The major diseases affecting the quality and quantity of life of Canadians, which include obesity, diabetes, coronary artery disease, depression and cancer, are all linked to physical inactivity. In Canada, 69% of women and 68% of men in Canada are considered physically inactive.(1) The cost of this inactivity and obesity was estimated at $4.3 billion in 2001.(2) A 10% increase in physical activity could potentially reduce direct health care expenditures by $150 million a year. This does not include indirect costs such as lost productivity due to illness, premature death or a range of other factors, including mental illness and poor quality of life.(3)
Thus far, efforts to increase physical activity by changing the behaviour of individuals have had limited success. One reason is that many people have difficulty sustaining behaviours that involve additional time commitments. That is one reason for the increasing emphasis being placed on active transportation, which is any human-powered form of transportation, such as walking and cycling.
Walking and cycling can be efficient alternatives to automobile travel. Cycling is usually the fastest mode of travel door to door for distances under five km, and for up to 10 km in city cores. Walking is simpler and nearly as fast for distances up to two km. When travel times are similar for active and motorized transportation, physical activity is gained with no net time lost, and at much lower cost. The cost of operating a motor vehicle is typically $10,000 per year,(4) while operating costs for a bicycle are much lower.
Communities that have sidewalks, enjoyable scenery, street lights and nearby stores have improved levels of active transportation and physical activity. However, in recent decades communities have often been designed around the automobile. Street design, parking space, sidewalks and distance to retail destinations have all been planned assuming motorized transportation, and this often makes it difficult to move around communities by walking or cycling.
Although individual decision-making remains important in any strategy for increasing active transportation, there is an essential role for communities and governments to play. Major improvements in the health of Canadians in the past 200 years have been due to improved sanitation, access to clean water and injury prevention. The role of individual decision-making in effecting these changes is dwarfed by the impact of the public health measures and infrastructure involved. Just as potable tap water is a health issue, so are decisions about land use, transportation policy and infrastructure.
Community design is a major determinant of whether people use active transportation, whether they are physically active and whether they are obese. Canadians need communities that make it easy to be physically active in their daily living.
Communities can create an environment in which the physically active choice is the easy choice. They can do this via sidewalks, trails, bicycle lanes and bicycle paths, and by providing pedestrian-friendly intersections, parks and green spaces, and safe bicycle parking spaces. They can also arrange zoning so that retail destinations are within walking or cycling distance of residential areas. This process also includes dedicating a sufficient portion of their street maintenance budget (including snow clearing) to maintaining active transportation routes as well as routes for motorized vehicles. It may include redesigning intersections, giving up vehicle lanes or parking spaces, or increasing the price of parking.
Additional benefits to designing communities for pedestrians and cyclists.
* a stronger sense of community with greater civic involvement by citizens
* increased property values and retail activity
* less noise pollution
* lower crime rates
* less smog and other air pollution
* less greenhouse gas production
* decreased risk of injury to pedestrians and cyclists
* decreased costs of roadway and parking construction.
A role for everyone
Other sectors can support communities in making active transportation choices easy choices:
* Businesses can create a work environment friendly to active transportation, including a corporate culture friendly to physical activity. They can incorporate active transportation planning into building design and create an environment friendly to physical activity. These steps could include making bicycle parking, showers and lockers available, and providing stairs that are pleasant and easier to access than elevators. They can also incorporate a culture of physical activity in decisions about where and how to hold meetings, and what people are allowed to wear to work.
* School boards can develop policies to promote active transportation to and from school. These include building and maintaining secure bicycle parking, ensuring safe walking routes within communities, and assisting parents in walking their children to school.
* Citizens can use active transportation themselves and treat with respect those who are already making active transportation choices. They can also lobby governments to make their community safer and easier places for cycling and walking.
* Physicians can encourage patients to use active transportation as a way to boost their physical activity levels and improving their health. They can also lead by example and use active transportation themselves.
The CMA recommends that all sectors (government, business and the public) work together, as a matter of priority, to create a culture in their communities that supports and encourages active transportation.
The CMA urges governments to:
* Commit to long-term plans for active transportation networks that are in keeping with these goals and that include specific benchmarks to measure progress.
* Require that active transportation be part of all infrastructure renewal projects, with investment in active transportation vs. motorized transportation in proportion to targeted active transportation use. (Some cities have achieved active transportation rates of up to 15%.)
* Develop an awareness campaign to help Canadians to recognize the value of active transportation in their communities.
* Require public health impact assessments for all land-use and transportation decisions, including the impact on the chemical environment and on physical activity.
* Assess the impact that changes in the "built" environment can have on public health, and which interventions are most safe and effective.
1 Tremblay MS, Katzmarzyk PT, Willms JD. Temporal trends in overweight and obesity in Canada, 1981-1996. Int J Obes Relat Metab Disord 2002;26(4):538-43.
2 Katzmarzyk PT, Janssen I. The economic costs associated with physical inactivity and obesity in Canada: an update. Can J App Phys 2004;29(1):104.
3 Katzmarzyk PT, Gledhill N, Shephard RJ. The economic burden of physical inactivity in Canada. CMAJ 2000;163(11): 1435-40.
4 Canadian Automobile Association. Driving Costs: 2005 Edition. Available: www.carpool.ca/pdf/CAA-driving-costs-05.pdf (accessed 2007 Feb. 2).
Clinical photography is a valuable tool for physicians. Smartphones, as well as other devices supporting network connectivity, offer a convenient, efficient method to take and share images. However, due to the private nature of the information contained in clinical photographs there are concerns as to the appropriate storage, dissemination, and documentation of clinical images. Confidentiality of image data must be considered and the dissemination of these images onto servers must respect the privacy and rights of the patient. Importantly, patient information should be considered as any information deriving from a patient, and the concepts outlined therefore apply to any media that can be collected on, or transmitted with, a smart-device.
Clinical photography can aid in documenting form and function, in tracking conditions and wound healing, in planning surgical operations, and in clinical decision-making. Additionally, clinical photographs can provide physicians with a valuable tool for patient communication and education. Due to the convenience of this type of technology it is not appropriate to expect physicians to forego their use in providing their patients with the best care available.
The technology and software required for secure transfer, communication, and storage of clinical media is presently available, but many devices have non-secure storage/dissemination options enabled and lack user-control for permanently deleting digital files. In addition, data uploaded onto server systems commonly cross legal jurisdictions. Many physicians are not comfortable with the practice, citing security, privacy, and confidentiality concerns as well as uncertainty in regards to regional regulations governing this practice.1 Due to concern for patient privacy and confidentiality it is therefore incredibly important to limit the unsecure or undocumented acquisition or dissemination of clinical photographs.
To assess the current state of this topic, Heyns et al. have reviewed the accessibility and completeness of provincial and territorial medical regulatory college guidelines.2 Categories identified as vital and explored in this review included: Consent; Storage; Retention; Audit; Transmission; and Breach. While each regulatory body has addressed limited aspects of the overall issue, the authors found a general lack of available information and call for a unified document outlining pertinent instructions for conducting clinical photography using a smartphone and the electronic transmission of patient information.2
The discussion of this topic will need to be ongoing and it is important that physicians are aware of applicable regulations, both at the federal and provincial levels, and how these regulations may impact the use of personal devices. The best practices supported here aim to provide physicians and healthcare providers with an understanding of the scope and gravity of the current environment, as well as the information needed to ensure patient privacy and confidentiality is assessed and protected while physicians utilize accessible clinical photography to advance patient care. Importantly, this document only focusses on medical use (clinical, academic, and educational) of clinical photography and, while discussing many core concepts of patient privacy and confidentiality of information, should not be perceived as a complete or binding framework. Additionally, it is recommended that physicians understand the core competencies of clinical photography, which are not described here.
The Canadian Medical Association (CMA) suggests that the following recommendations be implemented, as thoroughly as possible, to best align with the CMA policy on the Principles for the Protection of Patient Privacy (CMA Policy PD2018-02). These key recommendations represent a non-exhaustive set of best practices - physicians should seek additional information as needed to gain a thorough understanding and to stay current in this rapidly changing field.
* Informed consent must be obtained, preferably prior, to photography with a mobile device. This applies for each and any such encounter and the purpose made clear (i.e. clinical, research, education, publication, etc.). Patients should also be made aware that they may request a copy of a picture or for a picture to be deleted.
* A patient's consent to use electronic transmission does not relieve a physician of their duty to protect the confidentiality of patient information. Also, a patient's consent cannot override other jurisdictionally mandated security requirements.
* All patient consents (including verbal) should be documented. The acquisition and recording of patient consent for medical photography/dissemination may be held to a high standard of accountability due to the patient privacy and confidentiality issues inherent in the use of this technology. Written and signed consent is encouraged.
* Consent should be considered as necessary for any and all photography involving a patient, whether or not that patient can be directly recognized, due to the possibility of linked information and the potential for breach of privacy. The definition of non-identifiable photos must be carefully considered. Current technologies such as face recognition and pattern matching (e.g. skin markers, physical structure, etc.), especially in combination with identifying information, have the potential to create a privacy breach.
* Unsecure text and email messaging requires explicit patient consent and should not be used unless the current gold standards of security are not accessible. For a patient-initiated unsecure transmission, consent should be clarified and not assumed.
* Transmission of photos and patient information should be encrypted as per current-day gold standards (presently, end-to-end encryption (E2EE)) and use only secure servers that are subject to Canadian laws. Explicit, informed consent is required otherwise due to privacy concerns or standards for servers in other jurisdictions. Generally, free internet-based communication services and public internet access are unsecure technologies and often operate on servers outside of Canadian jurisdiction.
* Efforts should be made to use the most secure transmission method possible. For data security purposes, identifying information should never be included in the image, any frame of a video, the file name, or linked messages.
* The sender should always ensure that each recipient is intended and appropriate and, if possible, receipt of transmission should be confirmed by the recipient.
* Storing images and data on a smart-device should be limited as much as possible for data protection purposes.
* Clinical photos, as well as messages or other patient-related information, should be completely segregated from the device's personal storage. This can be accomplished by using an app that creates a secure, password-protected folder on the device.
* All information stored (on internal memory or cloud) must be strongly encrypted and password protected. The security measures must be more substantial than the general password unlock feature on mobile devices.
* Efforts should be made to dissociate identifying information from images when images are exported from a secure server. Media should not be uploaded to platforms without an option for securely deleting information without consent from the patient, and only if there are no better options. Automatic back-up of photos to unsecure cloud servers should be deactivated. Further, other back-up or syncing options that could lead to unsecure server involvement should be ascertained and the risks mitigated.
4. Cloud storage should be on a Canadian and SOCII certified server. Explicit, informed consent is required otherwise due to privacy concerns for servers in other jurisdictions.
5. AUDIT & RETENTION
* It is important to create an audit trail for the purposes of transparency and medical best practice. Key information includes patient and health information, consent type and details, pertinent information regarding the photography (date, circumstance, photographer), and any other important facts such as access granted/deletion requests.
* Access to the stored information must be by the authorized physician or health care provider and for the intended purpose, as per the consent given. Records should be stored such that it is possible to print/transfer as necessary.
* Original photos should be retained and not overwritten.
* All photos and associated messages may be considered part of the patient's clinical records and should be maintained for at least 10 years or 10 years after the age of majority, whichever is longer. When possible, patient information (including photos and message histories between health professionals) should be retained and amalgamated with a patient's medical record. Provincial regulations regarding retention of clinical records may vary and other regulations may apply to other entities - e.g. 90 years from date of birth applies to records at the federal level.
* It may not be allowable to erase a picture if it is integral to a clinical decision or provincial, federal, or other applicable regulations require their retention.
* Any breach should be taken seriously and should be reviewed. All reasonable efforts must be made to prevent a breach before one occurs. A breach occurs when personal information, communication, or photos of patients are stolen, lost, or mistakenly disclosed. This includes loss or theft of one's mobile device, texting to the wrong number or emailing/messaging to the wrong person(s), or accidentally showing a clinical photo that exists in the phone's personal photo album.
