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

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

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

Physician health

https://policybase.cma.ca/en/permalink/policy13739
Date
2017-10-21
Topics
Health human resources
Ethics and medical professionalism
  3 documents  
Policy Type
Policy document
Date
2017-10-21
Replaces
PD98-04 Physician health and well-being
Topics
Health human resources
Ethics and medical professionalism
Text
The term physician health encompasses the prevention and treatment of acute or chronic issues of individual physicians, as well as the optimization of interconnected physical, mental and social factors to support health and wellness.1 Attributable to a range of personal, occupational and system-level factors, physicians and learners alike are increasingly voicing distress and calling for resources and support. As a central issue for Canadian physicians, and a growing concern within the medical profession, physician ill-health is being increasingly understood as a set of risk-management practices,2 including the use of strategies rooted in organizational psychology and occupational medicine, as well as intensified oversight by professional bodies, and the integration of maintaining personal health as a core medical competency.3 Physician health, is important to the long-term sustainability of the physician workforce and health systems.4 As a quality indicator5-6 addressing the complex array of related issues is a shared responsibility of individual physicians and the systems in which they work.2,4,5 This involves efforts from individuals as well as system-level influencers, such as stakeholder groups from areas including academic medicine, medical education, practice environments, accrediting and regulatory bodies, provincial and territorial medical associations, regional and local health authorities, national medical associations and their affiliates, governments and other decision-making bodies. Meaningful, system-wide change can only occur via deliberate and concerted efforts on a national scale5 to address personal, workplace, and cultural barriers and normalize the promotion of opportunities and conditions for optimizing health and wellness. Although considerable progress has been made, it is necessary to continue working towards a more coordinated and sustained system of health promotion, illness prevention and tertiary care to build on these successes.4-5 This policy aims to provide broad, aspirational recommendations to help guide stakeholders at all levels of the health system to promote a healthy, vibrant, and engaged profession - including a healthy practice and training culture, and work environment. RECOMMENDATIONS Individual level The CMA recommends that physicians and learners: * demonstrate a commitment to physician health and well-being as part of their responsibilities under the CanMEDS Professional Role, including: Exhibiting self-awareness and managing influences on personal well-being (e.g., self-regulation and assessment, mindfulness, resilience); managing personal and professional demands for a sustainable practice throughout the career life cycle; and promoting a professional culture that recognizes, supports, and responds effectively to colleagues in need;3 * actively engage in fostering supportive work and training environments; * assume responsibility for individual actions and behaviours that may contribute to negative culture and stigma;5 * foster relationships with family and friends, as well as interests outside of medicine, and ensure sufficient rest (including time-off); and * have a family physician and visit him or her regularly for comprehensive and objective care. System level The CMA recommends that: * national-level advocacy be undertaken to address issues related to physician and learner health; * efforts to address physician health incorporate individually targeted initiatives and optimize learning and practice environments, including cultivating a healthy culture,6-7 and that stakeholders collaborate (including input from physicians and learners) to develop and promote initiatives that strengthen physician health at both the individual and system levels; * health systems adopt an understanding of their obligation to the health of physicians that is similar to the obligation of other Canadian employers to their workers (e.g., psychological safety, work hours, employee resources, standards and expectations); * policies aiming to cultivate a healthy culture be modelled, and behaviours not conducive to supporting and enabling a healthy culture dealt with in an effective manner; * physician and health system leaders acknowledge and demonstrate that physician health is a priority, and continually assess whether actions and policies align with desired values and culture;4 * physician and health system leaders be better equipped to identify and address behaviours that are symptomatic of distress (e.g., psychological) and receive more comprehensive training to address with colleagues, including within teams; * mechanisms and opportunities for physicians and learners to access existing services and programs (e.g., provincial, institutional) are maximized, and that these resources are regularly promoted and barriers to access addressed in a timely manner;5,8 * standards, processes and strategies be developed to address occupational barriers to positive health8 (at a minimum, these should address the meaningful integration of occupational and personal life, provision of resources to enhance self-care skills,4 and prioritization of opportunities for adequate rest, exercise, healthy diet and leisure;8 * wellness (including enhancement of meaning, enjoyment and engagement) be promoted, instead of an exclusive focus on reduction of harm;5 * physicians and learners be encouraged to have a family physician, and that barriers to access such care be identified and addressed; * physicians, particularly those providing primary care to other physicians, have access to training in treating physician colleagues; * physicians and learners be given reasonable access to confidential assistance in dealing with personal and professional difficulties, provided in a climate free of stigmatization; * programs and services be accessible to physicians and learners at every stage of their diagnosis and treatment, and that seeking treatment should not feel punitive or result in punitive consequences; * physicians and learners have supportive learning and work environments free of discrimination, and for processes which provide reasonable accommodations to physicians and learners with existing disabilities, while allowing for safe patient care, to be bolstered; and * practices which enable safe and effective patient care, and support workflow and efficient capture of information (e.g., electronic medical records), do not create excessive work and time burdens on physicians. Physician organizations, professional associations and health authorities The CMA recommends that: * all physicians and learners have access to a robust and effective provincial physician health program (PHP), and for long-term, sustained efforts to be made to maintain and enhance physician health, including a commitment to resourcing PHPs5 via the provision of stable funding through provincial and territorial medical associations, or the negotiation of such funding from provincial governments; * training programs, hospitals, and other workplaces ensure appropriate programs, services, and policies are developed, in-place, and enforced for physicians and learners to get help to manage health and behavioural issues, support the need for treatment, and facilitate return to work or training while protecting individual confidentiality, privacy, as well helping the institution manage risk; * the range of continuing medical education offerings aimed at personal health be expanded (content should develop individual skills and extend to training for leaders and administrators that targets improved training and practice environments and culture); * continuing education credits for physicians' efforts to enhance their personal wellness or that of colleagues be established and promoted, free of conditions requiring links to patient care; * emerging champions from learner and early-career segments be identified and supported; and * the unique health and wellness challenges faced by physicians and learners in rural, remote, or otherwise under-serviced regions (including the Canadian territories) be recognized, and for access to services and other resources to be enhanced. Medical schools, residency training programs, and accreditation bodies The CMA calls for: * accreditation standards for health and wellness programs and initiatives for medical faculties and training programs, and health authorities to be raised, reviewed in an ongoing manner and that standards and competencies be enforced; * action to bring meaningful change to the 'hidden curriculum' by aligning formal and 'hidden' curriculums that promote and reinforce positive conduct, and for accreditation bodies to consider this in their review and enforcement of standards for training programs; and * formal health and wellness curricula to be integrated and prioritized at the undergraduate and postgraduate levels, including but not limited to training around how to recognize and respond to distress or illness in oneself and colleagues, as well as self-management strategies (e.g., resilience and mindfulness). Medical regulatory authorities The CMA calls for medical regulatory authorities to: * work with provincial and territorial medical associations, PHPs, governments and other key stakeholders to; (a) create a regulatory environment that protects the public (their explicit duty) while limiting barriers for physicians seeking diagnosis and treatment,5 and (b) promote resources for early self-identification of potential health issues; and * while maintaining their duty to protect the