Medical publishing on the Internet: The CMA goes online

The CMA's Publications Department has created an interactive information service on the Internet, CMA Online (http://hpb1.hwc.ca:8400/), to provide physicians with rapid access to up-to-date clinical information and health care news, as well as to facilitate electronic discussion among health care professionals throughout the world and to provide information to patients. The CMA is the first national medical association in the world to do this. The service, part of the Internet's multimedia system known as the World Wide Web, is the first totally electronic product from the CMA. Because anyone with access to the Web can use the service, CMA Online will be an important vehicle for raising the profile of the medical profession in Canada and for disseminating health care information to the computer-literate public. It is tangible evidence of the CMA's commitment to provide strong leadership in the health care field.     

Core and comprehensive health care services

CMA believes that physicians must be actively involved in the decision-making process on core and comprehensive services. It has developed a new framework for this purpose after review and analysis of national and international decision-making frameworks, and after consideration of the political, policy and legal context of Canadian health care decision making. In addition to the framework, key terms associated with core and comprehensive health care services are operationally defined. Quality of care and ethical and economic factors are considered in a balanced and flexible manner, recognizing that the relative importance of any one factor may vary depending on the health care service being considered.     

E-health in Australia: time to plunge into the 21st century

E-health is the health care buzzword of the moment, with a person-controlled electronic health record funded in the 2010 federal Budget and legislation to introduce health identifiers recently passed by Parliament. E-health can ease the patient journey, improve quality of care and reduce costs. Australia's health care system lags behind all other sectors of our economy in the use of computerised systems. While general practice and community pharmacy are highly computerised, the hospital sector is not. Adopting e-health is likely to result in higher quality practice, but general practice and hospitals need a mechanism for securely sharing patient data. Uncoordinated implementation of differing, incompatible systems within and between hospitals compounds a dire lack of national coordination of effort. Multiple funding streams and jurisdictions and the lack of an implementation strategy have slowed e-health development. Government programs underestimate the costs of change management and the need for training and technology. Confusion reigns about responsibilities, but governments must ensure connectivity between health care providers and recognise that the benefits will accrue into the future. The National E-Health Transition Authority has developed national open-access standards, and its foundation projects and the National Broadband Network are now coming into place. To ensure the clinical relevance, utility, safety and acceptability of e-health systems, health professionals urgently need technical capacity and expert guidance.     

Polls point to growing gap between MDs, patients over financing of health care

An unprecedented round of CMA polling points to some startling differences in the way physicians and patients perceive the financial problems facing Canada's health care system. One poll indicates that doctors consider recent federal budget cuts a sign that the private sector will soon have a major role to play in health care financing. However, a poll of nonphysicians shows that Canadians oppose any move toward “out-of-pocket” payments for health care services, including payments for private insurance. The CMA board has responded by turning much of the 1995 annual meeting over to the topic of the future of health care in Canada, including financing, and the medical profession's response.     

Decision to make donations to political parties marks new role for CMA in federal arena

The CMA, which has generally been apolitical in its dealings with federal political parties, has decided to take a marked change in direction. It is creating a fund from which donations will be made to major political parties. It will also consider offering financial support to CMA members who are running in federal elections, and will buy seats at federal fund-raising dinners. As well, senior CMA representatives will attend national conventions of the major political parties.     

Federal budget thrusts CMA into media spotlight during 1995 Leadership Conference

The CMA's March Leadership Conference provided the forum for a debating match about the future of Canada's health care system. Two politicians, Premier Frank McKenna of New Brunswick and Diane Marleau, the federal health minister, challenged the CMA contention that the 1995 federal budget may “sound the death knell” for Canada's medicare system.     

Vehicle safety

To help reduce the number of deaths and injuries caused by vehicle accidents on Canadian roads, the CMA has for several years made recommendations on a wide range of vehicle safety standards. Since the 1960s the association has urged the provinces to enact mandatory seatbelt legislation, although it was not until 1976 that the first two provinces (Ontario and Quebec) did so. The CMA believes that the nonuse of restraint systems should be considered contributory negligence in the event of an accident producing injury to vehicle occupants. It has urged governments to approve and promote appropriate child restraint systems and to require the legislated provision of suitable and standardized tether anchorage. To increase the conspicuousness of motor vehicles the association has advocated the introduction of daytime running lights in all new vehicles. In 1965 the CMA recommended that motorcyclists wear approved helmets; indeed, it believes that there is no medical reason that would justify exemption from wearing a helmet. The CMA has also made several recommendations on safety standards for mopeds, all-terrain vehicles, minivans and light trucks and has encouraged its provincial divisions to form highway safety committees. As well as recognizing the importance of appropriate and enforced vehicle safety standards in reducing the rates of death and injury, the CMA has recommended and supported legislation aimed at decreasing the incidence of drinking and driving (Can Med Assoc J 1985; 133:806A).     