* It should be noted that non-identifying information, when combined with other available information (e.g. a text message with identifiers or another image with identifiers), can lead to highly accurate re-identification.
* At present, apps downloaded to a smart-device for personal use may be capable of collecting and sharing information - the rapidly changing nature of this technology and the inherent privacy concerns requires regular attention. Use of specialized apps designed for health-information sharing that help safeguard patient information in this context is worth careful consideration.
* Having remote wipe (i.e. device reformatting) capabilities is an asset and can help contain a breach. However, inappropriate access may take place before reformatting occurs.
* If a smartphone is strongly encrypted and has no clinical photos stored locally then its loss may not be considered a breach.
* In the event of a breach any patient potentially involved must be notified as soon as possible. The CMPA, the organization/hospital, and the Provincial licensing College should also be contacted immediately. Provincial regulations regarding notification of breach may vary.
Approved by the CMA Board of Directors March 2018
i Heyns M†, Steve A‡, Dumestre DO‡, Fraulin FO‡, Yeung JK‡
† University of Calgary, Canada
‡ Section of Plastic Surgery, Department of Surgery, University of Calgary, Canada
1 Chan N, Charette J, Dumestre DO, Fraulin FO. Should 'smart phones' be used for patient photography? Plast Surg (Oakv). 2016;24(1):32-4.
2 Unpublished - Heyns M, Steve A, Dumestre DO, Fraulin FO, Yeung J. Canadian Guidelines on Smartphone Clinical Photography.
CMA CODE OF ETHICS AND PROFESSIONALISM
A compassionate physician recognizes suffering and vulnerability, seeks to understand the unique circumstances
of each patient and to alleviate the patient’s suffering, and accompanies the suffering and vulnerable patient.
An honest physician is forthright, respects the truth, and does their best to seek, preserve, and communicate
that truth sensitively and respectfully.
A humble physician acknowledges and is cautious not to overstep the limits of their knowledge and skills or the
limits of medicine, seeks advice and support from colleagues in challenging circumstances, and recognizes the
patient’s knowledge of their own circumstances.
A physician who acts with integrity demonstrates consistency in their intentions and actions and acts in a
truthful manner in accordance with professional expectations, even in the face of adversity.
A prudent physician uses clinical and moral reasoning and judgement, considers all relevant knowledge
and circumstances, and makes decisions carefully, in good conscience, and with due regard for principles of
exemplary medical care.
The CMA Code of Ethics and Professionalism articulates the ethical and professional commitments and responsibilities of the
medical profession. The Code provides standards of ethical practice to guide physicians in fulfilling their obligation to provide
the highest standard of care and to foster patient and public trust in physicians and the profession. The Code is founded on
and affirms the core values and commitments of the profession and outlines responsibilities related to contemporary medical
In this Code, ethical practice is understood as a process of active inquiry, reflection, and decision-making concerning what
a physician’s actions should be and the reasons for these actions. The Code informs ethical decision-making, especially in
situations where existing guidelines are insufficient or where values and principles are in tension. The Code is not exhaustive;
it is intended to provide standards of ethical practice that can be interpreted and applied in particular situations. The Code and
other CMA policies constitute guidelines that provide a common ethical framework for physicians in Canada.
In this Code, medical ethics concerns the virtues, values, and principles that should guide the medical profession, while
professionalism is the embodiment or enactment of responsibilities arising from those norms through standards,
competencies, and behaviours. Together, the virtues and commitments outlined in the Code are fundamental to the ethical
practice of medicine.
Physicians should aspire to uphold the virtues and commitments in the Code, and they are expected to enact the professional
responsibilities outlined in it.
Physicians should be aware of the legal and regulatory requirements that govern medical practice in their jurisdictions.
Trust is the cornerstone of the patient–physician relationship and of medical professionalism. Trust is therefore
central to providing the highest standard of care and to the ethical practice of medicine. Physicians enhance
trustworthiness in the profession by striving to uphold the following interdependent virtues:
A. VIRTUES EXEMPLIFIED BY THE ETHICAL PHYSICIAN
B. FUNDAMENTAL COMMITMENTS OF THE MEDICAL PROFESSION
Consider first the well-being of the patient; always act to benefit the patient and promote the good of the patient.
Provide appropriate care and management across the care continuum.
Take all reasonable steps to prevent or minimize harm to the patient; disclose to the patient if there is a
risk of harm or if harm has occurred.
Recognize the balance of potential benefits and harms associated with any medical act; act to bring about
a positive balance of benefits over harms.
Commitment to the well-being of the patient
Promote the well-being of communities and populations by striving to improve health outcomes and
access to care, reduce health inequities and disparities in care, and promote social accountability.
Commitment to justice
Practise medicine competently, safely, and with integrity; avoid any influence that could undermine
your professional integrity.
Develop and advance your professional knowledge, skills, and competencies through lifelong learning.
Commitment to professional integrity and competence
Always treat the patient with dignity and respect the equal and intrinsic worth of all persons.
Always respect the autonomy of the patient.
Never exploit the patient for personal advantage.
Never participate in or support practices that violate basic human rights.
Commitment to respect for persons
Contribute to the development and innovation in medicine through clinical practice, research, teaching,
mentorship, leadership, quality improvement, administration, or advocacy on behalf of the profession or
Participate in establishing and maintaining professional standards and engage in processes that support
the institutions involved in the regulation of the profession.
Cultivate collaborative and respectful relationships with physicians and learners in all areas of medicine
and with other colleagues and partners in health care.
Commitment to professional excellence
Value personal health and wellness and strive to model self-care; take steps to optimize meaningful
co-existence of professional and personal life.
Value and promote a training and practice culture that supports and responds effectively to colleagues in
need and empowers them to seek help to improve their physical, mental, and social well-being.
Recognize and act on the understanding that physician health and wellness needs to be addressed at
individual and systemic levels, in a model of shared responsibility.
Commitment to self-care and peer support
Value and foster individual and collective inquiry and reflection to further medical science and to
facilitate ethical decision-making.
Foster curiosity and exploration to further your personal and professional development and insight; be
open to new knowledge, technologies, ways of practising, and learning from others.
Commitment to inquiry and reflection
C. PROFESSIONAL RESPONSIBILITIES
The patient–physician relationship is at the heart of the practice of medicine. It is a relationship of trust that recognizes the
inherent vulnerability of the patient even as the patient is an active participant in their own care. The physician owes a duty of
loyalty to protect and further the patient’s best interests and goals of care by using the physician’s expertise, knowledge, and
prudent clinical judgment.
In the context of the patient–physician relationship:
1. Accept the patient without discrimination (such as on the basis of age, disability, gender identity or expression, genetic
characteristics, language, marital and family status, medical condition, national or ethnic origin, political affiliation, race,
religion, sex, sexual orientation, or socioeconomic status). This does not abrogate the right of the physician to refuse to
accept a patient for legitimate reasons.
2. Having accepted professional responsibility for the patient, continue to provide services until these services are no longer
required or wanted, or until another suitable physician has assumed responsibility for the patient, or until after the
patient has been given reasonable notice that you intend to terminate the relationship.
3. Act according to your conscience and respect differences of conscience among your colleagues; however, meet your
duty of non-abandonment to the patient by always acknowledging and responding to the patient’s medical concerns and
requests whatever your moral commitments may be.
4. Inform the patient when your moral commitments may influence your recommendation concerning provision of, or
practice of any medical procedure or intervention as it pertains to the patient’s needs or requests.
5. Communicate information accurately and honestly with the patient in a manner that the patient understands and can
apply, and confirm the patient’s understanding.
6. Recommend evidence-informed treatment options; recognize that inappropriate use or overuse of treatments or
resources can lead to ineffective, and at times harmful, patient care and seek to avoid or mitigate this.
7. Limit treatment of yourself, your immediate family, or anyone with whom you have a similarly close relationship to
minor or emergency interventions and only when another physician is not readily available; there should be no fee for
8. Provide whatever appropriate assistance you can to any person who needs emergency medical care.
9. Ensure that any research to which you contribute is evaluated both scientifically and ethically and is approved by a
research ethics board that adheres to current standards of practice. When involved in research, obtain the informed
consent of the research participant and advise prospective participants that they have the right to decline to participate
or withdraw from the study at any time, without negatively affecting their ongoing care.
10. Never participate in or condone the practice of torture or any form of cruel, inhuman, or degrading procedure.
Physicians and patients
11. Empower the patient to make informed decisions regarding their health by communicating with and helping the patient
(or, where appropriate, their substitute decision-maker) navigate reasonable therapeutic options to determine the best
course of action consistent with their goals of care; communicate with and help the patient assess material risks and
benefits before consenting to any treatment or intervention.
12. Respect the decisions of the competent patient to accept or reject any recommended assessment, treatment, or plan of
13. Recognize the need to balance the developing competency of minors and the role of families and caregivers in medical
decision-making for minors, while respecting a mature minor’s right to consent to treatment and manage their personal
14. Accommodate a patient with cognitive impairments to participate, as much as possible, in decisions that affect them;
in such cases, acknowledge and support the positive roles of families and caregivers in medical decision-making and
collaborate with them, where authorized by the patient’s substitute decision-maker, in discerning and making decisions
about the patient’s goals of care and best interests.
15. Respect the values and intentions of a patient deemed incompetent as they were expressed previously through advance
care planning discussions when competent, or via a substitute decision-maker.
16. When the specific intentions of an incompetent patient are unknown and in the absence of a formal mechanism for
making treatment decisions, act consistently with the patient’s discernable values and goals of care or, if these are
unknown, act in the patient’s best interests.
17. Respect the patient’s reasonable request for a second opinion from a recognized medical expert.
Physicians and the practice of medicine
Patient privacy and the duty of confidentiality
18. Fulfill your duty of confidentiality to the patient by keeping identifiable patient information confidential; collecting,
using, and disclosing only as much health information as necessary to benefit the patient; and sharing information only
to benefit the patient and within the patient’s circle of care. Exceptions include situations where the informed consent of
the patient has been obtained for disclosure or as provided for by law.
19. Provide the patient or a third party with a copy of their medical record upon the patient’s request, unless there is a
compelling reason to believe that information contained in the record will result in substantial harm to the patient or
20. Recognize and manage privacy requirements within training and practice environments and quality improvement
initiatives, in the context of secondary uses of data for health system management, and when using new technologies in
21. Avoid health care discussions, including in personal, public, or virtual conversations, that could reasonably be seen as
revealing confidential or identifying information or as being disrespectful to patients, their families, or caregivers.
Medical decision-making is ideally a deliberative process that engages the patient in shared decision-making and is informed
by the patient’s experience and values and the physician’s clinical judgment. This deliberation involves discussion with the
patient and, with consent, others central to the patient’s care (families, caregivers, other health professionals) to support
In the process of shared decision-making:
22. Recognize that conflicts of interest may arise as a result of competing roles (such as financial, clinical, research,
organizational, administrative, or leadership).
23. Enter into associations, contracts, and agreements that maintain your professional integrity, consistent with evidenceinformed
decision-making, and safeguard the interests of the patient or public.
24. Avoid, minimize, or manage and always disclose conflicts of interest that arise, or are perceived to arise, as a result of
any professional relationships or transactions in practice, education, and research; avoid using your role as a physician to
promote services (except your own) or products to the patient or public for commercial gain outside of your treatment role.
25. Take reasonable steps to ensure that the patient understands the nature and extent of your responsibility to a third party
when acting on behalf of a third party.
26. Discuss professional fees for non-insured services with the patient and consider their ability to pay in determining fees.
27. When conducting research, inform potential research participants about anything that may give rise to a conflict of
interest, especially the source of funding and any compensation or benefits.
28. Be aware of and promote health and wellness services, and other resources, available to you and colleagues in need.
29. Seek help from colleagues and appropriate medical care from qualified professionals for personal and professional
problems that might adversely affect your health and your services to patients.
