) has been responsible for promoting a uniform standard qualification to practice medicine for all physicians across Canada. This qualification, known as the Licentiate of the Medical Council of Canada (LMCC) is obtained by being successful on a two-part Qualifying Examination.
While licensure of physicians is a provincial/territorial responsibility, there is a national standard for portable eligibility for licensure that was adopted in 1992 by the Federation of Medical Licensing (now Regulatory) Authorities of Canada (FMRAC), the Association of Canadian Medical Colleges (now Association of Faculties of Medicine of Canada) (AFMC) and the MCC. The basis of this standard is that "in all provinces except Quebec the basis for licensure for most trainees will be the successful completion of the two-part Qualifying Examination of the Medical Council of Canada plus certification by either the College of Family Physicians of Canada (CFPC) or the Royal College of Physicians and Surgeons of Canada (RCPSC)". A similar standard is applied by the Collège des médecine du Quèbec.
This standard also applies to IMGs, although the provincial/territorial licensing bodies have the ability to grant exemptions in particular circumstances.
SHORT, MEDIUM AND LONG TERM STRATEGY
The CMA has advocated a short, medium and longer term strategy for integrating more IMGs into the Canadian medical workforce.
In the short term the federal government should provide funding to clear the backlog of qualified physicians and other health professionals eligible to pursue supplementary training.
In the medium term the federal government needs to work with the provincial and territorial governments and key stakeholders in the development of sufficient health professional education and training opportunities to accommodate:
* Canadians who want to pursue careers as health professionals;
* Currently practising health professionals who require supplementary training or who wish to retrain;
* Internationally trained health professionals who are permanent residents and citizens of Canada who require supplementary training; and
* International trained health professionals, non-residents of Canada who wish to pursue postgraduate training as visa trainees.
In the long term Canada needs to adopt a policy commitment of increased self-sufficiency in the education and training of health professionals in Canada.
In progressing these strategies I would stress the importance of the need for the federal government to engage the national health professional associations, as this is critical in moving the agenda forward. I would cite as one success story the outcomes of the multi-partite Canadian Task Force on Licensure of International Medical Graduates, which brought together federal and provincial/territorial governments and key medical organizations.
Several initiatives are underway in follow-up to its 2004 report. An IMG database is being developed by the Canadian post-MD Education Registry of AFMC, sponsored by the federal government's Foreign Credential Recognition Program. The Physician Credentials Registry of Canada (PCRC) which is being developed under the leadership of the Medical Council of Canada (MCC) and the Federation of Medical Regulatory Authorities of Canada (FMRAC) will reduce duplication and increase the efficiency of data collection by providing a centralized uniform process to obtain primary source verification of a physician's diploma and other core medical credentials. Several provinces have greatly enhanced their ability to integrate IMGs, including supervised assessment programs in the community. We look forward to seeing results from a similar task force that is underway for nursing.
CANADIAN AGENCY FOR ASSESSMENT AND RECOGNITION OF FOREIGN CREDENTIALS
In conclusion, I would like to offer some ideas for the implementation of the Canadian Agency for the Assessment and Recognition of Foreign Credentials that was included in the 2006 federal budget.
The Constitution Act 1867 clearly assigns the majority of responsibility for the delivery of health care to the provinces. On this basis, the licensure of physicians and other health professionals should continue to be a matter of provincial/territorial jurisdiction. In the case of medicine however, Canada has been well-served by the national standard for medical licensure that has been promoted by the MCC in concert with the national certification standards that are set by the RCPSC and CFPC.
Based on the foregoing, it is proposed that the broad mandate for the Canadian agency is to promote and facilitate the adoption and awareness of national standards for certification and licensure with clearly articulated procedures for the assessment of the credentials of internationally trained professionals and pathways to licensure to practice in Canada. This might include the following activities:
* promote understanding among educational institutions and professional organizations about the implications of the various international agreements that Canada is party to (e.g., NAFTA, WTO);
* promote a sharing of leading practices between different disciplines;
* facilitate international exchanges with regulatory bodies, within and between disciplines;
* develop an evaluation framework that can assess the extent to which processes for the assessment of foreign credentials are fair, accessible, coherent, transparent and rigorous;
* develop template materials that will help promote international sharing of information about career prospects in Canada for various occupations;
* fund development and pilot projects on the application of information technology solutions; and
* serve as a focal point for federal/provincial/territorial administrative requirements.
I would stress that this will only be effective if representatives from the education and regulatory authorities and the practising community are at the table.
Canadian Medical Association Ottawa, September 21, 2006
Review of the Personal Information Protection and Electronic Documents Act (PIPEDA) : CMA's Presentation to the House of Commons Standing Committee on Access to Information, Privacy and Ethics - December 13, 2006
The Canadian Medical Association (CMA) is pleased to be here today to participate in your review of the Personal Information Protection and Electronic Documents Act, or PIPEDA.
The CMA has had a long-standing interest in privacy-related matters, including enhancing measures to protect and promote the privacy of health information. We welcome the opportunity to share our policies and thoughts on these vital matters.
As a pediatric oncologist from Winnipeg and Chair of the CMA's Committee on Ethics, I come here today with one bottom line: Physicians have always- and continue to - take their patients' privacy very seriously. This is the cornerstone of the special bond between patients and their doctor and has been thus since the time of Hippocrates. In recognition of the importance of privacy, the CMA has produced such documents as the CMA Code of Ethics and the CMA Health Information Privacy Code to guide our more than 64,000 members across the country. These documents existed before the federal government introduced PIPEDA.
It is out of our concern for protecting and ensuring the privacy of medical information that we speak to you today.
