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During the International Year of Co-operatives, which just ended, we made a presentation to the Special Committee on Co-operatives on the issues and specific characteristics of the Canadian co-operative movement.
We would like to bring your attention to the following recommendations. First, spur the development of new health care co-operatives by building partnership agreements with local health care networks and by offering start-up financial support. Second, clarify the rules regarding annual contributions made by members of health care co-operatives. Third, acknowledge the investment made by members of health care co-operatives by allowing them to claim their contributions as medical expenses. Fourth, promote the development of new health care co-operatives in order to create new drivers of innovation adapted to the specific needs of communities. And lastly, set up a committee to study the opportunities for complementarity between the heath care co-operative model and the development of health service offerings in Canada.
The following supports our recommendations.
The Canadian health care system has some undeniable strengths, including access to a variety of basic services for all citizens. Some serious dysfunctions must nevertheless be acknowledged. Co-operatives arise out of the desire of a group of individuals to meet a collective social, economic or cultural need. They pool their resources and skills to achieve it. They equip themselves with means and expertise they would not have had access to without the co-operative. They follow the co-operative principles of democracy—one member, one vote—financial participation, autonomy, intercooperation and engagement in their community. When we talk about the principle of accessibility, we are referring to the Canada Health Act.
The health care co-operatives concept is both simple and innovative: a community identifies common health care access needs or new health service requirements. Next, it establishes a co-operative offering free or competitively priced facilities, equipment, technological tools and administrative services to health professionals and/or physicians. They tag on complementary services, such as health prevention services, as determined by members.
A health care co-operative can be defined as a collective enterprise which produces services to promote, maintain and improve the health and living conditions of communities, while involving its members in the organization of its services, at the decision-making level. The members define and manage the co-operative's services and investments to suit their needs. This democratic management ensures that services offered match local needs.
Members agree to fund the co-operative's operations through qualifying shares, annual contributions and donations. Most such co-operatives receive absolutely no funding for their operational costs.
It must be noted here that the co-operative does not purport to offer health services, but rather it aims to ensure access to such services on its territory. It considers itself as having a dual role. First, it provides a competitively priced modern professional environment. Next, the co-operative aims to improve access to various health services by becoming actively involved in the hiring of physicians and other professionals, and by offering health prevention or support services to address local health problems.
While rental activities can generate independent revenues, all of the co-operative's other activities—equipment, administrative services and so on—do not generate any revenue at all, and it cannot rely on any public support. That is why members' contributions and donations from the community are requested to fund this portion of its activities. By collectively assuming this structure's operating costs, the community becomes attractive to such professionals.
It is also noteworthy that in 54% of cases, these co-operatives create a new service in the community, while in the remaining 46%, they replace a clinic that has closed or that is at risk of closing.
Doctors who decide to practice in a co-operative are paid by their provincial public system. No part of their salary is borne by members. In return, access to the physician's services is open to the entire population, to both members and non-members alike, without restriction.
Individual and collective empowerment, which are the values underlying the co-operative model, are the core elements of health care co-operatives. Rather than being mere consumers of health services, members of co-operatives are involved in their own health care and take part in the necessary follow-up. They are also asked to get involved in prevention activities.
The co-operative movement also believes in collective health management. It is managed democratically by a board of directors made up of elected members, and all members can vote at the annual general meeting on policy matters. Thus, the community determines not only how it wishes to shape its local health service delivery, but also how members will fund these projects.
We believe that between the private and the public sector, there is room for the co-operative. Health care co-operatives do not represent a privatization of health services. Rather, they are a partner which alleviates the public system's task by improving access to first-line health services and offering supplementary services. They are not-for-profit organizations that allow citizens to invest in local access to publicly funded health services.
Health co-operatives represent a wonderful opportunity for the Canadian health care system. They are an additional collective investment in access and in primary health care coverage. In that respect, this model represents a partnership opportunity for governments and communities to improve the delivery of health services. It gives back to the individual the power to manage his or her health and gives the community better access to health services.
The creation of a health care co-operative requires the involvement of many volunteers, as well as the financial commitment of thousands of members. Add to this challenge that of developing a partnership agreement with local public health authorities.