30. Cultivate training and practice environments that provide physical and psychological safety and encourage help-seeking
31. Treat your colleagues with dignity and as persons worthy of respect. Colleagues include all learners, health care partners,
and members of the health care team.
32. Engage in respectful communications in all media.
33. Take responsibility for promoting civility, and confronting incivility, within and beyond the profession. Avoid impugning
the reputation of colleagues for personal motives; however, report to the appropriate authority any unprofessional
conduct by colleagues.
34. Assume responsibility for your personal actions and behaviours and espouse behaviours that contribute to a positive
training and practice culture.
35. Promote and enable formal and informal mentorship and leadership opportunities across all levels of training, practice,
and health system delivery.
36. Support interdisciplinary team-based practices; foster team collaboration and a shared accountability for patient care.
Physicians and self
Physicians and colleagues
Managing and minimizing conflicts of interest
38. Recognize that social determinants of health, the environment, and other fundamental considerations that extend
beyond medical practice and health systems are important factors that affect the health of the patient and of
39. Support the profession’s responsibility to act in matters relating to public and population health, health education,
environmental determinants of health, legislation affecting public and population health, and judicial testimony.
40. Support the profession’s responsibility to promote equitable access to health care resources and to promote resource
41. Provide opinions consistent with the current and widely accepted views of the profession when interpreting scientific
knowledge to the public; clearly indicate when you present an opinion that is contrary to the accepted views of the
42. Contribute, where appropriate, to the development of a more cohesive and integrated health system through interprofessional
collaboration and, when possible, collaborative models of care.
43. Commit to collaborative and respectful relationships with Indigenous patients and communities through efforts
to understand and implement the recommendations relevant to health care made in the report of the Truth and
Reconciliation Commission of Canada.
44. Contribute, individually and in collaboration with others, to improving health care services and delivery to address
systemic issues that affect the health of the patient and of populations, with particular attention to disadvantaged,
vulnerable, or underserved communities.
Approved by the CMA Board of Directors Dec 2018
37. Commit to ensuring the quality of medical services offered to patients and society through the establishment and
maintenance of professional standards.
Physicians and society
The CMA’s stance on intervention and judicial advocacy is to bring an evidence-based perspective to assist in relation to the decision-making of issues at hand.
CMA’s strategic plan and guiding principles opens the possibility that there may be circumstances when legal advocacy, and in particular judicial advocacy, may be leveraged strategically and proactively as a further tool in CMA’s advocacy toolbox to bring a non-partisan, evidence-based perspective to the courtroom that would further the organization’s vision for “a vibrant professional and a healthy population”.
Purpose and Scope of Policy
Given CMA 2020, and informed by knowledge of past experiences, the purpose of this policy is to provide guidelines to assist with decision making as to whether CMA should use legal action, as part of its advocacy toolbox, to move CMA’s work forward on a cause or issue.
Cases Deemed Appropriate for CMA Judicial Advocacy – General Principles
1. Stage and Venue of Proceedings
a) Generally, CMA will only engage in a proposed case at an appellate level or in the highest forum in which a matter is likely to be finally decided.
b) Exceptionally, the CMA may engage in a proposed case at a lower court or a court of first instance where:
i) circumstances justify engagement, such as an invitation from the court or where physicians’ expertise is necessary to create a trial record that supports the CMA’s policy position(s) or provides added relevant information that is not otherwise being provided or would highlight a critical issue that requires attention or would attract the attention of relevant parties.
c) Exceptionally, CMA may leverage international fora (e.g., United Nations treaty bodies) where involvement could help advance a specific cause or issue being championed by the CMA.
2. CMA’s Role in Proceedings
With some rare exceptions , , the CMA will only assume the role of intervener in a proposed case. The CMA will intervene where the CMA may bring a non-partisan, evidence-based analysis to an issue and where there are compelling reasons for doing so, considering the evaluation criteria contained in the Reference Guide in Appendix 1 of this policy.
3. Relevance to Existing CMA Policy
a) The CMA may engage in a proposed case where engagement would constitute a significant contribution to the consideration of the issue or issues involved and only when the position sought to be advanced is:
i. supported by and consistent with previously adopted policy of CMA; or
ii. a matter of compelling public or professional interest which the Board of Directors then adopts as CMA policy following appropriate consultation.
b) Where there is CMA policy that is clear, relevant to the proposed case and a matter of record, the policy should be cited and explained (e.g., in factum or affidavit).
c) If the CMA’s proposed stance in a case proceeding supports a position which the CMA has not previously adopted as policy, the CMA Board of Directors must adopt the position as policy before authorizing the activity.
4. Issue of National, Special and/or Unifying Significance to Profession
a) The CMA will generally only engage in a proposed case of special and unifying significance to the medical profession.
b) The CMA will not engage in a proposed case where the matter is only of local or regional concern or of a private nature with no public interest or compelling professional or public policy component.
5. Potential Case Outcome(s) and Effect(s)
Prior to engagement, the CMA must consider the potential impact(s) (both favourable and unfavourable) of the legal precedent that may set by the proposed case on members of the medical profession and patients.
6. Collaboration with Provincial/Territorial Associations, Affiliates and other Organizations
a) In the spirit of community building and collaborating with those who share our vision, the CMA welcomes opportunities to collaborate with provincial or territorial associations, affiliates and other organizations provided that these Guidelines are followed and that the other organizations
i. share positions on the issues at stake in the case that are consistent with CMA policy.
ii. can follow through on tasks, deadlines and communication needs related to collaboration.
b) While not mandatory, CMA would expect mutual assistance in funds and in kind when it collaborates with another organization (in relation to a judicial proceeding) or is asked to intervene.
7. Reputational Risk and Stakeholder Relations Implications
The CMA will consider as a general principle whether involvement in a proposed case:
a) may present the CMA with reputational risk(s) (e.g., inconsistent with mission and values, controversial, too political).
b) may impact relations with other stakeholders, including provincial/territorial medical associations, associates, affiliates and other organizations.
8. Financial and Resource Implications
The CMA will consider as a general principle the financial and resource implications of involvement in a proposed case such as the affordability of the proceeding, or competing demands for limited resources and staff availability. To the extent possible, the CMA will seek pro bono external legal assistance.
Authorization to Engage in Judicial Advocacy
CMA’s Senior Management Team will generally perform a preliminary analysis of the proposal to engage in a proposed case and may use the Reference Guide appended to these guidelines as a decision-making tool (see Appendix 1). The decision to engage in a proposed case must be ultimately authorized by the CMA Board of Directors. Once the Board has authorized the application, CMA staff will follow established internal protocol and procedures in the preparation of the required documentation according to the appended Working Draft Protocol (see Appendix 3). CMA staff will regularly provide the CMA Board with updates of the Court proceeding.
Appendix 1: Reference guide for determining if appropriate for CMA to engage in judicial advocacy on a matter, in accordance with CMA Guidelines on Judicial Advocacy
Degree to which criterion favours proposed judicial advocacy initiative
(please provide reasons for choice)
Somewhat favours Mildly favours Does not favour
Stage and venue of proceedings
Court of highest level?
If yes, mark as “strongly favours”
If yes, mark as “somewhat favours”
If not court of highest level or other appellate court, indicate jurisdiction
Relevance of matter to existing CMA policy
Is matter consistent with previously adopted policy?
Is matter of compelling public interest that may be adopted as policy?
Is matter of compelling professional interest that may be adopted as policy?
Issue of National, Special or Unifying Significance to the Profession
Does matter have impact beyond local/regional level?
Does matter have special or unifying significance for medical profession?
Collaboration or Request for Involvement
Other request for involvement?
Stakeholder relations implications
Appendix 2: Contents of Request for CMA to Intervene
1. Requests for CMA to intervene in court proceedings can arrive from multiple sources (internally – CMA Board, CMA provincial or territorial associations, affiliates, another organization, an individual member, etc.). CMA’s Legal Services Department may also monitor judicial developments and identify cases of special interest to CMA.
2. Unless there are exceptional circumstances, the request for CMA to intervene in a court proceeding shall contain the following:
(i) The style or caption of the case, identification of the last court to render a decision in the case and the court in which it is proposed to intervene. A copy of the decision or order appealed from, any accompanying reasons and other relevant documentation must be attached to (or linked from) the proposal;
(ii) The date by which the proposed application for leave to intervene and factum must be filed;
(iii) The issues before the Court and potential outcomes, dissenting views and likelihood of success, including policy implications for CMA depending on the various outcomes;
(iv) The position sought to be advanced on CMA’s behalf and how this position is consistent with existing CMA policy. If there is no existing CMA policy, the request should state why CMA should adopt the policy prior to intervention;
(v) If the request relates to a local or regional matter, an explanation of how the position to be taken is not inconsistent with CMA policy and the broader interests and concerns of CMA;
(vi) Consultations undertaken, if any, on why the matter warrants CMA intervention as a compelling issue of public policy and special interest to the medical profession;
(vii) A list of other organizations that might have an interest in the intervention or co-intervening with CMA;
(viii) Disclosure of any personal or professional interest, in the matter on the part of any individual or organization participating in the decision to seek the Board of Directors’ authorization to intervene; and
(ix) Budget development.
3. Where the request to intervene arises in a case where there is no existing CMA policy on the issue, the party making the request should demonstrate the urgency and importance of adopting the policy position to be advanced.
Appendix 3: Working Draft Protocol and Procedures for Court Intervention Document
CMA staff will prepare the application documents for leave to intervene in concert with expert litigation legal counsel.
Depending on the issues before the Court, the President or Chair or the CMA Board may review the contents of the application documents for leave to intervene and the actual factum prior to filing with the Court. Alternatively, the application documents and factum will be shared as information items with the CMA President and Board after filing. The decision to obtain the President and/or Chair and/or Board approval or not prior to filing lies with the CMA CEO.
CMA staff may also consult with the President and Chair on the choice of individual filing the affidavit (called the “affiant”) on CMA’s behalf. The affiant will in most circumstances be a physician, usually at the elected level, with experience and expertise on the issues before the Court.
All CMA Departments will consult with and co-ordinate with the CMA Legal Department. For example, the content of any Communication Strategy documents (e.g. press releases, media alerts, news articles, etc.) as part of the court proceeding must be consistent with the contents of CMA’s application for leave to intervene documents and factum.
Approved by the CMA Board of Directors Dec 2018
These Guidelines constitute an implementation tool of seven recommendations and are informed by Guidelines for CMA’s Activities and Relationships with Other Parties (aka CMA’s Corporate Relationships Policy) and CMA’s Advertising and Sponsorship Policy.
These Guidelines apply to the Canadian Medical Association (and not to its subsidiaries). As these are Guidelines, exceptions may be necessary from time to time wherein staff may use their discretion and judgment.
Endorsement is an umbrella term encompassing “policy endorsement”, “sponsorship1” and “branding”.
Policy endorsement includes:
(a) CMA considering upon request, non-pecuniary public approval, which may include the use of
CMA’s name and/or logo, of an organization’s written policy, on an issue that aligns with CMA policy, where there is no immediate expectation of return; or,
(b) CMA adopting the policy of another organization as our policy; or
(c) CMA asking another organization to publicly support our policy.
(a) Criteria: For policy endorsement requests from another organization to endorse their policy2 the following criteria shall be applied:
i) we have a policy on the subject-matter and
ii) we are actively working on advancing that policy position and
iii) the organization has a follow-up action plan associated with its request.
(b) Approval: Where policy exists, approval requires a policy staff member (with portfolio responsibility) and the VP of Medical Professionalism, or the policy staff member (with portfolio responsibility) and the Chief Policy Advisor. Where no policy exists, approval of the Board of Directors is required.
(c) Annual confirmation: Where CMA adopts the policy of another organization3, CMA staff shall confirm annually, or more frequently if circumstances dictate, that the policy has not been altered by the other organization.
(d) Requests: Pursuit of personal endorsement requests are not appropriate. Wherever possible, requests should come from an organization and not an individual.