public, review their approach to mental health challenges to ensure that focus is placed on the existence of impairment (illness interferes with ability to engage safely in professional activities,9 and not the mere presence of a diagnostic label or act of seeking of care5 (in order to ensure that physicians and learners who are appropriately caring for their health not be impacted in their ability to work). Governments The CMA calls for: * governments to acknowledge the adverse impact their policies and processes can have on the health of physicians, and to adopt and enforce health and wellness standards through a lens of occupational health for physicians that are similar to those afforded to other Canadian workers; * governments to work with employers and key stakeholders to create more effective systems that provide better practice and training conditions;5 and * enhanced support for provincial PHPs, institutions (e.g., medical schools, training programs), and other providers of physician health services.5 Researchers The CMA recommends that: * national and regional data for major health and wellness indicators be assessed at regular intervals to establish and compare norms and to better target and assess initiatives; * a national research strategy be developed through collaboration among relevant stakeholders to identify priorities, coordinate efforts, and promote innovation (consider the specific recommendations from a 2016 research summit to improve wellness and reduce burnout,10 including: Estimating economic impacts; using common metrics; developing a comprehensive framework for interventions with individual and organizational components; and sharing the best available evidence); and * further research in a range of areas including, but not limited to: efficacy of programs, strategies, and systems for promoting and managing health and wellness; examination of the factors exerting the greatest influence on physician health; and system-level interventions.5 Approved by the CMA Board of Directors October 2017 See also Background to CMA Policy on Physician Health REFERENCES 1 World Medical Association (WMA). WMA Statement on physicians well-being. France: WMA; 2015 Oct. Available: https://www.wma.net/policies-post/wma-statement-on-physicians-well-being/ (accessed 2017 Oct 30). 2 Albuquerque J, Deshauer D. Physician health: beyond work-life balance. CMAJ 2014;186:E502-503. Available: https://doi.org/10.1503/cmaj.140708 (accessed 2017 Oct 30). 3 Frank JR, Snell L, Sherbino J, Royal College of Physicians and Surgeons of Canada (RCPSC). CanMEDS 2015 physician competency framework. Ottawa: RCPSC; 2015. Available: http://canmeds.royalcollege.ca/uploads/en/framework/CanMEDS%202015%20Framework_EN_Reduced.pdf (accessed 2017 Oct 30). 4 Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: Nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc 2017;92:129-6. Available: https://doi.org/10.1016/j.mayocp.2016.10.004 (accessed 2017 Oct 30). 5 Canadian Medical Association (CMA). Physician health matters: A mental health strategy for physicians in Canada. Ottawa: CMA; 2010. Available: https://www.cma.ca/Assets/assets-library/document/en/practice-management-and-wellness/Mentalhealthstrat_final-e.pdf (accessed 2017 Oct 30). 6 Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. Lancet 2009;374:1714-21. Available: https://doi.org/10.1016/S0140-6736(09)61424-0 (accessed 2017 Oct 30). 7 Panagioti M, Panagopoulou E, Bower P, Lewith G, Kontopantelis E, Chew-Graham C, et al. Controlled interventions to reduce burnout in physicians: A systematic review and meta-analysis. JAMA Intern Med 2017;177:195-205. Available: https://doi.org/10.1001/jamainternmed.2016.7674 (accessed 2017 Oct 30). 8 Ruotsalainen JH, Verbeek JH, Mariné A, Serra C, Ruotsalainen JH, Verbeek JH, et al. Preventing occupational stress in healthcare workers. Sao Paulo Medical Journal 2016;134:92-92. Available: https://doi.org/10.1590/1516-3180.20161341T1 (accessed 2017 Oct 30). 9 Rondinelli RD, Genovese E, Brigham CR, American Medical Association (AMA). Guides to the evaluation of permanent impairment. Chicago: AMA; 2008. Available: https://commerce.ama-assn.org/store/catalog/productDetail.jsp?product_id=prod1160002 (accessed 2017 Oct 30). 10 Dyrbye LN, Trockel M, Frank E, Olson K, Linzer M, Lemaire J, et al. Development of a research agenda to identify evidence-based strategies to improve physician wellness and reduce burnout. Ann Intern Med 2017;166:743-4. Available: https://doi.org/10.7326/M16-2956 (accessed 2017 Oct 30). BACKGROUND TO CMA POLICY PHYSICIAN HEALTH See also CMA Policy on Physician Health In recent decades there has been growing recognition of the impact of physician health on systemic outcomes and patient-care.1,2 Physician health encompasses the prevention and treatment of acute or chronic issues of individual physicians, as well as the optimization of of interconnected physical, mental and social factors to support health and wellness.3 It is also being increasingly understood as a set of risk-management practices aimed at shifting perceptions of health from being an individual (private) matter to more of a shared resource.4 In Canada evidence for this includes the use of strategies adapted from organizational psychology and occupational medicine to change physician behaviour, as well as intensified oversight by professional bodies, and the inclusion of maintaining personal health as a core competency for physicians.4,5 Despite concerted efforts to promote and protect the health and wellness of physicians, the collective state of physician health remains a significant threat to the viability of Canada's health system.1 Physician distress is emerging as an important quality indicator in medical practice,4,6 and both individual- and system-level factors are well-established contributors to compromised physician health.2,7 As such, the advancement of a model of shared responsibility - targeting the relative roles of individual physicians and system-level influencers8 - represents a robust response to this reality. 1. The state of learner and physician health Poor health may develop before or during training and persist into medical practice. Medical school and residency training are particularly challenging times, when a myriad of competing personal and professional demands threaten learner health. In Canada, it has been reported that most students suffer from at least one form of distress over the course of their training9,10 and recent national data point to higher rates compared to their age and education-matched peers. With respect to burnout, characterized by a high level of emotional exhaustion and/or high level of depersonalization (at least weekly), overall rates are reportedly 37%.11,12 Similarly higher levels of depression, anxiety and burnout are reported among American medical students than in the general population.13 While both residents and physicians are reported to be physically healthier than the general population, their mental and social health are cause for concern.1,14 Compared with the general population, physicians are at a higher risk of experiencing adverse outcomes such as depression and burnout15,16 - the latter of which is nearly twice as common among physicians compared with workers in other fields, even after adjusting for age, sex, education level, relationship status, and work hours.17 Results from the 2017 CMA National Physician Health Survey18 showed that 49% of residents and 33% of physicians screened positive for depression, and high burnout rates were reported in 38% of residents 29% of physicians. Furthermore, although the mental health, addiction and substance-use problems, including alcohol, among physicians are not dissimilar to those in the general population, the abuse of prescription drugs (e.g., opioids) is reportedly higher.1,19 Although most physicians referred to monitoring programs have been diagnosed with substance use disorders, an increasing number are being referred for recurrent mood disorders, often stemming from workplace concerns.20,21 1.1 Contributing factors Adverse health outcomes among learners and physicians are linked to a range of contributing factors, including intrinsic ones (e.g., personality characteristics22 and other personal vulnerabilities) and extrinsic ones (e.g., excessive workloads, excessive standards of training and practice, excessive duty hours, lack of autonomy, disruptive behaviour, poor work-life integration, increasing demands with diminishing resources, systemic failures, financial issues, and the practice and training environment).2,15,23 Moreover, the management of risk that many physicians are involved with as it relates to the treatment and management of their patients can be challenging and impacts their health4. A dearth of recent data on the health status of physicians in Canada represents a critical gap in knowledge and limits future efforts to refine, select and assess initiatives. 