A consensus action agenda for achieving the national health information infrastructure

BackgroundImproving the safety, quality, and efficiency of health care will require immediate and ubiquitous access to complete patient information and decision support provided through a National Health Information Infrastructure (NHII).MethodsTo help define the action steps needed to achieve an NHII, the U.S. Department of Health and Human Services sponsored a national consensus conference in July 2003.ResultsAttendees favored a public–private coordination group to guide NHII activities, provide education, share resources, and monitor relevant metrics to mark progress. They identified financial incentives, health information standards, and overcoming a few important legal obstacles as key NHII enablers. Community and regional implementation projects, including consumer access to a personal health record, were seen as necessary to demonstrate comprehensive functional systems that can serve as models for the entire nation. Finally, the participants identified the need for increased funding for research on the impact of health information technology on patient safety and quality of care. Individuals, organizations, and federal agencies are using these consensus recommendations to guide NHII efforts.     

Physician referral--the AMA view

Todd and Horan present the American Medical Association's view of the problem of physician referral of patients to health facilites in which the physician has a financial interest. Studies of physician referral by the federal government and the AMA raise additional questions about the relationship between physician ownership and utilization of services. The AMA argues against banning legitimate investments, an action that it believes would adversely affect access to care, the introduction of new technology, and efforts to improve care and reduce costs. It proposes the development of clear guidelines on physician ownership and referral practices that should include: (a) standards for investment options, (b) establishment of a process to help physicians determine the legality of proposed investment in advance, and (c) establishment of a phase-in period for federal regulations and/or legislation and required divestiture.     

Resuscitation of the terminally ill

The CMA believes that there are conditions of ill health and inevitable death for which a “no resuscitation” order, signed by the attending physician, is appropriate and ethically acceptable. The association encourages physicians who are faced with the decision of writing a “no resuscitation” or “do not resuscitate” order to consider the clinical criteria and procedural guidelines in the Joint Statement on Terminal Illness. This protocol is intended as a basic, national guideline for those involved in the care of the terminally ill. Individual institutions may wish to develop their own directives as an adjunct to the national statement.     

Canadian Medicare: prognosis guarded.

Beset by unprecedented fiscal pressures, Canadian medicare has reached a crossroads. The authors review the impact of recent cuts in federal transfer payments on provincial health care programs and offer seven suggestions to policymakers trying to accommodate these reductions. (1) Go slowly: public health care spending is no longer rising and few provinces have the necessary systems in place to manage major reductions. (2) Target reductions, rewarding quality and efficiency instead of making across-the-board cuts. (3) Replace blame with praise:give health care professionals and institutions credit for their contributions. (4) Learn from the successful programs and policies already in place across the country. (5) Foster horizontal and vertical integration of services. (6) Promote physician leadership by rewarding efforts to promote the efficient use of resources. (7) Monitor the effects of cutbacks: physician groups should cooperate with government in maintaining a national "report card" on services, costs and the health status of Canadians.     

Emergency Health Planning

This paper outlines the development of emergency health planning as a function of government. Ten provinces have the basic responsibility for the organization, preparation and operation of medical, nursing, hospital and public health services in an emergency. The Department of National Health and Welfare is responsible for the provision of advice and assistance to the provincial and municipal governments in such matters. Eight provinces have now hired full-time planning staffs to co-ordinate the health planning of the Provincial Departments of Health and Provincial Emergency Measures Organization.

Four major programs have been established. The first program provides for the continuity of leadership and guidance by health authorities at the federal, provincial and municipal level. Essential records have been developed and emergency legislation prepared. This program, however, will be of little use unless health services are organized at the municipal level. In this organizational program, advice and assistance have been provided to existing hospitals and departments of health in the conduct of disaster planning. The efforts of these agencies are co-ordinated by municipal health authorities into a community disaster plan. The third program deals with information and education of the general public and the health workers. This program is designed to make the family unit self-sufficient for up to seven days and the health worker prepared to undertake his emergency role. The first three programs are directed to the organization and training of manpower; the fourth program provides the necessary supplies. From the national medical stockpile of $18,000,000, some $12,000,000 has been received, packaged for long-term storage and distributed to regional depots across the country. To ensure their ready availability in time of emergency an agreement has been reached with seven provinces for the release of hospital disaster kits.