(a) Where CMA adopts the policy of another organization, the adopted policy shall become CMA policy, and will include a notation on the document as being an adopted policy of [organization].
(b) All adopted policies will be housed in an accessible searchable database.
(c) All requests by organizations for CMA to endorse their policy will be tracked in a central location, along with any response.
1 Sponsorship means, to consider upon request, pecuniary public approval, which may include the use of CMA’s name and/or logo, of an organization’s event (eg., conference), on an issue that is supported by CMA policy or that promotes CMA brand awareness, where there is an immediate expectation of return.
2 That is, part (a) of the definition in Section 2.
3 That is, part (b) of the definition in Section 2.
Industrialization and manufacturing have had enormous positive benefits for humankind, but the consequences of hazardous by-products (chemical contamination) to human health and the environment are less well recognized. A major incident such as Bhopal is an unequivocal example of catastrophic poisoning caused by industry. However, more subtle human health impacts can result from low levels of exposure to chemical and industrial by-products from agriculture, consumer products, manufacturing, and even medical sources. Chemicals from industrial sources have been found in the soil, water, air, food and human tissue. Due to improving technology, even minuscule amounts of potentially noxious substances can be detected.
Some exposures warrant remedial action, but in others the health impact may be negligible: the toxin, dose, route and duration of exposure must be considered. Of course, there are potentially toxic substances that have been found to pose little or no harm to human health, but there are many more for which the health effects are unknown. A substantial knowledge gap exists in that the effects of many chemical agents have not been fully studied. As a result, rigorous surveillance and assessment to ensure potential health impacts are reduced or avoided is necessary. Chemicals like dichlorodiphenyltrichloroethane (DDT) can persist in the environment or in living beings long after the product was pulled from the market, making it essential that full and rigorous testing of new and existing chemicals is undertaken. Finally, research is needed to determine whether emerging issues, such as the presence of pharmaceuticals in drinking water, pose a legitimate threat to human health.
Chemicals, properly managed, can and will continue to provide enormous benefits to society, but caution is warranted because of the potential health consequences. Provided below is a discussion of certain classes of chemicals that need to be regulated, monitored and properly researched.
Agriculture represents the largest component of the global economy. Rising pressures to meet the needs of a growing population have resulted in the mechanization of farming, and the widespread use of fertilizers and pesticides.1 Fertilizer and pesticide run-off has been found in soil, water and the human food supply.2 Approximately 40 chemicals classified by the International Agency for Research on Cancer (IARC) as known, probable, or possible human carcinogens, are EPA registered pesticides available on the open market.3 Long-term low dose pesticide exposure has been linked to various cancers, immune suppression, hormonal disruption, reproductive abnormalities, birth defects, and developmental and behavioural problems.4 Certain pesticides are also known to be persistent in the human body.5 While many individual pesticides can be safely used, there is a lack of research on the effect of certain pesticides when used in combination.
Modern technologies have led to advances with a positive impact on the quality of human life. While newer consumer products have benefits over earlier materials, their use is not without side effects. Both the chemicals used to make these products and those that form key components of the products themselves may be harmful. Bisphenol A (BPA) is an industrial chemical added to many hard plastic bottles and to metal based food and beverage cans since the 1960s.6 In August 2010, Statistics Canada reported that measurable levels of BPA were found in the urine of 91 per cent of Canadians aged six to 79.7 Concerns have been raised about effects on the brain, behaviour, and prostate gland from exposure to this chemical, particularly in fetuses, infants, and children.8 In 2008, Canada banned BPA in infant bottles.9 In October 2010, Canada went a step further by becoming the first jurisdiction in the world to declare BPA toxic.10
With the growing demand for consumer products, there has been a corresponding growth in manufacturing. Manufacturing is one of the biggest contributors to outdoor air pollution, and contributes to soil and water pollution.11 In 2004, US industry released 1.8 billion pounds of potentially toxic chemicals. Exposure to some of these chemicals has been linked to severe health effects, including cancer. 12 One of the released chemicals, dioxin, can be harmful at very low levels. Dioxins accumulate in fats and break down slowly. This leads to contamination of the food supply, and human exposure through the consumption of meat, dairy, fish and shellfish.13 Even in the far north, animals have been found to contain dioxins.14 The EPA estimates that the cancer risk from dioxins already present in the general public is 1-per-1,000.15 In most cases the emissions pose minimal risk to human health. However, chemicals, and chemical combinations which remain unstudied should be properly assessed.16
Advancements in medical science and the use of pharmaceuticals, diagnostic equipment and other medical treatments have prolonged life expectancy. However, these interventions can also contribute to environmental contamination. In 2008, the Associated Press reported pharmaceuticals in the water of 24 major metropolitan areas in the United States, serving 41 million people.17 There is a concern that these pharmaceuticals could negatively impact male fertility, lead to birth defects, cause breast and testicular cancer in humans, and lead to antibiotic resistance.18 For many pharmaceuticals found in water sources, no concerted environmental impact surveys have been carried out.19
Mercury is used in fever thermometers, sphygmomanometers, gastrointestinal tubes, and oesophageal dilators20. Reports indicate that medical waste incinerators are among the largest sources of anthropogenic mercury emissions in both the United States and Canada.21 Medical waste, while not the principle source of mercury poisoning, contributes to the mercury levels present in the environment. In fetuses, infants and children, low-dose exposure to mercury can cause severe and lifelong behavioural and cognitive problems.22 At higher exposure levels, mercury may adversely affect the kidneys, the immune, neurological, respiratory, cardiovascular, gastrointestinal, and haematological systems of adults.23 It has also been linked to cancer.24
These examples highlight the major categories of human exposure to chemicals. As the review suggests, some of these chemicals have been linked to harmful human health impacts. What is important to keep in mind, however, is that the harm is conditional on the level and lengths of exposure. For most people, these chemicals pose no harm because the exposure is so low. In some cases, such as BPA, it has been determined that the potential harm is not worth the risk: the Canadian government has decided to declare BPA toxic and regulate it accordingly. In other cases, such as pharmaceuticals, the evidence simply warrants further study and surveillance. Given the potential harm to human health, surveillance and research are vitally important in all categories. The more information that is available to policy makers and health care professionals, the better the chance of limiting human health impacts.
What has been done?
Concerns regarding chemical contamination and human health have led to numerous interventions from the international community. These include the International Programme on Chemical Safety (1980), the Inter-Organization Programme for the Sound Management of Chemicals (1995), the Globally Harmonized System of Classification and Labelling (2002), and the Strategic Approach to International Chemicals Management, which was adopted by governments and stakeholders at the first International Conference on Chemicals held in Dubai in 2006. 25
Various conventions have also been passed, including the Stockholm Convention (2004) on persistent organic pollutants such as DDT, and the Rotterdam Convention (2004) which applies to pesticides and industrial chemicals.26 There is some concern about the continued effectiveness of the Rotterdam convention. In 2006, the Canadian government was instrumental in preventing the listing of asbestos as a toxic chemical. Given the persuasive evidence of the harm caused by asbestos, this action undermines the legitimacy of voluntary international conventions.27
In addition to being a signatory to all international agreements listed above, the Canadian government has programs for chemical management domestically. The main tool is the Canadian Environmental Protection Act (CEPA) 1999. Jointly administered by Environment Canada and Health Canada, it is intended to prevent pollution and address the potentially dangerous chemical substances to which Canadians are exposed.28 The plan calls for increased surveillance of certain chemicals to monitor exposure and health effects, and will increase focus on the management of the health and environmental risks of pharmaceuticals, personal care products, and chemical contamination in food.29
There were 23,000 chemical substances on the Domestic Substances List (DSL) in Canada in 1999. To date, only about 1,000 of these chemicals have been fully assessed. Of the remaining 22,000, 85% have been categorized as not requiring any additional action.30The most recent Canadian Chemicals Management Plan states that full assessments will be done on 550 substances identified as potentially harmful. Even with these additional assessments, more than 3,000 chemicals will not have been assessed.
Canadian Medical Association
In 2009, the Canadian Medical Association and the Canadian Nurses Association released a joint position statement on environmentally responsible activity for the health-care sector. Recommendations included the proper handling and disposal of toxic chemicals and the reduction of products using these substances. An adapted version of this position statement was then endorsed by a coalition of 12 national healthcare organizations and the David Suzuki Foundation.
In October 2010, the World Medical Association, of which CMA is a member, adopted a policy statement on environmental degradation and the management of chemicals. The statement calls for mercury-free health care, support for international efforts to restrict chemical pollution and to monitor harmful chemicals in humans and the environment, and mitigation of the health effects of toxic exposure to chemicals.
What needs to be done?
Research and Surveillance
Research on chemicals produced through man-made activities remains insufficient. While some of the more toxic chemicals have been reviewed and are now more closely regulated, thousands remain that have had neither health nor environmental assessments. The Domestic Substances List in Canada has 3,300 chemicals of concern that have not been assessed. There is limited research on the effect of these chemicals in combination or in different mediums. Finally, work must be done to ensure environmental and human surveillance of potential chemical exposure threats.
1. Urges the government to complete the health and environmental assessment of the chemicals on the Domestic Substances List.
2. Encourages research on the health impacts of chemical substances, as well as the combinations of these substances in different products (e.g. pesticides), and in different mediums (e.g. pharmaceuticals in drinking water). Long-term research programs are required to determine health impacts from prolonged low-dose exposures.
3. Encourages ongoing surveillance of chemicals in the environment.
4. Encourages ongoing research on the impact of regulations and monitoring of chemicals on human health and the environment.
Regulations have been developed both internationally and domestically to undertake chemical management. However, gaps remain, largely due to the voluntary nature of the frameworks. Canada can play a lead role by respecting its commitments, seeking continued adherence to these agreements and providing leadership in developing effective domestic programs and legislation.
5. Urges the government to continue to support international efforts to manage chemical pollution. In particular CMA urges the government to fully support the principles of the Rotterdam Convention and support the listing of Asbestos as an Annex III toxic chemical.
6. Supports government legislation and regulation which reduces dangerous chemical pollution, detects and monitors harmful chemicals in both humans and the environment, mitigates the health effects of toxic exposures, and requires an environmental and health impact assessment prior to the introduction of a new chemical. Regulatory frameworks should be favoured over voluntary frameworks in order to ensure a level playing field for all manufacturers and to secure rapid and equitable health protection for all Canadians. CMA encourages the government to advocate for similar legislation internationally.
Physicians can participate in the monitoring of patients for potential health effects from chemical exposure. Additionally, physicians can be leaders in encouraging greener health care practices. Finally, physicians can support national medical organizations in developing clinical tools to assess patient risk to chemical exposure.
7. Supports the phase out of mercury and other persistent, bio-accumulating and toxic chemicals in health care devices and products.
8. Supports the development of effective and safe systems to collect and dispose of pharmaceuticals that are not consumed.
9. Supports the development of clinical tools for physicians to help assess their patients' risk from chemical exposures.
Education and Professional Development
Physicians have a role to play in educating their patients, the public, and current and future colleagues about the potential human health consequences of chemical contamination. Medical education and continuing professional development in this area could have a significant impact on human health.
10. Should assist in building professional and public awareness of the impact of the environment and global chemical pollutants on personal health.
11. Supports the development of locally appropriate continuing medical education on the clinical signs, diagnosis and treatment of diseases that are introduced into communities as a result of chemical pollution.
12. Encourages physicians to inform patients about the importance of safe disposal of pharmaceuticals that are not consumed.
National and International initiatives have substantially reduced the incidence of harmful chemical contamination, but more work is needed. Evidence of health effects (or lack thereof) may be strong for certain chemicals, but for others it remains incomplete. Given the dangers of chemicals such as dioxin, which can cause severe effects with small doses, more comprehensive research is warranted. To ensure human health consequences are identified and risks are minimized, improved surveillance is essential.
Further policies and regulations are needed to ensure that chemicals utilized are as safe as possible. The Canadian BPA ban demonstrates the use of the precautionary principle in the presence of convincing if not complete evidence. While there are clear benefits associated with the use of chemicals, it is necessary to ensure that potential harmful effects are considered.'