2. Consequences 2.1. Impact on learners and physicians Compromised physician health can result in decreased personal and professional satisfaction, dysfunctional personal and professional relationships, increased attrition and increased rates of suicide and suicidal ideation.6,24,25 Perhaps most troubling, completed suicide rates among physicians are 1.4-2.3 times higher than in the general population - between 300 and 400 physicians annually in the United States.26 In Canada, suicidal ideation among physicians (including residents) has been recently reported at 19% (lifetime) and 9% (in the last year)18, while Canadian medical student data report 14% (lifetime) and 6% (in the last year).11 Overall, ideation rates are higher among both physicians and learners than in the general population.27 2.2. Impact on patient care The impact of the mental and physical health of physicians extends to the quality of care provided to patients.16,28,29 For instance, physicians suffering from burnout are reportedly two to three times more likely to report their conduct with their patients as sub-optimal.24 Indeed, physicians remain a primary source of health information for patients, and they act as both role models and health advocates.15 Characteristics of burnout (e.g., poor communication and reduced empathy) run counter to the core principles of patient-centred care,30 and physicians who maintain healthy lifestyles are more likely to focus on preventive strategies with their patients.31,32 Although deficits in physician health can negatively affect patient care, it is notable that evidence linking the health of physicians to medical errors is incomplete, if not difficult to establish. Nevertheless, studies have reported a relationship between medical error and specific adverse outcomes such as burnout.17,33 2.3 Impact on health system Issues that are associated with compromised physician health, such as reduced productivity, increased turnover, absenteeism and the likelihood of early retirement,25,34 contribute to the strained state of the health system. Given that physicians represent a significant proportion of the Canadian medical workforce, more attention must be paid to physician health if the health system is to be sustainable.2 Encouragingly, studies have shown that resources and services such as workplace wellness programs produce investment returns,35,36 such as decreases in medical leave and absenteeism2,36,37 Implementing strategies from occupational medicine are also being increasingly employed to ensure patient safety when doctors return to work after illness.4 This contributes to helping balance the need of institutions and medical regulatory agencies to minimize the risk while maximizing quality of patient care, with the desire of individual physicians to help their patients while leading healthy, fulfilling lives.4 Although there are moral grounds for addressing physician and learner ill-health, an economic case can also be made to support and guide initial and ongoing investment to address the problem.7,18 In navigating the many external challenges facing the Canadian the health system, it is critical that system-level leaders not neglect internal threats, including physician distress and dissatisfaction6,7, and challenges in navigating complex work environments.24 To this end, although there are many positive and supportive elements within medical culture, it is also important to acknowledge aspects that contribute to poor health. 2.4 Impact on the culture of medical practice and training and on the workplace Enduring norms within the culture of medicine are directly contributing to the deterioration of the health of Canadian learners and physicians.2 Culturally rooted impediments, such as the reluctance to share personal issues or admit vulnerability, discourage the medical profession from acknowledging, identifying and addressing physician health issues.7 Physicians and learners alike face pressure not to be ill, to care for patients regardless of their personal health and even to attempt to control their own illness and treatment by self-medicating.1,38 Indeed, physicians are often portrayed as being invincible professionals who put patient needs above all else, including their own needs.39,40 Although the CMA Code of Ethics encourages physicians to seek help from colleagues and qualified professionals when personal or workplace challenges compromise patient care41 physicians tend to delay or avoid seeking treatment, especially for psychosocial or psychiatric concerns. Moreover, nearly 33% of Canadian physicians are not registered with a family physician.42 which means they are among the lowest users of health services.43 Providing care to physician colleagues is both complex and challenging, yet this is an area where formal training has not been explicitly or systematically provided on a national scale.1 There is a need to identify physicians willing to treat colleagues, to develop or adapt existing approaches that encourage help-seeking and to help physicians to navigate the treatment of colleagues. Stigma around mental health within medical practice and training acts as a significant barrier to early intervention.1,44 In a localized study of Canadian physicians, 18% reported distress, but only 25% considered getting help and only 2% actually did.39 Similarly, national CMA data reported that 'feeling ashamed to seek help' was identified (76%) as a major reason for physicians not wanting to contact a physician health program.18 Indeed, common concerns include not wanting to let colleagues or patients down, believing seeking help is acknowledging weakness, being apprehensive about confidentiality, and fearing negative reprisals (e.g., from colleagues, supervisors, regulatory bodies, other licence-granting bodies, insurers)1,45 Fear of retribution is also a frequent reason why physicians may feel hesitant to report impaired colleagues, even if supportive of the concept.46 From the outset of training, medical learners are introduced to system-wide cultural aspects and values of the medical profession, which they then internalize and pass on to others.2 Extensive literature on the "hidden curriculum" points to a performance culture that includes norms such as the view that adversity is character building and the valorization of emotional repression (e.g., mental toughness).2,47 Culture-related issues are being increasingly addressed as a function of medical professionalism. For instance, commitment to physician health, collegiality and support have been established as key competencies within the Professional Role of the CanMEDS Framework,5 the most widely accepted and applied physician competency framework in the world.48 This involves a commitment to exhibiting self-awareness and managing influences on personal well-being and professional performance; managing personal and professional demands for a sustainable practice throughout the physician life cycle, and promoting a professional culture that recognizes, supports, and responds effectively to colleagues in need. In support of these commitments to personal care, physicians must develop their capacity for self-assessment and monitoring, mindfulness and reflection, and resilience for sustainable practice.5 Intra-professionalism, characterized by effective clinical and personal communication among physicians,49 significantly influence job satisfaction, which in turn has been shown to predict physician health outcomes.50 Furthermore, peer support can buffer the negative effects of work demands;39 collegial, professional environments are known to be healthier for both providers and patients.51 Conversely, unprofessional behaviour is associated with physician dissatisfaction,50 and dysfunctional workplaces and poor collegiality are linked to burnout.52 Unprofessional workplace behaviour is tolerated, and in fact is often customary, within medical training and practice environments.53 Of particular concern, such behaviour carried out by more senior physicians has been shown to encourage similar conduct among learners,54 highlighting the importance of promoting effective professional role modelling.55 Unfortunately, poor supervisory behaviour, and even mistreatment of learners, is common within the medical training environment.56 Although expectations for professional behaviour are increasingly being incorporated into both undergraduate and postgraduate teaching, issues related to a lack of professionalism persist in both training and practice.51 System-wide efforts are needed to counter what is perceived to be an eroding sense of collegiality and to promote professionalism as a way to address physician burnout and enhance engagement.7,39 3. Treatment and preventive approaches 3.1 Physician health services The scope of physician health services has expanded from focusing primary focus on identifying treating and monitoring physicians with substance abuse issues to more recent efforts to de-stigmatize poor physician health and integrate proactive resources to complement tertiary approaches.1 In Canada, there are multiple services to support the health needs of learners and physicians. These can be conceptualized along a continuum of approaches,1 including the following: health-promoting environments (e.g., efforts to ensure balanced workloads, provide more support staff, and encourage physicians to make sure they get adequate exercise, nutrition and sleep in training and practice); primary prevention (e.g., resilience training, stress-reduction groups, fatigue management programs, strategies to enhance teamwork and collaborative care); secondary prevention (e.g., access to assessment and counselling; services and workshops on coping with adverse events, litigation and career transitions and on managing difficult behaviour); and tertiary prevention (e.g., more intensive outpatient counselling, inpatient treatment). Many of these approaches, including those at the system level, focus on assisting the individual physician rather than addressing more contextual issues. Most jurisdictions in Canada have consolidated a number of services under the banner of a provincial physician health program (PHP).These range from counselling, treatment and/or peer support to fitness-to-practice and return-to-work assessments, workplace behaviour management and relationship management. The services available to physicians in a given area vary greatly.1,15 More established and resourced programs often offer services across the continuum, while less established programs tend to focus on secondary and tertiary services.2 Provincial PHPs have been shown to produce positive outcomes1,20,21,48 and are generally considered to be effective in addressing user issues,57 however but many physicians remain reluctant to access them.58 In addition to provincial programs, many learners and physicians in Canada can access support and treatment from other sources, including medical school and faculty wellness programs, employee assistance or workplace programs, and more individual-led options such as physician coaches.1 There has been a steady accumulation of evidence on the positive returns of workplace health and wellness programs,35 as well as indications that even modest investments in physician health can make a difference.17 In response to challenges posed by the considerable diversity in the organizational structure of provincial PHPs, the ways in which PHPs classify information, the range of services they offer, the mechanisms of accountability to stakeholders and the manner in which they pursue non-tertiary activities (e.g., education and prevention work)59 a consortium of PHPs released a preliminary Descriptive Framework for Physician Health Services in Canada in 2016. Through this framework a series of core services (and modes of activity within each) were defined.59 Potential users of the framework include PHPs, academic institutions, medical regulators, national associations, hospitals and health authorities, as well as other local groups. The framework may serve a range of purposes, including program reviews and planning, quality improvement, resource allocation, advocacy, stakeholder consultation and standards development.59 Initiatives such as this framework help address a persistent gap in Canada around equity of and access to services. Overall, fulfilling the needs of all learners and physicians through enhanced service quality and functional equivalence is an ongoing challenge for provincial PHPs and other service providers, and it must be a priority moving forward. 