     

Beyond universal health insurance to effective health care

The history of the U.S. governmental health care reform indicates that efforts toward universal health insurance cannot be expected from a financially strapped federal government. Ambitious governmental programs such as veterans' services and Medicaid have encountered accessibility problems associated with location, arbitrary limitations of reimbursement criteria, and opposition from taxpayers due to the higher taxes and premiums necessitated by program reform. Nonfinancial obstacles to access include physicians migration away from minorities and the poor, the strained conditions of many public hospitals, and immigrants' isolation due to language barriers and paranoia over citizenship status. Ginzberg presents interim targets for the expansion of access to health care: the expansion of Medicaid, subsidized coverage for the near poor, private sector catastrophic insurance policies, expansion of the Federal Community Health Center program, expansion of the National Health Service Corps and State Educational Debt Forgiveness Programs, and state subsidies for uncompensated care.     

Physicians and the pharmaceutical industry (update 1994). Canadian Medical Association.

The history of health care delivery in Canada has been marked by close collaboration between physicians and the pharmaceutical and health supply industries, this collaboration extending to research as well as to education. Since medicine is a self-governing profession physicians have a responsibility to ensure that their participation in such collaborative efforts is in keeping with their duties toward their patients and society. The following guidelines have been developed by the CMA to assist physicians in determining when a relationship with industry is appropriate. Although directed primarily to individual physicians, including residents and interns as well as medical students, the guidelines also govern the relationships between industry and medical associations. These guidelines focus on the pharmaceutical companies; however, the CMA considers that the same principles apply to the relationship between its members and manufacturers of medical devices, infant formulas and similar products, and health care products and service suppliers in general. These guidelines reflect a national consensus and are meant to serve as an educational resource for physicians throughout Canada.     

CMA membership survey: opinions on issues facing the medical profession

A sample survey of Canadian Medical Association (CMA) members, conducted in early summer 1985 and designed to provide information to help guide the association's activities and policies, shows that most Canadian physicians support involvement in political activities both by CMA and by indivudual physicians. A majority wishes to maintain the concept of extra/balance billing, to pursue the position that the health care system is underfunded and favours medicare premiums and hospital user fees as the preferred methods for increasing revenue.

Most respondents believe that the number of doctors in Canada is about right but would prefer any reduction to be achieved by cutting medical school admissions or reducing postgraduate training positions open to graduates of foreign medical schools.

Most of those members who know of CMA policies on a number of health care issues agree with them and also find them useful, but a significant proportion are not aware of their content.

There is support for compulsory payment of dues by all licensed physicians to both their provincial medical association and CMA. A majority would like more information on pharmaceutical products and additional membership surveys.

     

Patient care and professional staffing patterns in McKinney Act clinics providing primary care to the homeless.

OBJECTIVE--To describe the patient care and staffing patterns of the 157 clinics that receive federal funding to provide health care to the homeless. DATA SOURCES--Telephone interviews with clinic medical directors. RESULTS--Clinics treated a mean of 96 homeless patients per week, approximately 50% of the estimated homeless population. Three quarters treated homeless patients only, the others integrated homeless patients into an existing setting. One third of the clinics had no physician more than 5 hours per week, 10% had no physician staff at all, and 80% employed a nurse practitioner. The proportion of patients initially examined by a nurse practitioner and the proportion subsequently referred to a physician ranged between 10% and 100%. Clinic directors reported that in over 50% of clinics, physician recruitment was hampered by poor working conditions, inadequate salaries, physician biases against working with the homeless, and the lack of respect this work receives from the medical profession. CONCLUSIONS--Current financial constraints may be impeding the ability of clinics serving the homeless to ensure adequate access to high quality care. Additional research should evaluate the impact various staffing patterns have on access and quality of care and develop methods to improve physician recruitment.     

Visions of our Medicare future: status quo has become a dirty word in Canadian health care.

This is the second article in a three-part series on the future of Canada's health care system. The articles are presented as a follow-up to the impassioned debate on the topic during the CMA's 1995 annual meeting in Winnipeg. The first article, which appeared in the Feb. 1 issue, dealt with the development of a parallel private health care system in the United Kingdom. This article deals with the consequences of maintaining the health care status quo in Canada. The final one, to appear Apr. l, will debate whether a parallel private system is a worthwhile option for Canada to consider. Last August, General Council decided unanimously that the CMA should spark a national debate on the advisability of introducing private insurance for all medical services.     