Finally, public and health care provider information is sorely lacking. Physicians can play a role in correcting some of these deficiencies through their actions to support research and surveillance, advocacy, leadership, education, and professional development.
1 Ongley, Edwin D. (1996) Control of water pollution from agriculture- FAO irrigation and drainage paper 55.Chapter 1: Introduction to agricultural water pollution Food and Agriculture Organization of the United Nations. Available at: http://www.fao.org/docrep/w2598e/w2598e00.HTM
2 Peters, Ruud J.B. (2006) Man-Made Chemicals in Food Products. TNO Built Environment and Geosciences. Available at: http://assets.panda.org/downloads/tno_report.pdf
3 Reuben, Suzanne H. (2010) Reducing Environmental Cancer Risk: What We Can Do Now: 2008-2009 Annual Report. President's Cancer Panel. Available at: http://deainfo.nci.nih.gov/advisory/pcp/annualReports/pcp08-09rpt/PCP_Report_08-09_508.pdf
4 Reuben, Suzanne H. (2010) Reducing Environmental Cancer Risk...; Shah, Binod P. & Bhupendra Devkota (2009) "Obsolete Pesticides: Their Environmental and Human Health Hazards." The Journal of Agriculture and Environment. Vol:10 June 2009. Available at: http://www.nepjol.info/index.php/AEJ/article/view/2130/1961 ; Kjellstrom, Tord et.al. (2006) Chapter 43: Air and Water Pollution: Burden and Strategies for Control in Disease Control Priorities in Developing Countries. Disease Control Priorities Project. Available at: http://files.dcp2.org/pdf/DCP/DCP43.pdf
5 California Environmental Protection Agency (2002) Environmental Protection Indicators for California: Chapter 3: Environmental Exposure Impacts Upon Human Health. Available at: http://oehha.ca.gov/multimedia/epic/2002reptpdf/Chapter3-7of8-HumanHealth.pdf
6 United States Food and Drug Administration (2010) Update on Bisphenol A for Use in Food Contact Applications. Available at: http://www.fda.gov/newsevents/publichealthfocus/ucm064437.htm
7 CBC News (October 13, 2010) BPA declared toxic by Canada. Available at: http://www.cbc.ca/health/story/2010/10/13/bpa-toxic.html
8 States Food and Drug Administration (2010) Update on Bisphenol A...
9 Health Canada (2008) Government of Canada Protects Families with Bisphenol A Regulations Available at: http://www.hc-sc.gc.ca/ahc-asc/media/nr-cp/_2008/2008_167-eng.php
10 CBC News (October 13, 2010) BPA declared toxic by Canada...
11 Kjellstrom, Tord et.al. (2006) Chapter 43: Air and Water Pollution...
12 Cassady, Alison & Alex Fidis (2007) Toxic Pollution and Health: An Analysis of Toxic Chemicals Released in Communities across the United States. U.S. PIRG Education Fund. Available at: http://cdn.publicinterestnetwork.org/assets/KTfes5EXnCLOgG9eWTKU6g/ToxicPollutionandHealth2007.pdf
13 World Health Organization (2010) Dioxins and their effects on human health. Available at: http://www.who.int/mediacentre/factsheets/fs225/en/index.html
14 Woolford, Julian & Noemi Cano Ed. (2006) Killing them softly...
15 Cassady, Alison & Alex Fidis (2007) Toxic Pollution and Health...
17 Natural Resources Defense Council (2010) Dosed Without Prescription: Preventing Pharmaceutical Contamination of Our Nation's Drinking Water. Available at: http://www.nrdc.org/health/files/dosed4pgr.pdf
18 Wright-Walters, Maxine & Conrad Volz (2009) Municipal Wastewater Concentrations of Pharmaceutical and Xeno-Estrogens: Wildlife and Human Health Implications. Available at: http://www.chec.pitt.edu/Exposure_concentration_of_Xenoestrogen_in_pharmaceutical_and_Municipal_Wastewater__Final8-28-07%5B1%5D.pdf; Daughton, Christian G. (N.D.) Pharmaceuticals and the Environment. Available at: www.epa.gov/osp/regions/emerpoll/daughton.ppt; Nikolaou, Anastasia; Meric, Sureyya & Despo Fatta (2007) "Occurrence patterns of pharmaceuticals in water and wastewater environments." Analytical and Bioanalytical Chemistry. 387: 1225-1234; Natural Resources Defense Council (2010) Dosed Without Prescription...
19 Daughton, Christian G. (N.D.) Pharmaceuticals and the Environment...
20 Environment Canada. (N.D.)Mercury and the Environment. Available at: http://www.ec.gc.ca/MERCURY/SM/EN/sm-mcp.cfm#MD
21 Health Care Without Harm (2007) The Global Movement for Mercury Free Health Care. Available at: http://www.noharm.org/lib/downloads/mercury/Global_Mvmt_Mercury-Free.pdf; World Health Organization (2005) Mercury in Health Care: Policy Paper. Available at: http://www.who.int/water_sanitation_health/medicalwaste/mercurypolpaper.pdf
22 Environmental Working Group (N.D.) Chemical Pollution: The Toll on America's Health. Available at: http://www.ewg.org/files/EWG-kid-safe-toll-on-health.pdf
23 California Environmental Protection Agency (2002) Environmental Protection Indicators...
24 Reuben, Suzanne H. (2010) Reducing Environmental Cancer Risk...
25 World Health Organization (N.D.) International Programme on Chemical Safety: About us. Available at: http://www.who.int/ipcs/en/; World Health Organization (N.D.) Inter-Organization Programme for the Sound Management of Chemicals. Available at: http://www.who.int/iomc/brochure/brochure_english.pdf; United Nations Economic Commission for Europe (N.D.) Globally Harmonized System of Classification and Labelling of Chemicals (GHS). Available at: http://www.unece.org/trans/danger/publi/ghs/ghs_welcome_e.html; Weinberg, Jack (2008) An NGO Guide to SAICM: The Strategic Approach to International Chemicals Management. Available at: http://www.ipen.org/ipenweb/documents/book/saicm%20introduction%20english.pdf
26 Eskenazi, Brenda et.al. (2009) "The Pine River Statement: Human Health Consequences of DDT Use." Environmental Health Perspectives. 117:1359-1367 Available at: http://www.eoearth.org/article/Human_Health_Consequences_of_DDT_Use#gen4; World Health Organization (N.D.) Rotterdam Convention: Share Responsibility. Available at: http://www.pic.int/home.php?type=t&id=5&sid=16
27 Kazan-Allen, Laurie (2007) Rotterdam Treaty Killed by Chrysotile Asbestos! International Ban Asbestos Secretariat. Available at: http://www.ibasecretariat.org/lka_rott_meet_geneva_oct_06.php
28 Government of Canada (2007) The Canadian Environmental Protection Act, 1999 (CEPA 1999). Available at: http://www.chemicalsubstanceschimiques.gc.ca/about-apropos/cepa-lcpe-eng.php
29 Government of Canada (2010) Chemicals Management Plan. Available at: http://www.chemicalsubstanceschimiques.gc.ca/plan/index-eng.php
FETAL ALCOHOL SPECTRUM DISORDER (UPDATE 2009)
Fetal Alcohol Spectrum Disorder (FASD) is a leading cause of environment-related birth defects and developmental disabilities in North America. The Canadian Medical Association (CMA) believes that the prudent choice for women who are or may become pregnant is to abstain from alcohol, and encourages their partners to support them in this endeavour. The CMA urges Canadian governments to enact legislation that requires alcoholic beverages sold in Canada to be labelled with warnings of the hazards of consuming alcohol during pregnancy. The CMA also calls upon the federal government to examine the role that advertising plays in promoting the consumption of alcoholic beverages and to review existing policies and regulations in this area.
Fetal alcohol spectrum disorder (FASD) is an umbrella term used to describe the range of disabilities and diagnoses that result from drinking alcohol during pregnancy. It is estimated that more than 3,000 babies in Canada are born with FASD every year.
Those who live with FASD may have mild to very severe problems with their health. They may have delays in their development, intellectual problems and problems in their social lives. Examples of these include:
* skeletal abnormalities such as facial deformities
* physical disabilities such as kidney and internal organ problems
* depression or obsessive-compulsive disorder
* difficulty understanding the consequences of their actions
These disabilities are lifelong and those affected may need lifelong support.
The drinking patterns of teenagers and the potential for women of reproductive age to consume alcohol mean that the health care system must actively address the prevention of FASD. Also, alcohol use may play a considerable role in unplanned pregnancy and inadequate prenatal and postnatal care.
The CMA strongly supports all activities that encourage Canadians to moderate their alcohol consumption. The association encourages the public to be aware of the issues related to alcohol consumption, particularly the adverse effects on the fetus.
In a continued effort to support the reduction of alcohol consumption, the CMA urges Canadian governments to enact legislation that requires alcoholic beverages sold in Canada to be labelled with warnings of the hazards of alcohol consumption during pregnancy.1 Appropriate agencies should also adopt regulations and/or policies to ensure that warnings about the adverse interaction between alcohol and both prescription and non-prescription products are prominently displayed or distributed wherever alcohol and drugs are sold or dispensed.2 The CMA also calls upon the federal government to examine the role that advertising plays in promoting the consumption of alcoholic beverages and to review existing policies and regulations in this area.
The adverse effects of alcohol consumption by pregnant women are preventable. The CMA believes that the prudent choice for women who are or may become pregnant is to abstain from alcohol and encourages their partners to support them in this endeavour. Physicians should use appropriate screening methods to identify alcohol use in their patients. Physicians can play a leading role in educating and counselling women, spouses and family members about the dangers of alcohol to the fetus. The CMA also recommends that alcohol and drug addiction treatment services give high priority to the needs of pregnant women seeking help.
1 General Council resolution 89-67: That the Canadian Medical Association urge Governments in Canada to enact legislation requiring that all alcoholic beverages sold in Canada be labelled with warnings on the hazard from the consumption of alcohol during pregnancy. Note: this motion was rescinded because it was superseded by the Policy on Fetal Alcohol Syndrome (2000).
2 General Council resolution 87-31
Flexibility in Medical Training (Update 2009)
The Canadian Medical Association (CMA) believes that the medical training system must be sufficiently flexible to enable medical students to make informed career choices, accommodate resident program changes, and allow practising physicians the opportunity to re-enter training to enhance their skills and knowledge, or to enter a new sphere of practice. The system must also be able to accommodate international medical graduates (IMGs) to provide them with a reasonable opportunity to attain their postgraduate credentials and become licensed to practise in Canada. For physicians-in-training, effective career guidance and positive influences on career options (e.g., role modelling, early clinical exposure, etc.) may foster confidence with career path selection and minimize program changes during residency. A flexible and well-designed re-entry postgraduate system would be characterized by: long-term stability, sufficient and appropriate capacity, accessibility, flexibility in the workforce and accountability.
The CMA believes that, ultimately, society benefits from a flexible medical training system. These benefits may include enhanced patient care, improved access to physician services, as well as physician retention, particularly in rural and remote communities. A flexible system may also improve morale and satisfaction among students, residents and physicians, and facilitate better career choices. This policy outlines specific recommendations to help create and maintain a well-designed system for flexibility in physician training in Canada. Commitment and action by all stakeholders, including governments, medical schools, regulatory authorities and others, is required.
The CMA believes that this policy must be considered in the context of other relevant CMA policies, including but not limited to the CMA's policies on physician resource planning, physician health and well-being, physician workforce issues and others.
- Postgraduate trainee - Also known as a "resident," an individual who has received his/her MD degree and is currently enrolled in an accredited program in a Canadian school of medicine that would lead to certification by either the College of Family Physicians of Canada or the Royal College of Physicians and Surgeons of Canada.
- Medical student - An individual enrolled in an undergraduate program in a Canadian school of medicine that would lead to an MD degree.