3.2 Individual primary prevention Prevention and promotion activities can help mitigate the severity and decrease the incidence of adverse outcomes associated with physician health issues among learners and physicians.3 Although secondary and tertiary services are critical components of any health strategy, complementary, proactive, preventive initiatives promote a more comprehensive approach. Some of the best-documented strategies include attuning to physical health (e.g., diet, exercise, rest), psychosocial and mental health (e.g., mindfulness and self-awareness, resilience training, protecting and maintaining cultural and recreational interests outside of medicine, and protecting time and relationships with family and friends).60 For instance, resilience has been identified as an indicator of physician wellness61 and as a critical skill for individuals working in health care environments.39 Innovative, coordinated approaches such as resilience and mindfulness training are instrumental in helping physicians overcome both anticipated and unexpected difficulties, to position them for a sustainable career in medicine. Many internal (e.g., personal) and external (e.g., occupational) factors can interfere with a physician's capacity to consistently maintain healthy lifestyle behaviours and objectively attend to personal health needs. Although the emergence of individually targeted proactive and preventive activities is encouraging, a greater focus on system-level initiatives to complement both proactive and tertiary approaches is needed. This also aligns with recent CMA member data indicating that medical students (61%), residents (55%), physicians (43%) and retired physicians (41%) want more access to resources to ensure their emotional, social and psychological well-being.62 Such an approach is increasingly important in light of physicians' professional responsibility to demonstrate a commitment to personal health.5 4. Physician health as a shared responsibility Although physicians are a critical component of Canadian health systems, those systems do not necessarily promote health in the physician community. It cannot be overstated that many health challenges facing learners and physicians are increasingly systemic in nature.1 Despite increasing challenges to the cultural norm that health-related issues are an individual-physician problem,2 system-level factors are often ignored.1,7 Although solutions targeted at the individual level (e.g., mindfulness and resilience training) are important proactive approaches and are a common focus, they often do not address occupational and organizational factors.7 Intervention exclusively at the individual level is unlikely to have meaningful and sustainable impacts. Interventions targeting individual physicians are likely most effective when paired with efforts to address more systemic (e.g., structural and occupational) issues.63 Moreover, organization-directed interventions have been shown to be more effective in reducing physician burnout than individual-directed interventions, and meaningful reductions in negative outcomes have been linked to system-level interventions.22,34 Concerted efforts at the system level will ultimately drive substantive, meaningful and sustainable change. This includes coordination among leaders from national, provincial and local stakeholders as well as individual physicians.16,22,64 Potential influencers include medical schools and other training programs, regulatory bodies, researchers (and funding bodies), professional associations and other health care organizations, as well as insurers.1 Indeed, addressing the complex array of issues related to physician health is a shared responsibility. A clear mandate exists to guide individuals and leaders in promoting and protecting the health of learners and physicians.1,7 5. Conclusion Physician health is a growing priority for the medical profession. Medical practice and training present complex occupational environments34, in which leaders play a central role in shaping training, practice and organizational culture through the implicit and explicit ways in which they communicate core values.2 When promoting physician health across the career lifecycle it is also important to consider the unique challenges and experiences of physicians who are not actively practicing (e.g., on leave; have non-clinical roles) as well as those who are retired. Notwithstanding the impact on patient care or health systems, promoting the health of individual physicians and learners is in and of itself worthy of attention. Indeed, leaders in the health system have a vested interest in helping physicians to meet the personal and professional challenges inherent in medical training and practice as well as in promoting positive concepts such as wellness and engagement.7 The increasingly blurred lines between physician health, professionalism and the functioning of health systems40 suggest that leaders at all levels must promote a unified and progressive vision of a healthy, vibrant and engaged physician workforce. This involves championing health across the career life cycle through advocacy as well as promoting solutions and outcomes through a lens of shared responsibility at both individual and system levels. Broad solutions skewed towards one level, without requisite attention given to the other level, are unikely to result in meaningful change. Moving from rhetoric to action, this next frontier integrates the promotion of self-care among individuals, support for healthy and supportive training and practice environments - both physical and cultural - as well as continued innovation and development of (and support for) physician health services. This constellation of efforts will ultimately contribute to the success of these actions. October 2017 See also CMA Policy on Physician Health REFERENCES 1 Canadian Medical Association (CMA). Physician health matters: A mental health strategy for physicians in Canada. Ottawa: CMA; 2010. Available: https://www.cma.ca/Assets/assets-library/document/en/practice-management-and-wellness/Mentalhealthstrat_final-e.pdf (accessed 2017 Oct 30). 2 Montgomery AJ. The relationship between leadership and physician well-being; A scoping review. Journal of Healthcare Leadership 2016;55:71-80. Available: http://www.ingentaconnect.com/content/doaj/11793201/2016/00000055/00000001/art00010 (accessed 2017 Oct 30). 3 World Medical Association (WMA). WMA Statement on physicians well-being. France: WMA; 2015 Oct. Available: https://www.wma.net/policies-post/wma-statement-on-physicians-well-being/ (accessed 2017 Oct 30). 4 Albuquerque J, Deshauer D. Physician health: beyond work-life balance. CMAJ 2014;186:E502-503. Available: https://doi.org/10.1503/cmaj.140708 (accessed 2017 Oct 30). 5 Frank JR, Snell L, Sherbino J, Royal College of Physicians and Surgeons of Canada (RCPSC). CanMEDS 2015 physician competency framework. Ottawa: RCPSC; 2015. Available: http://canmeds.royalcollege.ca/uploads/en/framework/CanMEDS%202015%20Framework_EN_Reduced.pdf (accessed 2017 Oct 30). 6 Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. Lancet 2009;374:1714-21. 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Available: https://doi.org/10.1001/jamainternmed.2016.7674 (accessed 2017 Oct 30). 35 Chenevert D, Tremblay MC. Analyse de l'efficacité des programmes d'aide aux employés : Le cas du PAMQ. Montreal: HEC Montreal; 2016. Available: http://www.professionsante.ca/files/2016/07/Rapport-Chenevert-VF.pdf (accessed 2017 Oct 30). 36 Morneau Shepell Ltd. Workplace mental health priorities report 2015. Toronto: Morneau Shepell Ltd.; 2015. Available: https://www.morneaushepell.com/ca-en/insights/workplace-mental-health-priorities-report (accessed 2017 Oct 30). 37 Baicker K, Cutler D, Song Z. Workplace wellness programs can generate savings. Health Aff (Millwood) 2010;29:304-11. Available: https://doi.org/10.1377/hlthaff.2009.0626 (accessed 2017 Oct 30). 38 Harrison J. Doctors' health and fitness to practise: The need for a bespoke model of assessment. Occup Med (Lond) 2008;58:323-7. Available: https://doi.org/10.1093/occmed/kqn079 (accessed 2017 Oct 30). 39 Wallace JE, Lemaire J. On physician well being-you'll get by with a little help from your friends. Soc Sci Med 2007;64:2565-77. Available: https://doi.org/10.1016/j.socscimed.2007.03.016 (accessed 2017 Oct 30). 40 Lesser CS, Lucey CR, Egener B, Braddock CH, Linas SL, Levinson W. A behavioral and systems view of professionalism. JAMA 2010;304:2732-7. Available: https://doi.org/10.1001/jama.2010.1864 (accessed 2017 Oct 30). 