Three Decades of Research on Computer Applications in Health Care: Medical Informatics Support at the Agency for Healthcare Research and Quality

The Agency for Healthcare Research and Quality and its predecessor organizations—collectively referred to here as AHRQ—have a productive history of funding research and development in the field of medical informatics, with grant investments since 1968 totaling $107 million. Many computerized interventions that are commonplace today, such as drug interaction alerts, had their genesis in early AHRQ initiatives.This review provides a historical perspective on AHRQ investment in medical informatics research. It shows that grants provided by AHRQ resulted in achievements that include advancing automation in the clinical laboratory and radiology, assisting in technology development (computer languages, software, and hardware), evaluating the effectiveness of computer-based medical information systems, facilitating the evolution of computer-aided decision making, promoting computer-initiated quality assurance programs, backing the formation and application of comprehensive data banks, enhancing the management of specific conditions such as HIV infection, and supporting health data coding and standards initiatives.Other federal agencies and private organizations have also supported research in medical informatics, some earlier and to a greater degree than AHRQ. The results and relative roles of these related efforts are beyond the scope of this review.Three decades ago, when the federal government''s National Center for Health Services Research and Development began to support research on computer applications in health care, few imagined the impact that information systems and sciences would have on medical care today. For most, the idea of a national clearinghouse of guidelines, available through a computer that sits on a home office desktop, seemed like science fiction. For a few researchers and those supporting their work, however, visions of what could become possible in the management of health care information called for development of computerized systems and the evaluation of their effects on quality, cost, and access to care.The Agency for Healthcare Research and Quality (AHRQ, from 1999) and its predecessor agencies—the National Center for Health Services Research and Development (beginning in 1968) and the Agency for Health Care Policy and Research (from 1989 to 1999)—have a rich history of funding research, development, and evaluation in medical informatics. Although the grant investments since 1968 total only $107 million ($246 million in 2000 dollars), they supported initiatives that have established a research framework for many of the computer applications now being used today.The focus of AHRQ''s early research funding in medical informatics was on acquiring patient care data and communicating patient care management information. The goal was not only to improve the quality of care, but also to achieve reductions in costs and medical personnel resource use by processing data more efficiently. Research aimed at improving communication of information was targeted at what we would call today “getting the right information to the right place at the right time.” The promise of this research was its ability to provide findings that would guide reorganization of care delivery, take advantage of the more rapid communication of necessary information, and reduce manpower needs.¹ Over time, AHRQ''s funding has emphasized the application of health services research methods to evaluations of information technology used in community health settings. This article highlights key accomplishments emerging from AHRQ''s funding that have improved the quality of patient care in studied sites and have the potential to improve health care in all settings.Other federal agencies (such as the National Library of Medicine, the Veterans Health Administration, and the Department of Defense) and private organizations (such as The John A. Hartford Foundation, The Robert Wood Johnson Foundation, and the American Hospital Association) have supported developments in medical informatics, with some having greater research expenditures and earlier histories than AHRQ. Nevertheless, it is the Agency''s contributions to medical informatics that are the focus of this study. The purpose of this article is to provide a historical perspective for understanding the benefits of past research funded by AHRQ that supports health care applications of information technology today and that foreshadows AHRQ''s medical informatics initiatives for the future.     

Confidential health care for adolescents: reconciling clinical evidence with family values

Community debate about confidential health care for adolescents was triggered recently by the federal government's proposal to allow parents of teenagers aged 16 years and under access to their children's Health Insurance Commission data without their consent. Extensive research evidence highlights the importance of confidentiality in promoting young people's access to health care, particularly for sensitive issues such as mental and sexual health, and substance use. Involving parents is important, but evidence for any benefit from mandatory parental involvement is lacking. The law recognises the rights of mature minors to make decisions about their medical treatment and to receive confidential health care; however, the doctor must weigh up certain factors to assess maturity and ensure that confidentiality around such treatment will be in the young person's best interests. Evaluation of maturity must take into account characteristics of the young person, gravity of the proposed treatment, family factors, and statutory restrictions.     

Collaborative care receives stamp of approval in CMA, CNA study involving HIV/AIDS.

The CMA wants to work with national health care groups, such as the Canadian Nurses Association (CNA), to explore ways providers can work collaboratively to provide quality health care. A joint working group of the CMA and the CNA recently examined collaborative care, focusing on examples provided in HIV/AIDS care. The group developed principles to help people work collaboratively in a variety of settings.