- International medical graduate - An individual who received his/her MD degree from a training program other than from one of Canada's undergraduate schools of medicine.
- Designated positions - Postgraduate positions within the determined complement of residency positions that are identified to meet a need other than that of accommodating the annual number of new graduates of Canadian medical schools to complete the usual training for certification and licensure. Designated positions may be identified for a variety of purposes.
The need for informed career decision-making and positive influences
Choice of practice discipline as lifelong career can be one of the most difficult aspects of physician training. Exacerbating this challenge are the vast array of available specialties, timing of choices, as well as practice considerations in terms of lifestyle and physician resource needs. The rapidly changing face of medical practice as well as the limited amount of information and time available to consider options, are also contributing factors.
A number of other forces, both positive and negative, may affect students' choices of practice specialty. These can include financial considerations in light of student debt incurred by high tuition fees and insufficient financial support. 12 The biases of faculty, family and others may also impact decisions. In addition, limited training opportunities in general, as well as a lack of flexibility to switch training programs, may also restrict choice of practice specialty. While a myriad of personal factors are acknowledged to also play contributing roles in influencing program selection, these issues are too complex to discuss here. Ultimately, students need to have access to financial support so as to reduce stress and the influence of debt on specialty choice. They also need objective information and guidance and broad clinical experiences early in their medical training as this has been identified as a critical factor in making decisions about their future careers.3
The rotating internship, abolished in the early 1990s, used to permit residency selection at a later stage in medical training. The residency program match now takes place during the final year of undergraduate studies. As a consequence of this earlier timing, some students feel pressured to make their specialty choice too early in their medical education and often before their clerkship has even begun. This can include focusing research and program electives4 in one specific area, rather than sampling a broad range of disciplines, to demonstrate conviction of choice to residency program directors at the time of the match. Fifty-nine percent of respondents to the Canadian Resident Matching Service's (CaRMS) 2006 post-match survey indicated they completed more than half of their electives in their first-choice discipline.5 This, combined with the early timing of the residency match, can lead to an uninformed choice of residency program and the realization, at a later date, that a different training program would be more suitable. Eighty percent of medical leader respondents to the 2008 Core Competency Project survey indicated that timing of career choice was the biggest challenge for career decision-making.6
Those residents who wish to change to new training programs may not believe they have the opportunity to do so. Thirty-seven percent of resident respondents to the Core Competency Project survey considered switching disciplines during their residency training7 and 39% had spoken to a faculty member about switching programs.8 Others who do change programs are ultimately delayed entry into the workforce as a result of their prolonged training. This problem is exacerbated by an insufficient number of re-entry postgraduate training positions and large debt that confine trainees to a single career path.
Lack of student confidence and preparedness in choosing a postgraduate training program, or lack of success in achieving a first choice in the postgraduate match, may predict subsequent program changes. A broad range of strategies must be available to help medical students make informed career choices. These include a wider choice of electives at an earlier stage of training, positive and unbiased mentoring experiences, improved access to career information from residents, as well as career seminars and other resources.
In light of the above, the CMA recommends that:
1. the undergraduate medical school curriculum be re-designed to facilitate informed career choice and, in particular, to ensure that students enjoy a broad range of clinical experiences before they have to choose a specific discipline (i.e., via CaRMS match);
2. national career counselling curricula for both medical students and residents be developed and include the following components: national standardization; stakeholder input (students, residents and others); positive and fair role modelling by both residents and practising physicians/faculty, with appropriate professional respect among medical disciplines; and formal and informal mentorship programs;
3. a wide-range of elective opportunities be developed and communicated at a national level;
4. electives reflect a broad spectrum of experiences, including community-based opportunities;
5. clinical experiences be introduced at the earliest possible stage of undergraduate learning;
6. a national policy be implemented to ensure mandatory diversification of student elective experiences; and
7. medical schools be permitted and encouraged to model alternate systems of postgraduate learning.
The need for broad-based medical education
In order to provide medical students with the greatest options for flexibility in medical training, they should be actively encouraged to pursue a broad-based medical education. Previously, CMA advocated for a common postgraduate year (PGY1). In the 2008 Core Competency Project survey, 77% of physician respondents, 70% of medical student respondents and 67% of program director respondents expressed support for first year residents to do a broad-based common PGY1-like rotating internship.9 The rationale for and importance of ensuring flexibility has been outlined in the previous sections.
Capacity of the postgraduate training system
An essential component in ensuring flexibility within the medical training system is to establish and maintain sufficient capacity at the postgraduate training level. This is necessary for the following reasons:
* Sufficient capacity may prevent highly-skilled and well-trained Canadian physicians from being forced to seek postgraduate training in the U.S. and remain there to practise medicine.
* It is necessary to provide IMGs with a reasonable opportunity to attain their postgraduate credentials and become licensed to practise in Canada. This reflects the CMA's recognition of the important contribution that IMGs have made, and continue to make, in the provision of medical services, teaching and research in Canada. Opportunities for IMGs will also permit Canadians who study medicine abroad to pursue their medical careers in Canada.
* It is essential to provide students with sufficient choice to seek the training that best matches their skills and interests as well as societal demands.
* It is crucial to provide sufficient re-entry positions to allow practising physicians to seek training in other areas of medicine to meet the demands of their communities. [Please refer to the "Re-entry" section of this policy for more details.]
In light of the above, the CMA recommends that:
8. mechanisms be developed to permit reasonable movement of residents within the overall residency structure and career counselling supports be made available to residents considering such a change;
9. the capacity of the postgraduate training system be sufficiently large to accommodate the needs of the graduating cohort, the re-entry cohort, and the training needs of international medical graduates;
10. there be a clearly defined pool of re-entry postgraduate positions and positions for international medical graduates;
11. government match and maintain undergraduate medical enrolment with a target of at least 120 ministry-funded postgraduate training positions per 100 Canadian medical graduates, to accommodate the training needs of the graduating cohort, the re-entry cohort and international medical graduates; and
12. options be explored for influencing governments to support a flexible postgraduate medical education system that also meets societal needs.
Re-entry medical training system
Note: This section addresses only one kind of designated position, specifically, those for licensed physicians wishing to re-enter training after a period in practice (also known as "re-entry positions"). The re-entry positions addressed in this paper would require no return for service. Designated positions for training in return for service in a specified discipline and location is a separate entity from general re-entry.
Increased opportunity for exposure to the breadth of medical fields in undergraduate training, improved undergraduate career counselling and a postgraduate system that makes the changing of disciplines easier are some of the many aspects that should facilitate residents' satisfaction with career choice. There will, however, inevitably be individual cases where issues of societal need, personal health, lifestyle or personal choice necessitate a change in career direction after postgraduate training. This requires the availability of additional postgraduate positions allotted specifically to this sub-set.
A sufficient and stable supply of re-entry positions is needed within the postgraduate training system to enable practising physicians to enhance their skills or re-enter training in another discipline. While this may apply mostly to family physicians and general practitioners wishing to train in a specialty discipline, it can also include practising specialists wanting to sub-specialize or train in another area, which could be Family Medicine.
The additional or new training of primary care physicians, particularly in obstetrics, emergency medicine, anaesthesia, surgery, psychiatry and general internal medicine, will be of benefit to smaller communities lacking regular access to these specialty medical services. In addition, the availability of adequate re-entry positions may encourage new physicians to accept locum tenens, thus relieving overworked physicians in underserviced communities. Potentially, it could help to increase a community's long-term retention rate of established physicians.
The CMA believes that a well-designed re-entry system for Canadian postgraduate medical education would be characterized by an accessible national registry, long-term stability, sufficient and appropriate capacity, accessibility, flexibility in the workforce and accountability.
Medical students need reassurance that re-entry positions will be available if they wish to re-enter training after a period in practice. This will enable them to better plan their careers, reduce anxieties about career selection and ultimately help to meet the health care needs of society. For physicians re-entering the postgraduate training system, there must also be the guarantee that sufficient program funding will be available to ensure completion of training.
The CMA therefore recommends that:
13. a complement of clearly defined, permanent re-entry positions with stable funding be a basic component of the Canadian postgraduate training system and that the availability of these positions be effectively communicated to potential candidates; and
14. funding for re-entry positions be specifically allocated for the entire training period.
The CMA believes that the capacity of the postgraduate training system must be sufficiently large to accommodate the needs of the re-entry cohort and that postgraduate re-entry positions should be supernumerary to the numbers required for the graduating cohort. [Please refer to the "Capacity of the Postgraduate Training System" section of this policy for specific recommendations.]
The CMA believes that re-entry physicians should not be restricted to competing for particular disciplines for which there is an identified need in their jurisdiction. Re-entry physicians should also be able to compete for any available disciplines across all training programs. Not every discipline will be available for re-entry each year but all should be accessible over the course of a three-year period.
The CMA therefore recommends that:
15. there be accessibility within re-entry postgraduate training positions including:
* open and fair competition at the national level among all re-entry candidates for the clearly defined pool of re-entry positions,
* that the mix of positions available reflect the overall mix of positions in the postgraduate training system, and
* recognizing the limited size of the re-entry pool, access to all specialties be available over a three-year period rather than on an annual basis; and
16. access to entry should be possible through both national and regional pools of re-entry positions, with a process comparable to that currently used for the postgraduate training system.
Flexibility in the Workforce
As previously mentioned, the re-entry positions discussed in this paper would require no return for service. Designated positions for training in return for service in a specified discipline and location is a separate entity from general re-entry.
The CMA therefore recommends that:
17. physicians who have retrained through the re-entry system have the same practice opportunities as physicians entering the workforce for the first time.
The CMA recognizes the importance of public accountability and sound fiscal management and therefore recommends that:
18. there be on-going evaluation of the re-entry system in Canadian postgraduate medical education.
1 Kwong JC, Dhalla IA, Streiner DL, Baddour RE, Waddell AE & IL Johnson. Effects of rising tuition fees on medical school class composition and financial outlook. CMAJ 2002; 166 (8): 1023-8.
2 2007 National Physician Survey Data.
3 Directions for Residency Education, 2009 - A final report of the Core Competency Project. February 2009. Royal College of Physicians and Surgeons of Canada and College of Family Physicians of Canada.
4 Ibid, page 23.
6 Ibid, page 59.
7 Ibid, page 27.
8 Ibid, page 60.
FUNDING THE CONTINUUM OF CARE
The continuum of care may be defined as the array of health services that spans the range over the life course from primary care (including prevention and health promotion) through institutionally based secondary and tertiary care to community and home-based services that promote health maintenance, rehabilitation and palliation at the end of life. Given the ever-increasing diversity of service offerings and providers, and aging populations, governments worldwide face the ongoing challenge of what to fund for whom.
After a lengthy period of examination that began in the 1930s, Canada arrived at a social consensus on universal, first-dollar coverage provision of hospital (1957)1 and physician (1966)2 services. All provinces bought into "Medicare" by the early 1970s and the 1984 Canada Health Act (CHA)3 was the capstone of the national hospital and medical insurance program, adding the principle of accessibility, which effectively prohibited user charges for insured hospital and physician services.
Notwithstanding the more recent legislation, the foundation of Medicare was set in the health and health care reality of 1957. Hospital and medical services accounted for two-thirds of health spending (65%).4 Prescription drugs accounted for just 6% of spending, less than half of their 14.6% share in 2008. Life expectancy was almost a decade shorter than it is today, hence there was less concern about long-term care. The first knee replacement was not done until a decade later. The 1957 Hospital and Diagnostic Services Act specifically excluded tuberculosis hospitals, sanitaria and psychiatric hospitals as well as nursing homes/homes for the aged. These exclusions carried forward to the CHA.
By all accounts the CHA has taken on an iconic status, but at the same time it is agreed that it is an impediment to modernizing Medicare through its definitions and program criteria and how they are interpreted by the provinces and territories. The CHA narrowly defines insured health services as "hospital services, physician services and surgical dental services provided to insured persons." While the CHA recognizes "extended" health services such as home care and ambulatory health care services, these are not subject to the program criteria.