41 Canadian Medical Association (CMA). CMA code of ethics. Ottawa: CMA; 2004. Available: https://www.cma.ca/Assets/assets-library/document/en/PD04-06-e.pdf (accessed 2017 Oct 30). 42 ePhysician Health. Primary care: Physician patient module. Ottawa: ePhysician Health; 2017. Available: http://ephysicianhealth.com/ (accessed 2017 Oct 30). 43 Sibbald B, Bojke C, Gravelle H. National survey of job satisfaction and retirement intentions among general practitioners in England. BMJ 2003;326:22. 44 Thompson WT, Cupples ME, Sibbett CH, Skan DI, Bradley T. Challenge of culture, conscience, and contract to general practitioners' care of their own health: qualitative study. BMJ 2001;323:728-31. 45 Schwenk TL, Davis L, Wimsatt LA. Depression, stigma, and suicidal ideation in medical students. JAMA 2010;304:1181-90. Available: https://doi.org/10.1001/jama.2010.1300 (accessed 2017 Oct 30). 46 DesRoches CM, Rao SR, Fromson JA, Birnbaum RJ, Iezzoni L, Vogeli C, et al. Physicians' perceptions, preparedness for reporting, and experiences related to impaired and incompetent colleagues. JAMA 2010;304:187-93. Available: https://doi.org/10.1001/jama.2010.921 (accessed 2017 Oct 30). 47 Gaufberg EH, Batalden M, Sands R, Bell SK. The hidden curriculum: what can we learn from third-year medical student narrative reflections? Acad Med 2010;85:1709-16. Available: https://doi.org/10.1097/ACM.0b013e3181f57899 (accessed 2017 Oct 30). 48 Dupont RL, Skipper GE. Six lessons from state physician health programs to promote long-term recovery. J Psychoactive Drugs 2012;44:72-8. Available: https://doi.org/10.1080/02791072.2012.660106 (accessed 2017 Oct 30). 49 Beaulieu M-D, Samson L, Rocher G, Rioux M, Boucher L, Del Grande C. Investigating the barriers to teaching family physicians' and specialists' collaboration in the training environment: a qualitative study. BMC Med Educ 2009;9:31. Available: https://doi.org/10.1186/1472-6920-9-31 (accessed 2017 Oct 30). 50 Van Ham I, Verhoeven AAH, Groenier KH, Groothoff JW, De Haan J. Job satisfaction among general practitioners: a systematic literature review. Eur J Gen Pract 2006;12:174-80. Available: https://doi.org/10.1080/13814780600994376 (accessed 2017 Oct 30). 51 Bahaziq W, Crosby E. Physician professional behaviour affects outcomes: a framework for teaching professionalism during anesthesia residency. Can J Anaesth 2011;58:1039-50. Available: https://doi.org/10.1007/s12630-011-9579-2 (accessed 2017 Oct 30). 52 Cydulka RK, Korte R. Career satisfaction in emergency medicine: the ABEM Longitudinal Study of Emergency Physicians. Ann Emerg Med 2008;51:714-722.e1. Available: https://doi.org/10.1016/j.annemergmed.2008.01.005 (accessed 2017 Oct 30). 53 Doja A, Bould MD, Clarkin C, Eady K, Sutherland S, Writer H. The hidden and informal curriculum across the continuum of training: A cross-sectional qualitative study. Med Teach 2016;38:410-8. Available: https://doi.org/10.3109/0142159X.2015.1073241 (accessed 2017 Oct 30). 54 Case GA. Performance and the hidden curriculum in Medicine. Performance Research 2014;19:6-13. Available: https://doi.org/10.1080/13528165.2014.947120 (accessed 2017 Oct 30). 55 Schneider B, Barbera KM. The Oxford handbook of organizational climate and culture. Oxford: Oxford University Press; 2014. 56 Cook AF, Arora VM, Rasinski KA, Curlin FA, Yoon JD. The prevalence of medical student mistreatment and its association with burnout. Acad Med 2014;89:749-54. Available: https://doi.org/10.1097/ACM.0000000000000204 (accessed 2017 Oct 30). 57 Canadian Medical Protective Association (CMPA). Physician health: Putting yourself first. Ottawa: CMPA; 2015 Sep. Available: https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2015/physician-health-putting-yourself-first (accessed 2017 Oct 30). 58 Givens JL, Tjia J. Depressed medical students' use of mental health services and barriers to use. Acad Med 2002;77:918-21. 59 Canadian Medical Foundation (CMF). A descriptive framework for physician health services in Canada: A report prepared by the tricoastal consortium for the Canadian Medical Foundation. Ottawa, CMF, 2016 May. Available: http://medicalfoundation.ca/wp-content/uploads/2016/09/7.b-TCC-Descriptive-Framework-Survey-Companion-FINAL-May-24-2016.pdf (accessed 2017 Oct 30). 60 Epstein RM, Krasner MS. Physician resilience: what it means, why it matters, and how to promote it. Acad Med 2013;88:301-3. 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Principles for the protection of patient privacy

https://policybase.cma.ca/en/permalink/policy13833
Date
2017-12-09
Topics
Health information and e-health
Ethics and medical professionalism
  2 documents  
Policy Type
Policy document
Date
2017-12-09
Replaces
PD11-03 Principles for the Protection of Patients' Personal Health Information
Topics
Health information and e-health
Ethics and medical professionalism
Text
Patients have a right to privacy and physicians have a duty of confidentiality arising from the patient-physician relationship to protect patient privacy. The right to privacy flows from the principle of respect for patient autonomy, based on the individual's right to conduct and control their lives as they choose.1 When approaching any ethical question around privacy, the principle of respect for patient autonomy must be balanced against other competing principles (e.g. beneficence, non-maleficence). The protection of privacy and the concomitant duty of confidentiality are essential to foster trust in the patient-physician-relationship, the delivery of good patient care and a positive patient care experience. Privacy protection is an important issue for Canadians,2 and research suggests that patients may withhold critical health information from their health care providers because of privacy concerns.3 Patients will be more willing to share complete and accurate information if they have a relationship of trust with their physician and are confident that their information will be protected.4 In today's ever-evolving technological environment and due to the shift away from the traditional (paternalistic) physician-patient relationship, patients, physicians and other public and private stakeholders are using and sharing personal health information in new and innovative ways. This raises new challenges for clinical practice and, crucially, how to navigate expanded uses of data via the use of new technologies and the requirements of patient privacy. Institutions, clinics, and physician-group practices may share responsibility with the physician for the protection of patient information. There is thus a tension between physician and institutional responsibilities to protect patient information, challenged by the rapidly changing use and adoption of new technologies. While this will continue to redefine expectations of privacy and confidentiality, there are several foundational principles that remain unchanged. SCOPE OF POLICY The Canadian Medical Association (CMA) Principles for the Protection of Patients' Personal Health Information aim to provide guidance on key ethical considerations pertinent to the protection of patient information in a way that takes into account a physician's (including medical learner) ethical, professional, and legal obligations. The Principles are not designed to serve as a tool for legislative compliance in a particular jurisdiction or to provide a standard of care. Physicians should be aware of privacy legislation in the jurisdiction in which they practice, the standards and expectations specified by their respective regulatory authorities (including Privacy Commissioners), publications and risk management education provided by the CMPA as well as policies and procedures of any given setting (e.g., a regional health authority or a hospital). SUBSTANTIVE PRINCIPLES THAT GUIDE THE OBLIGATIONS OF THE PHYSICIAN TO PROTECT PATIENT PRIVACY 1. Trust * Trust is the cornerstone of the patient-physician relationship and plays a central role in providing the highest standard of care. * Physicians and their patients build relationships of trust that enable open and honest dialogue and foster patients' willingness to share deeply personal information (often) in conditions of vulnerability. * Physicians can cultivate and maintain patient trust by, unless the consent of the patient has been obtained to do otherwise, collecting health information only to benefit the patient, by sharing information only for that purpose, and by keeping patient information confidential; patient trust has been found to be the most powerful determinant of the level of control patients want over their medical records.5 * To maintain trust, physicians must consider the duty to care and the duty not to harm the patient in evaluating privacy requirements. * The extent to which a patient expects (and may tolerate a loss of) privacy and confidentiality is culturally and individually relative.6 2. Confidentiality * Physicians owe a duty of confidentiality to their patients; there is both an ethical (respect for autonomy) and a legal basis imposed by privacy legislation) for this duty. * The duty to maintain patient confidentiality, like trust, is fundamental to the therapeutic nature of the patient-physician relationship; it creates conditions that allow patients to openly and confidently share complete health information, resulting in a stronger physician-patient relationship and better delivery of care.7 * The duty to maintain patient confidentiality means that physicians do not share the health information with anyone outside of the patient's circle of care, unless authorized to do so by the patient.1,8 There are varying interpretations of what constitutes the patient's circle of care; this depends on the facts of the situation and the jurisdiction.9 * Privacy requirements raise complex issues in learning environments and quality improvement initiatives. It is desirable that any of the patient's physicians who will have ongoing care interactions with the patient can remain included in information-sharing about the patient. * Shared electronic health records present challenges to confidentiality. For example, patients may wish to limit some aspects of their record to only some providers within their circle of care.10 * In practice, respecting privacy and the duty of confidentiality govern the physician's role as data steward, responsible for controlling the extent to which information about the person is protected, used or disclosed.11 A central rule to balancing a patient's right to privacy and the duty of confidentiality is the "minimum necessary" use and disclosure of personal health information, whereby a data steward should use or disclose only the minimum amount of information necessary to fulfil the intended purpose. In some circumstances, de-identifying or aggregating personal health information before use or disclosure can minimize the amount of information disclosed.12 * The duty to maintain patient confidentiality is not absolute and is subject to exceptions in limited circumstances,13 i.e., when required or permitted by law to disclose information (see below in Data Stewardship: Collection, use and disclosure of personal health information). 