There are three specific areas which we would like to raise:
1) Recognition in law of the unique nature of health care;
2) Physician information as "work product"; and
3) Emerging Privacy and Health information issues.
1. Recognition in law of the unique nature of health care
I would like to highlight the importance of recognizing in law the special circumstances of protecting health information. In fact, when PIPEDA was first being debated, CMA posed questions about the scope of the Act and was told that the legislation, originally designed for commerce and the private sector, would not capture health information. We were also told that even if it did, PIPEDA wouldn't change how we practiced medicine.
The passing of PIPEDA generated enough concern and uncertainty that government agreed to delay its application to health for 3 years. For example, PIPEDA failed to clarify the issue of implied consent for the sharing of patient information between health professionals providing care.
For example, when the family physicians says to a patient "I'm going to send you to see an oncologist to run some tests" and the patient agrees and follows that course of action, then clearly there is "consent" to the sharing of their health information with others. As an oncologist I assume there is consent to send the test results to other specialists that I may need to consult in order to advance the patient's care in a timely fashion. This, however, needed to be addressed before PIPEDA was applied to health care.
The delayed application allowed the federal government and health care community to work together and develop a set of guidelines for how PIPEDA would be applied. The resulting PIPEDA Awareness Raising Tools, known as PARTs, contain a series of questions and answers that make up guidelines for health care providers. They answered many of our concerns, provided necessary definitions and allowed for the implied consent model to continue to be used within the circle of care. The CMA applauds the government for this collaborative effort and the resulting guidelines have been used by health care providers ever since.
However, we remain concerned that the PARTs guidelines have no legal status. This limitation creates a degree of uncertainty that the CMA would like this legislative review to see addressed by ensuring the PARTs series of questions and answers are referenced in PIPEDA.
In addition to participating in the PARTS initiative, since PIPEDA's implementation, the CMA has designed practical tools for physicians and patients:
* adopted the CMA policy Principles Concerning Physician Information to address the importance of protecting the privacy of physician information;
* produced Privacy in Practice: a handbook for Canadian physicians to help physicians maintain best practices in the protection of patient health information; and
* created the PRIVACYWIZARD(tm) designed to help physicians record their current privacy practices, communicate these to patients and identify possible areas for enhancement.
2. Physician Practice Information as "Work Product"
I referred earlier to CMA's Policy document on physician information. The CMA strongly believes that physicians have legitimate privacy concerns about the use by third parties of information - such as prescribing and other practice data for commercial purposes. Currently deemed "work product" this information can be collected, used and disclosed without consent.
We feel PIPEDA inadequately protects this information. We recognize that it is information generated out of the patient-physician relationship. We disagreed with findings of the previous Privacy Commissioner that physician prescribing information is not subject to PIPEDA's privacy protection provisions for "personal information". The CMA has consistently advocated that physician prescribing data and other practice information is personal information and appeared as an intervener in a Federal Court review of this issue that was ultimately settled by the main parties.
Also, insufficient regard for the privacy of prescribing and other physician data could have a negative impact on the sanctity of the physician-patient relationship. Patients confide highly sensitive information to physicians with the expectation this information will be kept in the strictest confidence. This expectation exists because they know that physicians are under ethical and regulatory dictates to safeguard their information and that physicians take this responsibilities very seriously. The perceived and indeed actual loss of control by physicians over information created in the patient encounter, such as prescribing data, could undermine the confidence and faith of our patients that we are able to safeguard their health information. This concern is not hypothetical.
For physicians, so called "work product" information also encompasses practice patterns such as discharge rates, referral rates, billing patterns, hospital length of stays, complaints, peer review results, mortality and re-admittance rates. With the advent of electronic medical records and growth in pay-for-performance and outcome-based incentive programs for physicians, there is an enormous potential for the resulting physician "performance" data or "work product" to be "mined" by other parties and used to influence performance review (traditionally the purview of the medical licensing authorities) as well as decisions around treatment funding and system planning.
The lack of transparency in the sale and compilation of physicians' prescribing and other performance data means that physicians might find themselves to be the unwitting subject and targets of marketing research. We believe practice decisions must be made in the best interest of patients and not the bottom-line interests of businesses and marketers.
CMA therefore recommends a legislative change to include physician information as personal information under PIPEDA. Legislation in Quebec provides an example that is consistent with CMA's approach since it requires regulatory oversight and gives individuals the right to opt out of the collection, use and disclosure of "professional" information.
3. Emerging Privacy and Health information issues
With budgetary and demographic pressures, our health care system is under strain and physicians are striving to deliver timely, quality care to patients, often with competing and multiple demands. Physicians are therefore seeking assurances from law makers that any amendments to PIPEDA will take into account the potential impact on them and their patients. Therefore, we seek assurances that:
* health care is recognized as unique when it comes to the disclosure of personal information before the transfer of a business (one physician transferring his/her practice to another) because it is regulated at the provincial level through the appropriate licensing body. As a general rule, physicians must give notice to the public, whether via a newspaper ad or a notice in the office about the change in practice.
* the federal government will consider the impact of the trans-border flow of personal information on telehealth and Electronic Health Record activities. Communications between patients and physicians via electronic means are likely to increase and to move across geographic boundaries with increasing frequency; and
* the federal government will study the issue of international cross border data flows, particularly among Canadian researchers who receive funding from US drug companies. These arrangements should be governed by Canadian law (PIPEDA) not American (HIPAA or the US Patriot Act).
In closing, the privacy protection of personal health information is a responsibility that my colleagues and I do not take lightly. It is a key pillar of our relationship with Canadians, they not only expect it-they deserve it. I look forward to taking questions from Committee members.
Canadian Medical Association Ottawa, December 13, 2006