Over the years, the CHA has been extremely effective in preserving the publicly funded character of physician and hospital services. As of 2008, the Canadian Institute for Health Information (CIHI) has estimated that 98.4% of physician and 90.7% of hospital expenditures are publicly funded.5 The dividing line of the CHA may be seen in virtually all other categories of service. Fewer than one-half of prescription drugs (44.5%) and less than one-tenth (6.9%) of the services of other health professionals (e.g., dentistry and vision care) are publicly covered. Canada is unique among industrialized countries in its approach to Medicare. Countries with social insurance (Bismarck) funded systems tend to provide a similar total level of public expenditure over a wider range of services.
Over time, as health care has moved from institutions to the community, the CHA is diminishing with respect to the share of total health spending it covers. At the time the CHA was passed, physician and hospital services represented 57% of total health spending; this has declined to 41% as of 2008. It must be emphasized that there is significant public spending beyond CHA-covered services (in excess of 25% of total spending) for programs such as seniors' drug coverage and home care; however, those programs are not subject to the CHA's program criteria. In addition, they can be subject to arbitrary cutback. While a majority of the working age population and their families are covered by private health insurance, those with lower incomes are less likely to have such benefits. Since the late 1990s, notwithstanding the widely shared concern about the sustainability of Canada's Medicare program, several high profile studies have advocated for its expansion, starting with the 1997 Report of the National Forum on Health6 and latterly with the Kirby7 and Romanow8 reports in 2002, both of which strongly recommended home care and catastrophic drug coverage. There is also growing concern about the availability of so-called "orphan drugs" that treat rare diseases such as Fabry disease, and can cost hundreds of thousands of dollars per patient for a single year of treatment.
First Ministers have concluded three health accords in 20009, 200310 and 200411, each of which addresses expanding the boundaries of Medicare. To date there are a series of unfulfilled commitments from these accords, including a national basket of home care services and first-dollar coverage for home care and catastrophic drug coverage. In its 2007 report, the Health Council of Canada summarized progress on catastrophic drug costs as "disappointing."12
There is no appetite among governments in Canada to implement new universal programs with first-dollar coverage. In fact, recently governments have removed services that had previously been publicly insured, as evidenced by recent examples such as physiotherapy and chiropractic services in some jurisdictions.
The CMA puts forward the following principles for funding the continuum of care in a national context, recognizing that there will continue to be a mix of public-private funding.
* Canadians should take personal responsibility to plan ahead for the contingency that they may eventually require support with their activities of daily living;
* home care and long-term care should be delivered in appropriate and cost-effective settings that respect patient and family preferences;
* there should be quality and accreditation standards for both public and private service delivery;
* there should be uniform approaches to needs assessment for home care and long-term care;
* there should be a uniform means of distinguishing the medically necessary component of home care and long-term care from the accommodation component;
* there should be a means of mitigating against open-ended public coverage of pharmaceutical, home care and long-term care coverage;
* there should be recognition and financial support for informal care givers;
* there should be consideration of risk-pooling, risk adjustment and risk sharing1 between public and private funders/providers of pharmaceutical, home care and long-term care coverage;
* there should be a uniform approach to individual/household cost-sharing (e.g., copayments and deductibles); and
* provision should be made for pre-funding long-term care from public and private sources.
Prevention and Health Promotion
The continuum of care begins with prevention and this requires a strong public health foundation that includes the core elements of population health assessment, health surveillance, health promotion, disease and injury prevention and health protection.13 An investment in public health, including health promotion and disease prevention, is critical to the future health of Canadians.
One important component of effective prevention is immunization. The National Immunization Strategy was implemented in 2001 with the goal of reducing vaccine preventable diseases and improving vaccine coverage rates. The 2004 federal budget allocated $400 million to support this strategy and in 2007, $300 million was set aside in the federal budget for a Human Papillomavirus Immunization program. However, permanent funding should be allocated towards immunization programs for all illnesses that are preventable through vaccinations.
The federal government also has a role to play in establishing and promoting partnerships that will enhance prevention and promotion programming down to the local level.
The CMA recommends that:
the federal government continue funding of the national immunization strategy consistent with the original three-year funding program;
governments fund appropriate additions to the vaccination schedule, as new vaccines are developed, within the context of a national immunization strategy; and
the federal government establish a Public Health Infrastructure Renewal Fund ($350 million annually) to build partnerships between all levels of government to build capacity at the local level.
Prescription drugs are the fastest growing item in the health envelope. Over the past two decades, prescription drugs as a proportion of total health spending have doubled from 7% in 1986 to an estimated 14.6% in 2008, and they are now the second largest category of health expenditure. It is estimated that less than one-half (44.5%) of prescription drug costs were paid for publicly in 2008; just over one-third (37.1%) were paid by private insurers and almost one-fifth (18.4%) out-of-pocket.
The studies reported in 2002 by the Senate Standing Committee on Social Affairs, Science and Technology (Kirby) and by the Commission on the Future of Health Care in Canada (Romanow) have forged a consensus on the need for "catastrophic" pharmaceutical coverage, which may be defined as out-of-pocket prescription drug expenditures that exceed a certain threshold of household income.
In the Kirby proposal, in the case of public plans, personal prescription drug expenses for any family would be capped at 3% of total family income. The federal government would then pay 90% of prescription drug expenses in excess of $5,000. In the case of private plans, sponsors would have to agree to limit out-of-pocket costs to $1,500 per year, or 3% of family income (whichever is less). The federal government would then agree to pay 90% of drug costs in excess of $5,000 per year. Both public and private plans would be responsible for the difference between out-of-pocket and $5,000, and private plans would be encouraged to pool their risk. Kirby estimated that this plan would cost approximately $500 million per year. For his part, Romanow recommended a Catastrophic Drug Transfer through which the federal government would reimburse 50% of the costs of provincial and territorial drug insurance plans above a threshold of $1,500 per year. Romanow estimated that this would cost approximately $1 billion.
The National Pharmaceuticals Strategy (NPS) has continued to explore cost projections of catastrophic pharmaceutical coverage, leaning toward a variable percentage threshold linked to income but there has been no public reporting on progress since 2006.14 At their September 2008 meeting, provincial/territorial health ministers called for the federal government to be an equal partner (50/50) to support a national standard of pharmacare coverage so that prescription drug costs will not exceed 5% (on average) of the net income base of provincial/territorial populations. The total estimated cost of such a program for 2006 was estimated at $5.03 billion.15
Data from Statistics Canada indicate that there is wide variation in levels of household spending on prescription drugs in Canada. In 2006 almost one in twenty (3.8%) households in Canada spent more than 5% of net income on prescription drugs; there was almost a five-fold variation across the provinces, ranging from 2.2% in Ontario to 10.1% in Prince Edward Island.16
Canada does not have a nationally coordinated policy in the area of very costly drugs that are used to treat rare diseases. Moreover, there is also an issue of expensive drugs that may be used for common diseases (wide variation has been documented across provinces/territories).
Thus far the term "catastrophic" has been used by First Ministers and the NPS to describe their vision of national pharmaceutical coverage. As defined by the World Health Organization catastrophic expenditure reflects a level of out-of-pocket health expenditures so high that households have to cut down on necessities such as food and clothing and items related to children's education.17 From the CMA's perspective, this does not go far enough and what must be strived for is "comprehensive" coverage that covers the whole population and effectively pools risk across individuals and public and private plans in various jurisdictions.
The CMA recommends that:
governments, in consultation with the life and health insurance industry and the public, establish a program of comprehensive prescription drug coverage to be administered through reimbursement of provincial/territorial and private prescription drug plans to ensure that all Canadians have access to medically necessary drug therapies;
such a program should include the following elements:
* a mandate for all Canadians to have either private or public coverage for prescription drugs;
* a uniform income-based ceiling (between public and private plans and across provinces/territories) on out-of-pocket expenditures on drug plan premiums and/or prescription drugs (e.g., 5% of after-tax income);
* FPT cost-sharing of prescription drug expenditures above a household income ceiling, subject to capping the total federal and/or provincial/territorial contributions either by adjusting the federal share of reimbursement or by scaling the household income ceiling or both;
* group insurance plans and administrators of employee benefit plans to pool risk above a threshold linked to group size; and,
* a continued strong role for private supplementary insurance plans and public drug plans on a level playing field (i.e., premiums and co-payments to cover plan costs);
the federal government establish a program for access to expensive drugs for rare diseases where those drugs have been demonstrated to be effective;
the federal government assess the options for risk pooling to cover the inclusion of expensive drugs in public and private drug plan formularies;
the federal government provide adequate financial compensation to the provincial and territorial governments that have developed, implemented and funded their own public prescription drug insurance plans;
governments provide comprehensive coverage of prescription drugs and immunization for all children in Canada; and
the Canadian Institute for Health Information and Statistics Canada conduct a detailed study of the socio-economic profile of Canadians who have out-of-pocket prescription drug expenses to assess barriers to access and to design strategies that could be built into a comprehensive prescription drug coverage program.
Home care began in Canada in the late 19th century as a charitable enterprise delivered by non-profit groups such as the Victorian Order of Nurses. In the expansionary period of the 1960s and 1970s, governments moved increasingly into this area. The New Brunswick Extra-Mural Program, arguably Canada's most successful/ambitious home care program, accepted its first clients in 1981. The Established Programs Financing Act of 1977 recognized home care as one of several extended health services and included a fund initially set at $20 per capita to cover such services. These extended services are also recognized in the CHA but are not subject to the five program criteria (principles). The 1997 Report of the National Forum on Health recommended that home care be added to Medicare (along with pharmacare). The $150 million Health Transition Fund supported several demonstration projects in the home care area. Both the Kirby and Romanow reports recommended expanded home care funding. In February 2003, First Ministers concluded an accord in which they committed to determine a basket of home care services by 30 Sept. 2003, covering short-term acute home care, community mental health and end-of-life care. To date this has not happened. The federal government implemented a Compassionate Care Benefit in 2003 to support family caregivers; however, this only applies to those who are in the paid labour force.18
According to the Canadian Institute for Health Information, there is almost a five-fold variation in the use of home care across provinces/territories.19 The extent of private expenditure on home care services is not presently known. However, Statistics Canada has reported that the proportion of Canadians living in the community who require assistance with their personal activities of eating, bathing and dressing who are receiving government-subsidized home care declined from 46% in 1994-1995 to 35% in 2003; the suggestion is that some of the burden may have shifted to home care agencies or family and friends.20 Statistics Canada has reported that in 2002, over 1.7 million adults aged 45 to 64 provided informal care to almost 2.3 million seniors with long-term disabilities or physical limitations.21
In light of the foregoing, the CMA believes that:
optimal management of the continuum of care requires that patients take an active part in developing their care and treatment plan, and in monitoring their health status;
the issue of the continuum of care must go beyond the question of financing and address questions related to the organization of the delivery of care and to the shared and joint responsibilities of individuals, communities and governments in matters of health care and promotion, prevention and rehabilitation;
support systems should be established to allow elderly and disabled Canadians to optimize their ability to live in the community;
strategies should be implemented to reduce wait times for accessing publicly funded home and community care services;
integrated service delivery systems should be created for home and community care services; and
any request for expanding the public plan coverage of health services, in particular for home care services and the cost of prescription drugs, must include a comprehensive analysis of the projected cost and potential sources of financing for this expansion.
The CMA recommends that:
governments adopt a policy framework and design principles for access to publicly funded medically necessary services in the home and community setting that can become the basis of a "Canada Extended Health Services Act;"
governments initiate a national dialogue on the Canada Health Act in relation to the continuum of care;
governments and provincial/territorial medical associations review physician remuneration for home and community-based services; and
governments undertake pilot studies to support informal caregivers and long-term care patients, including those that:
a) explore tax credits and/or direct compensation to compensate informal caregivers for their work,
b) expand relief programs for informal caregivers that provide guaranteed access to respite services in emergency situations,
c) expand income and asset testing for residents requiring assisted living and long-term care, and
d) promote information on advance directives and representation agreements for patients.