3. Consent * Patient consent is an important mechanism for respecting patient autonomy; obtaining voluntary and informed consent to share patient information is fundamental to the protection of privacy and the duty of confidentiality. * Physicians are generally required to obtain informed consent from the patient before they can disclose the patient's personal health information. Consent is only informed if there is disclosure of matters that a reasonable person in the same circumstances would want to know, including 1) to whom the patient information will be disclosed, 2) whether it could be disclosed to other third parties, and 3) the purpose for which it could be used or disclosed. * While informed consent is required as a general rule, physicians may infer that they have the patient's implied consent to collect, use, disclose and access personal health information 1) for the purpose of providing or assisting in providing care (i.e., share only the necessary information with those involved within the patient's circle of care); and 2) to store personal health information in a medical record (i.e., paper, electronic, or hospital-based). Physicians will want to consider if it is appropriate in the circumstances to advise the patient when a disclosure has been made. * When the patient is a minor, the physician must consider whether it is the parent or the child who determines the use and disclosure of the minor's personal health information. A young person who is deemed to understand fully the implications of a decision regarding proposed collection, use or disclosure of personal health information is generally deemed to have control over their personal health information with respect to the decision. * Where the patient is not capable to provide the required consent (e.g. is deemed to be incompetent), physicians must seek consent from the patient's substitute decision-maker. 4. Physician as data steward * As data stewards, physicians have the responsibility to understand their role in protecting patient privacy and appropriate access to patient information. * The information contained in the medical record belongs to the patient who has a general right of access to their personal health information, and the right to control the use and further disclosure and to the continued confidentiality of that information. * A data steward (e.g., physician, institution or clinic) holds the physical medical record in trust for the care and benefit of the patient.14 * Physicians should provide their patients access to their medical record, if requested.15 (See below in Data Stewardship: Access to personal information). * Physicians ought to have appropriate access to personal health information and have the ability to provide their patients with access to their medical record. Appropriate access should be interpreted to include access for patient follow up (as part of the duty to care) and review for the purpose of improving patient care. * Physicians should consider consulting available resources to assist them in fulfilling their duties as data stewards. PROCEDURAL PRINCIPLES THAT GUIDE THE APPLICATION OF PHYSICIAN OBLIGATIONS Physicians must manage personal health information in compliance with relevant legislation that establishes rules governing the access, collection, use, disclosure, and retention of personal health information, provincial privacy laws, and professional expectations and regulations specified by their respective regulatory authorities. 1. Data Stewardship: Access to personal information * Patients have a right of reasonable access to the personal health information in their medical record (i.e., paper, electronic, or hospital-based) under the control or in the custody of a physician, institution, or clinic. * In exceptional situations, physicians can refuse to release the information in the patient's medical record. 2. Data Stewardship: Collection, use and disclosure of personal health information * There are circumstances where there are required (e.g., monitoring of claims for payment, subpoenas) and permitted disclosures of personal health information without patient consent (e.g., where the maintenance of confidentiality would result in a significant risk of substantial harm to the patient or to others). * Security safeguards must be in place to protect personal health information in order to ensure that only authorized collection, use, disclosure or access occurs. * Physicians play an important role in educating patients about possible consensual and non-consensual uses and disclosures that may be made with their personal health information, including secondary uses of data for, e.g., epidemiological studies, research, education, and quality assurance, that may or may not be used with explicit consent. 3. Data Stewardship: Retention of personal health information * Personal health information should be retained for the period required by any applicable legislation and as specified by their respective regulatory authorities. It may be necessary to maintain personal health information beyond the applicable period where there is a pending or anticipated legal proceeding related to the care provided to the patient. * Likewise, physicians should transfer and dispose of personal health information in compliance with any applicable legislation and professional expectations outlined by their respective regulatory authorities. * Physicians are encouraged to seek technical assistance and advice on the secure transfer, disposal, and/or selling of electronic records.15 4. Data Stewardship: Use of technology * Physicians should obtain patient consent to use electronic means and/or devices for patient care (e.g., sending digital photographs) and for communicating patient information (e.g., the use of email). To obtain informed consent, physicians should explain to patients that there are necessary benefits and risks in using technologies in clinical contexts. The CMPA has provided a written consent form to that effect that can be included in the patient's medical record. * As a general practice, physicians are encouraged to make use of technological innovations and must evaluate whether the technology is appropriate for patient care and has reasonable safeguards to protect patient privacy. Approved by the CMA Board of Directors December 2017 See also Background to CMA Policy Principles for the Protection of Patient Privacy REFERENCES 1 Martin JF. Privacy and confidentiality. In: ten Have H, Gordijn B (Eds). Handbook of global bioethics. New York: Springer, Dordrecht; 2014. p.119-37. 2 Office of the Privacy Commissioner of Canada. Canadians and privacy final report. Gatineau: Office of the Privacy Commissioner of Canada; 2009. Available: https://www.priv.gc.ca/information/por-rop/2009/ekos_2009_01_e.asp (accessed 2017 Nov 17). 3 Canadian Medical Protective Association (CMPA). Privacy and a wired world - Protecting patient health information. Ottawa: CMPA; 2011 Dec. Available: https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2011/privacy-and-a-wired-world-protecting-patient-health-information (accessed 2017 Nov 17). 4 Royal College of Physicians and Surgeons of Canada (RCPSC). Duty of confidentiality. Ottawa: RCPSC; 2017. Available: http://www.royalcollege.ca/rcsite/bioethics/cases/section-3/duty-confidentiality-e (accessed 2017 Dec 15). 5 Damschroder LJ, Pritts JL, Neblo MA, Kalarickal RJ, Creswell JW, Hayward RA. Patients, privacy and trust: patients' willingness to allow researchers to access their medical records. Soc Sci Med 2007;64:223-35. 6 Campbell JI, Eyal N, Musiimenta A, Haberer JE. Ethical questions in medical electronic adherence monitoring. J Gen Intern Med 2016;31:338-42. Available: https://link.springer.com/content/pdf/10.1007%2Fs11606-015-3502-4.pdf (accessed 2017 Nov 17). 7 Crook MA. The risks of absolute medical confidentiality. Sci Eng Ethics 2013;19:107-22. 8 Cohen I, Hoffman A, Sage W (Eds). The Oxford Handbook of U.S. Health Law. New York: Oxford University Press; 2015. 9 Canadian Medical Protective Association (CMPA). The voice of professionalism within the system of care. Ottawa: CMPA; 2012 Oct. Available: https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2012/the-voice-of-professionalism-within-the-system-of-care (accessed 2017 Nov 17). 10 Canadian Medical Protective Association (CMPA). Did you know? Patients can restrict access to their health information. Ottawa: CMPA; 2017 Nov. Available: https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2017/did-you-know-patients-can-restrict-access-to-their-health-information (accessed 2017 Nov 17). 11 Francis JG, Francis LP. Privacy, confidentiality, and justice. J Soc Philos 2014;45:408-31. 12 Burkle CM, Cascino GD. Medicine and the media: balancing the public's right to know with the privacy of the patient. Mayo Clin Proc 2011;86:1192-6. 13 Canadian Medical Protective Association (CMPA). When to disclose confidential information. Ottawa: CMPA; 2015 Mar. Available: https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2015/when-to-disclose-confidential-information (accessed 2017 Nov 17). 14 Canadian Medical Protective Association (CMPA). Releasing a patient's personal health information: What are the obligations of the physician? Ottawa: CMPA; 2012 Oct. Available: https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2012/releasing-a-patient-s-personal-health-information-what-are-the-obligations-of-the-physician (accessed 2017 Nov 17). 15 Canadian Medical Protective Association (CMPA). Protecting patient health information in electronic records. Ottawa: CMPA; 2013 Oct. Available: https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2013/protecting-patient-health-information-in-electronic-records (accessed 2017 Nov 17). (c) 2017 Canadian Medical Association. You may, for your non-commercial use, reproduce, in whole or in part and in any form or manner, unlimited copies of CMA Policy Statements provided that credit is given to Canadian Medical Association. BACKGROUND TO CMA POLICY PRINCIPLES FOR THE PROTECTION OF PATIENT PRIVACY See also CMA Policy on Principles for the Protection of Patient Privacy Context The advent of Electronic Medical Records, the rapid spread of mobile health apps, and the increasing use of social media within the health care community, have each created new challenges to maintaining a duty of confidentiality within the physician-patient relationship. These technologies present both opportunities and challenges with respect to medical professionalism.1 The permeation of these types of interactions into everyday life now places physicians in new situations that some find difficult to navigate.2 These challenges will only increase in the coming years, as the use of online technologies in health care is continuously growing.3 Canada is only in the early stages of managing the emerging issues of technology-induced errors that compromise privacy in the health care setting.4 Therefore, this paper will briefly discuss the importance of protecting privacy, followed by an overview of the main challenges to maintaining privacy as the physician-patient relationship evolves at the backdrop of emerging technologies. Privacy and Confidentiality The overlapping, but not identical, principles of the protection of privacy and the duty of confidentiality are essential to the physician-patient relationship. These principles not only foster trust, but also the delivery of effective and lasting care. Rooted in the Hippocratic Oath, the modern-day right to privacy flows from the principle of autonomy, which attributes to individuals the right to conduct and control their lives as they choose.5 Privacy protection is an important issue to Canadians,6 with research suggesting that patients may even withhold critical health information because of privacy concerns.7 Health care professionals are bound by legal and ethical standards to maintain privacy and confidentiality of patient information.8 Physicians must therefore be aware of the implications of privacy legislation specific to their jurisdiction.7 The duty to protect patient privacy is important to uphold, as health information can potentially be identifiable and sensitive; the confidentiality of this information must therefore be protected to ensure that patient privacy is not breached. 9 While the traditional, and largely obsolete, models of the physician-patient relationship involve a unidirectional flow of information, the ease at which patients can now access medical information through the Internet, and the use of social media within the health care community, have reinterpreted how information is communicated from physician to patient, and vice versa.10 We must therefore re-define expectations of privacy and confidentiality, first by distinguishing one from the other. The terms "privacy" and "confidentiality" are often used interchangeably by both researchers and clinicians. Several bioethics discussions on the distinction between these terms places confidentiality under the umbrella of privacy.11 While confidentiality involves the information itself, which is disclosed or not, privacy is about the impact of that disclosure on the person.9 Privacy seems to be more intimately linked to the individual, focusing on the circumstances under which the information is used.12-13 Confidentiality, on the other hand, is a duty that health professionals have towards their patients to not share the information exchanged during their encounter, unless authorized by the patient.5,12 In practice, the duty of confidentiality governs the physician's role as data stewards, responsible for controlling the extent to which information about the person is protected, used or disclosed.14 As one paper describes, "privacy is invaded, confidentiality is breached."13 From a patient perspective, it is important to respect and protect privacy because it allows individuals time and space to share their concerns without feeling judged or misunderstood,11 resulting in a stronger physician-patient relationship and better delivery of care. However, from a research perspective, a fine balance must be struck between using accurate information while still upholding the privacy rights of individuals.11 As such, the argument for absolute confidentiality puts a near impossible burden on research clinicians.11 Moreover, from a public safety perspective, a physician may be morally and legally required to break confidentiality in order to protect both the patient and others who may be involved. The challenge is to balance the traditional goal of confidentiality - to protect patient privacy and interest - with that of third parties and public health.5 Therefore, a central rule to balancing confidentiality with a patients' right to privacy is the "minimum necessary" use and disclosure of personal health information, whereby a data steward should use or disclose only the minimum amount of information necessary to fulfil the intended purpose.8 It is equally important to recognize that the extent to which a patient may tolerate a loss of privacy is culturally and individually relative.15 Health care providers have a legal and ethical obligation to keep patient health information private, sharing it only with the authorization of the patient.16 Informed consent, therefore, appears to be a fundamental requirement to upholding confidentiality and patient privacy rights. Issues While emerging privacy issues touch many areas of practice, this section will emphasize three of the most prominent issues in recent literature: access and use of information, electronic medical and health records and, online communication and social media. 1. Technological change and institutional data stewardship In today's ever-evolving technological environment, including the emergence of shared electronic health records, online communication, social media, mobile applications, and big data, physicians, patients and other public and private stakeholders are using and sharing personal health information in new and innovative ways. The traditional (paternalistic) model of the physician-patient relationship involved a bidirectional flow of information. However, the ease at which patients can now access medical information from alternative sources via the Internet, and the use of social media within the health care community, has redefined how information is communicated from physician to patient, and vice versa.10 This raises new challenges for clinical practice, specifically how to navigate expanded access of data via the use of new technologies and the requirements of patient privacy by effectively managing security concerns. In many situations, the physician may not be the sole or primary custodian of (i.e., control access to) the patient's records once the health information is collected. Institutions, clinics, and physician-group practices may also have responsibility for patient information and therefore play an important role in ensuring it is protected. There is thus a grey area between physician and institutional responsibilities to protect patient information, challenged by the rapidly changing use and adoption of new technologies, such as electronic health and medical records. While this will continue to redefine expectations of privacy and confidentiality, there are several foundational principles that remain unchanged. 2. Electronic medical and health records Medical records are compiled primarily to assist physicians and other health care providers in treating patients.16 Yet, they are particularly vulnerable to privacy breaches when this information is exposed to secondary uses, including epidemiological studies, research, education and quality assurance. As contemporary information management and stewardship have had to evolve in response to emerging technology, the parameters of the "medical record" have grown increasingly ambiguous.17 With the proliferation of a wide variety of new health information technology (including electronic health and medical records), concerns about quality and safety have been raised.4 There is evidence that if such technology is not designed, implemented and maintained effectively, it may result in unintended consequences, including technology-induced errors and breaches of patient privacy.4 Reports involving Canada Health Infoway have even pointed to health information technology as a tool that may sometimes reduce rather than enhance patient safety, most often due to human factors. 