Mental Health Care
In 2000 mental illness was the fourth-ranking contributor to the total economic burden of illness in Canada.22 The exclusion of psychiatric hospitals from the CHA means that they are not subject to the five principles and were not included in the original basis of the federal transfer payments. While a major Senate Committee report has pointed out that the closure of psychiatric facilities means that this exclusion is no longer pertinent, the Committee also noted that many essential services for persons with mental illness such as psychological services or out-of-hospital drug therapies are not covered under provincial health insurance plans.23 Moreover, there remain 53 psychiatric hospitals in Canada.24
The CMA recommends that:
the federal government make the legislative and/or regulatory amendments necessary to ensure that psychiatric hospital services are subject to the five program criteria of the Canada Health Act;
in conjunction with legislative and/or regulatory changes, funding to the provinces/territories through the Canada Health Transfer be adjusted to provide for federal cost sharing in both one-time investment and ongoing cost of these additional insured services; and
Canadian physicians and their organizations advocate for parity of allocation of resources (relative to other diseases) toward the continuum of mental health care and research.
According to Statistics Canada's most recent population projections, the proportion of seniors in the population (65+) is expected to almost double from its present level of 13% to between 23% and 25% by 2031.25 The Organization for Economic Cooperation and Development has projected that the share of Gross Domestic Product devoted to long-term care will at least double from its 2005 level of 1.2% to 2.4% by 2050, and could almost triple to (3.2%) depending on the success of efforts to contain cost.26
The potential need for long-term care is not confined to the senior population. Based on the results of its 2006 Participation and Activity Limitation Survey, Statistics Canada estimated that there were 2 million adults aged 15-64 with disabilities, of whom 40% were severely disabled; in addition there were 202,000 children with disabilities, of whom 42% were severely disabled.27
A lack of appropriate long term care is imposing a bottleneck in the acute care system. The term Alternate Level of Care (ALC) is used to describe a situation when a patient is occupying a bed in a hospital and does not require the acute care provided in this setting. According to a 2009 CIHI report, in 2007-08, there were more than 74,000 ALC patients and more than 1.7 million ALC hospital days in Canada (excluding Manitoba and Quebec), accounting for 5% of hospitalizations and 14% of hospital days. In other words, every day almost 5,200 beds in acute care hospitals were occupied by ALC patients28.
This has significant consequences; emergency departments are being used as holding stations while admitted patients wait for a bed to become available, surgeries are being postponed, and the care for ALC patients may not be as good as it might be in an alternate site that is better equipped to suit their specific needs. Insufficient access to long term care at all ages is an obstacle to improving the health care system. Major investment is required in community and institutionally based care.
Most of the discussion in Canada since the mid-1990s has focused on the sustainability of the current Medicare program and the prospect for enhancements such as pharmacare. There has been little attention since the early 1980s on the future funding of long-term care. Internationally, in contrast, the United Kingdom has had a Royal Commission on long-term care, and Germany has moved to put in place a contributory social insurance fund.
A cursory assessment of the literature would suggest that there is a consensus that long-term care cannot/should not be financed on the same pay-as-you-go basis (i.e., current expenditures funded out of current contributions) as medical/hospital insurance programs.
The federal government has several options available to promote the pre-funding of long-term care:
Long-term care insurance: Policies are offered in Canada and are of fairly recent origin. There has been little take-up of such policies to date. At the end of 2005, about 52,700 Canadians were covered under long-term care insurance. One option could be to make long-term care insurance premiums deductible through a tax credit, similar to what Australia has done for private health insurance.
Tax-deferred savings: The Registered Retirement Savings Plan (RRSP) has been a very popular method for Canadians to save for retirement. As of 2007, an estimated 7 out of 10 (68%) of Canadians reported having an RRSP. However, in 2002, just 27% of all tax returns filed in Canada reported deductions for RRSP contributions. In 1998, Segal proposed a Registered Long-term Care Plan that would allow Canadians to save against the possibility of their need for a lengthy period of care. Another option to consider would be to add a provision to RRSPs similar to the Lifelong Learning Plan and the Home Buyer's Plan. This would be referred to as the Long-term Care Plan and would allow tax-free withdrawals from RRSPs to fund long-term care expenses for either the RRSP investor's own care or their family members' care.
Tax-prepaid saving: In Canada, the Registered Education Savings Plan (RESP) is an example of a plan whereby after-tax earnings are invested and allowed to grow tax-free until they are distributed and included in the recipient's income. In the 2007 federal budget, the government announced the introduction of a Registered Disability Savings Plan. Parents and guardians will be able to contribute to a lifetime maximum of $200,000 and similar to the RESP program there will be a related program of disability grants and bonds, scaled to income. This approach could have more general applicability to long-term care. The 2008 federal budget has introduced a tax-free savings account (TFSA) that, starting in 2009, enables those 18 and over to contribute up to $5,000 per year in after-tax income to a TFSA, whose investment growth will not be taxed; however, funds can be withdrawn at any time for any purpose29.
Payroll deduction (Social Insurance): A compulsory payroll tax that would accumulate in a separate fund along the lines of the Canada Pension Plan has been recommended in provincial reports in Quebec and Alberta.
In summary, whatever vehicle might be chosen, governments need to impress upon younger Canadians the need to exercise personal responsibility in planning for their elder years, given continuing gains in longevity.
The CMA recommends that:
governments study the options for pre-funding long-term care, including private insurance, tax-deferred and tax-prepaid savings approaches, and contribution-based social insurance; and
the federal government review the variability in models of delivery of community and institutionally based long-term care across the provinces and territories as well as the standards against which they are regulated and accredited.
The Senate of Canada, and the Honourable Sharon Carstairs in particular, have provided leadership over the last decade in highlighting both the progress and the persistent variability across Canada in access to quality end-of-life care. In the latest (2005) of three reports issued since 1995, the Senate again calls for the development of and support for a national strategy for palliative and end-of-life care.30 In that report Still Not There it is noted that it is commonly estimated that no more than 15% of Canadians have access to hospice palliative care, and that for children, the figure drops further to just over 3%. To date, palliative care in Canada has primarily centred on services for those dying with cancer. However, cancer accounts for less than one-third (30%) of deaths in Canada. Diseases at the end of life such as dementia and multiple chronic conditions are expected to become much more prevalent in the years ahead. The demand for quality end-of-life care is certain to increase as the baby boom generation ages. By 2020 it is estimated that there will be 40% more deaths per year. While there has been a decreasing proportion of Canadians dying in hospital over the past decade, many more Canadians would prefer to have the option of hospice palliative care at the end of life than current capacity will permit. In its April 2009 report, the Special Senate Committee on Aging recommended a federally funded national partnership with provinces, territories and community organizations to promote integrated quality end-of-life care for all Canadians, the application of gold standards in palliative home care to veterans, First Nations and Inuit and federal inmates, and renewed research funding for palliative care.31
The CMA recommends that:
governments work toward a common end-of-life care strategy that will ensure all Canadians have equitable access to and adequate standards of quality end-of-life care.
1 Risk pooling is defined by the World Health Organization as the practice of bringing several risks together for insurance purposes in order to balance the consequences of the realization of such individual risk. Risk adjustment and risk sharing are means of adjusting or compensating for risk differentials between risk pools.
1 Canada. Hospital Insurance and Diagnostic Services Act. Statutes of Canada 1956-57 Chap 28. Ottawa: Queen's Printer, 1957.
2 Canada. Medical Care Act 1966-67, C. 64, 5.1. Revised Statutes of Canada 1970 Volume V. Ottawa: Queen's Printer, 1970.
3 Canada. Canada Health Act. Chapter C - 6. Ottawa, 1984.
4 Hall, E. Royal Commission on Health Services, Volume 1. Ottawa: Queen's Printer, 1964.
5 Canadian Institute for Health Information. National Health Expenditure Trends 1975-2008. Ottawa, 2008.
6 National Forum on Health. Canada Health Action: Building on the legacy - Volume 1 - the final report. Ottawa: Minister of Public Works and Government Services, 1997.
7 Standing Senate Committee on Social Affairs, Science and Technology. The health of Canadians - the federal role Volume six: recommendations for reform. Ottawa, 2002.
8 Commission on the Future of Health Care in Canada. Building values: the future of health care in Canada. Ottawa, 2002.
9 Canadian Intergovernmental Conference Secretariat. First Ministers' meeting communiqué on health. September 11, 2000. http://www.scics.gc.ca/cinfo00/800038004_e.html. Accessed 09/24/09.
10 Canadian Intergovernmental Conference Secretariat. 2003 First Ministers' Accord on Health Care Renewal. February 5, 2003. http://www.scics.gc.ca/pdf/800039004_e.pdf. Accessed 08/05/08.
11 Canadian Intergovernmental Conference Secretariat. A 10-Year plan to strengthen health care. September 16, 2004. http://www.scics.gc.ca/cinfo04/800042005_e.pdf. Accessed 08/05/08.
12 Health Council of Canada. Health care renewal in Canada: Measuring up? Toronto, 2007.
13 Canadian Institutes of Health Research. The future of public health in Canada: Developing a public health system for the 21st century. Ottawa, 2003.
14 Federal/Provincial/Territorial Ministerial Task Force on the National Pharmaceuticals Strategy. National Pharmaceuticals Strategy Progress Report. June 2006. http://www.hc-sc.gc.ca/hcs-sss/alt_formats/hpb-dgps/pdf/pubs/2006-nps-snpp/2006-nps-snpp-eng.pdf. Accessed 08/05/08.
15 Canadian Intergovernmental Conference Secretariat. Backgrounder: National Pharmaceutical Strategy Decision Points. September 24, 2009. http://www.scics.gc.ca/cinfo08/860556005_e.html. Accessed 09/24/09.
16 Statistics Canada. Survey of Household Spending 2006. Detailed table 2, 62FPY0032XDB.
17 Xu K, Evans D, Carrin G, Aguilar-Riviera A. Designing health financing systems to reduce catastrophic health expenditure. Geneva: World Health Organization, 2005.
18 Service Canada. Employment insurance (EI) compassionate care benefits. http://220.127.116.11/eng/ei/types/compassionate_care.shtml. Accessed 09/24/09.
19 Canadian Institute for Health Information. Public sector expenditures and utilization of home care services in Canada: exploring the data. Ottawa, 2007.
20 Wilkins K. Government-subsidized home care. Health Reports 2006;17(4):39-42.
21 Pyper W. Balancing career and care. Perspectives on labour and income 2006;18(4): 5-15.
22 Public Health Agency of Canada. Table 2 Summary - Economic burden of illness in Canada by diagnostic category, 2000. Ottawa, 2000.
23 Standing Committee on Social Affairs, Science and Technology. Out of the shadows at last: transforming mental health, mental illness and addiction services in Canada. Ottawa, 2006.
24 Canadian Healthcare Association. September 2009.
25 Statistics Canada. Population projections. The Daily, Thursday, December 15, 2005.
26 Organization for Economic Co-operation and Development. Projecting OECD health and long-term care expenditures. What are the main drivers? Paris, 2006.
27 Statistics Canada. Participation and Activity Limitation Survey 2006: Tables. Catalogue no. 89-628-XlE-No. 003. Ottawa: Minister of Industry, 2007.
28 Canadian Institute for Health Information. Alternate level of care in Canada. Ottawa, 2009.
29 Canada Revenue Agency. Tax-free savings account (TFSA). http://www.cra-arc.gc.ca/E/pub/tg/rc4466/rc4466-e.html#P44_1114. Accessed 09/24/09.
30 Carstairs S. Still not there. Quality end-of-life care: a status report. http://sen.parl.gc.ca/scarstairs/PalliativeCare/Still%20Not%20There%20June%202005.pdf. Accessed 09/24/09.
31 Special Senate Committee on Aging. Final report: Canada's aging population: Seizing the opportunity. Apr 2009.
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.
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
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
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.