4 As a result, recommendations have been made to develop a reporting system that would allow health professionals to anonymously report human errors resulting from the use of health information technology - a challenge in itself, as the distinction between human and technological error is often blurred.4 In Canada, a number of efforts have been undertaken by several organizations, including Health Canada and Canada's Health Informatics Organization.4 Yet, services aimed at improving health information technology safety, from a national level, remain poor.4 As a result, organizations like Canada Health Infoway have promoted the need for collaborative efforts to improve health information technology safety standards in Canada, 4 so to ensure that the current and future uses of "medical record" data are accurate and respectful of patient privacy. 3. Access and use of personal health information for research The courts have long established that health information belongs to the patient.18 As a result, privacy ownership refers to the belief that patients own their private information as well as the right to control access to this information.19 As in other jurisdictions, the overarching challenge in Canada is to strike a balance between enabling access to health and health-related data for research while still respecting Canadians' right to privacy and control over the confidentiality of their information.20 The integrity of healthcare information is fundamental, given that it is the basis on which treatment decisions are made both in research and in clinic. 9 There are three principles upon which information security is based: 9 1) only authorized people have access to confidential information; 2) information must be accurate and consistent, may only be modified by authorized people in ways that are appropriate; 3) information must be accessible by authorized users when needed. Canadian research ethics have demonstrated that beneficial work can be done while maintaining confidentiality to sensitive personal health information.21 Yet, the challenge remains to create a uniform system for accessing data and performing data-based research due to 1) the lack of consistency and clarity in Canada's ethical and legal framework and, 2) varied interpretations of key terms and issues across the country.21 For example, the term "non-identifiable data" remains ambiguous across provinces and is subject to interpretation by data custodians, who may consider their legal duty to protect privacy as precluding access to data.21 This lack of legal clarity has contributed to varied cautious and conservative interpretations of data access legislation.21 National uniform guidelines on the appropriate access, disclosure and use of personal health data would allow data stewards to advance their research while respecting their patients' right to privacy. 4. Online communication with patients and social media Social media and online communication is pervasive in Canadian society; from Facebook to Twitter, social media has changed the way people interact and disseminate information.21 There is currently widespread discussion among health care professionals and academics regarding the role that social media and online communication should play in the physician-patient relationship.22 A growing number of physicians have embraced the opportunities of interconnectivity that social media affords, implementing their own privacy procedures to reflect this new type of data collection, use and storage.7 While evidence has been lacking on whether the use of social media does improve patient outcomes,22 there is no denying that patients are seeking health care information from online platforms, including social media.22 This type of communication poses a unique set of opportunities and challenges for physicians: while the use of social media could increase physician reach and patient engagement, it can also blur boundaries between one's personal and professional life.22 Although patient-physician online communication is currently limited, physicians still feel that they are encountering an ethical dilemma, especially when they find themselves in boundary crossing situations, like a friend request from a patient.2 Physicians are particularly concerned that, through online communication, they may be exposed to medico-legal and disciplinary issues, especially with respect to patient privacy.2 Given different studies have suggested that unprofessional uses of social media are not uncommon,23 physicians who choose to communicate with patients online or through social media must remember that they are still governed by the same ethical and professional standards that remain paramount.22 As technology continues to evolve, so too will the traditional parameters of the patient-physician relationship. The physician's ethical and professional obligation to protect patient privacy, however, must remain paramount at the backdrop of technology use. Simply banning social media and online communication would neither eliminate risk, nor benefit patient care outcomes. 24 Instead, institutions should establish stringent policies that outline how to prevent or minimize the effects of privacy breaches associated with social media and online communication.25 This should also include a tracking mechanism to help balance the obligation to privacy with evolving technology.25 December 2017 See also CMA Policy on Principles for the Protection of Patient Privacy REFERENCES 1 Farnan JM, Snyder Sulmasy L, Worster BK, Chaudhry HJ, Rhyne JA, Arora VM. Online medical professionalism: patient and public relationships: policy statement from the American College of Physicians and the Federation of State Medical Boards. Ann Intern Med 2013;158(8):620-627. 2 Brown J, Ryan C. How doctors view and use social media: a national survey. J Med Internet Res 2014;16:e267. Available: https://doi.org/10.2196/jmir.3589 (accessed 2017 Nov 17). 3 Lambert KM, Barry P, Stokes G. Risk management and legal issues with the use of social media in the healthcare setting. J Healthc Risk Manag 2012;31(4):41-47. 4 Kushniruk AW, Bates DW, Bainbridge M, Househ MS, Borycki EM. National efforts to improve health information system safety in Canada, the United States of America and England. Int J Med Inform 2013;82(5):e149-160. 5 Martin JF. Privacy and confidentiality. In: ten Have H, Gordijn B (Eds). Handbook of global bioethics. New York: Springer, Dordrecht; 2014. p.120-1. 6 Office of the Privacy Commissioner of Canada. Canadians and privacy final report. Gatineau: Office of the Privacy Commissioner of Canada; 2009. Available: https://www.priv.gc.ca/information/por-rop/2009/ekos_2009_01_e.asp (accessed 2017 Nov 17). 7 Canadian Medical Protective Association (CMPA). Privacy and a wired world - Protecting patient health information. Ottawa: CMPA; 2011 Dec. Available: https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2011/privacy-and-a-wired-world-protecting-patient-health-information (accessed 2017 Nov 17). 8 Burkle CM, Cascino GD. Medicine and the media: balancing the public's right to know with the privacy of the patient. Mayo Clin Proc 2011;86:1192-6. 9 Williams PA. Information security governance: a risk assessment approach to health information systems protection. Stud Health Techol Inform 2013;193:186-206. 10 Borza LR, Gavrilovici C, Stockman R. Ethical models of physician-patient relationship revisited with regard to patient autonomy, values and patient education. Rev Med Chir Soc Med Nat Iasi 2015;119(2):496-501. 11 Crook MA. The risks of absolute medical confidentiality. Sci Eng Ethics 2013;19(1):107-122. 12 Cohen I, Hoffman A, Sage W (Eds). The Oxford handbook of U.S. health law. New York: Oxford University Press; 2015. 13 Francis L. Privacy and confidentiality: the importance of context. The Monist; 91(1);2008:52-67. 14 Francis JG, Francis LP. Privacy, confidentiality, and justice. J Soc Philos 2014;45:408-31. 15 Campbell JI, Eyal N, Musiimenta A, Haberer JE. Ethical questions in medical electronic adherence monitoring. J Gen Intern Med 2016;31:338-42. Available: https://link.springer.com/content/pdf/10.1007%2Fs11606-015-3502-4.pdf (accessed 2017 Nov 17). 16 Canadian Medical Association (CMA). Medical record confidentiality, access and disclosure. Ottawa: CMA; 2000. Available: https://www.cma.ca/Assets/assets-library/document/en/advocacy/policy-research/CMA_Policy_The_medical_record_confidentiality_access_and_disclosure_Update_2000_PD00-06-e.pdf (accessed 2017 Oct 30). 17 Fenton SH, Manion F, Hsieh K, Harris M. Informed Consent: Does anyone really understand what is contained in the medical record? Appl Clin Inform 2015;6(3):466-477. 18 Canada. Supreme Court. McInerney v MacDonald. Dom Law Rep. 1992 Jun 11;93:415-31. 19 Petronio S, Dicorcia MJ, Duggan A. Navigating ethics of physician-patient confidentiality: a communication privacy management analysis. Perm J 2012;16(4):41-45. 20 Council of Canadian Academies (CCA). Accessing health and health-related data in Canada. Ottawa: The Expert Panel on Timely Access to Health and Social Data for Health Research and Health System Innovation, Council of Canadian Academies; 2015. Available: http://www.scienceadvice.ca/uploads/eng/assessments%20and%20publications%20and%20news%20releases/Health-data/HealthDataFullReportEn.pdf (accessed 2017 Nov 17). 21 Canadian Medical Association (CMA). Social media and Canadian physician: Issues and rules of engagement. Ottawa: CMA; 2011. Available: https://www.cma.ca/Assets/assets-library/document/en/advocacy/CMA_Policy_Social_Media_Canadian_Physicians_Rules_Engagement_PD12-03-e.pdf (accessed 2017 Oct 30). 22 Eysenbach G. Medicine 2.0: Social networking, collaboration, participation, apomediation, and openness J Med Internet Res 2008;10(3):e22. 23 Mayer MA, Leis A, Mayer A, Rodriguez-Gonzalez A. How medical doctors and students should use social media: A review of the main guidelines for proposing practical recommendations. Stud Health Technol Info 2012;180:853-857. 24 Moses RE, McNeese LG, Feld LD, Feld AD. Social media in the health-care setting: Benefits but also a minefield of compliance and other legal issues. Am J Gastroenterol 2014;109(8):1128-1132. 25 Yang YT, Silverman RD. Mobile health applications: The patchwork of legal and liability issues suggests strategies to improve oversight. Health Aff (Millwood) 2014;33(2):222-227.
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