This exercise is difficult and tedious. We are dealing with small community organizations, a group of volunteers who are working to create their co-operative. Lack of funding at this stage can often discourage volunteers or slow down the project significantly.
We also believe that the government would benefit by acting as a facilitator for such communities looking to manage this crucial phase in the shaping of their local health care services. This support could take various forms, depending on the needs of the co-operative. Health care co-operatives are young, and their activities cost the government nothing. In fact they may lead to savings.
Since health care co-operatives are financially independent, they come at no operational cost to the government. By improving access to health services and by offering prevention services, these co-operatives allow the Canadian health system to better fulfill its mission and to avoid short-, medium- and long-term costs.
We believe it should be acknowledged that by voluntarily deciding to reinvest in our health system, members of health care co-operatives are first and foremost doing something positive for our society. They should be allowed to claim their contributions as medical expenses on their tax return.
The direct relationship between the members and managers of co-operatives requires ongoing innovation. In fact, members are quite demanding of their co-operative. They want to have concrete proof of how their additional contributions to the health care service offerings affect their access to these services.
The following are a few examples: the implementation of a telehealth service in order to give members in remote communities access to a public system doctor in Nova Scotia; the creation of a mobile medical clinic to service remote communities in British Columbia; the integration of a public emergency service and a medical clinic on the same floor in Beauce, Quebec; the creation of adapted services for the Native population—
I don't need to remind anybody sitting around this table that Canada is a vast country, but I wanted to share with you some specific statistics, courtesy of the Society of Rural Physicians of Canada.
One in seven rural physicians plans to leave their community within the next two years, threatening already underserviced areas.
Of Canada's 10 million square kilometres, 99.8% are considered rural by definition.
Nine million Canadians, which amounts to 31.4% of all Canadians, live in those rural areas.
Towns that account for a population under 10,000 are 22% of Canada, but are served by only 10.1% of Canadian physicians, so they have less than half the ratio they should have.
Larger rural and regional centres—that's between 10,000 and 100,000 population—constitute 15.9% of the population but have only 11.9% of Canada's physicians.
So right there, half of all Canadians are underserviced.
The doctor shortage is a severe problem. Many people are working hard to help. Both Dr. Ballagh and I have sat with Barrie's member of Parliament, Patrick Brown, on a physician recruitment task force, trying to attract doctors to Barrie, but the problem isn't going to be solved overnight. Yet in the meantime, things can be done to help these people. A lot of patients do not have family doctors, and as a specialist I'm concerned that they also then don't have access to specialists such as me, because you need the family doctor to access the specialists, especially in these remote areas.
This problem doesn't have to be as severe as it is, however. With the connectivity of the modern world, allowing everyone to be linked by things like e-mail and text messages, Facebook, Linkedin, Twitter, and Skype, there's no reason that these people can't access their specialist and their family physicians remotely. The technology exists today. This isn't something that has to be developed in the future.
I provide a few examples.
There's simulated training whereby primary care physicians working in rural areas don't even need to have the specialist on hand. They can learn the critical skills they need to have remotely by using simulated patients. These patients will breathe, moan, move, and verbalize, they can be intubated, they can be given medications, they can have tubes inserted into the various cavities in their bodies, and they will respond appropriately. So if mistakes are made, the lessons will be learned. This kind of training allows rural physicians in remote areas to learn the kinds of skill sets they need.
There's also remote video resuscitation. You don't always have to have a physician present. Many places don't have physicians on staff there. These resuscitation teams consist of nurses, maintenance staff, health attendants, and even members of the community—anybody who's interested in participating in that kind of a team.
Cameras can be used and are aimed at both the patient and at the equipment, and the physician from a remote area will offer the advice and the direction of where the resuscitation needs to go.
There's also robotic telemedicine, specifically in Nain, Newfoundland and Labrador, which is the most northern community in that province. There are no physicians on site, but there's a robot named Rosie. She's 165 centimetres tall, so just a little taller, I think, than I am. She has a screen for her face, and she has two-way audio and video capabilities so that a physician in a remote area can use a joystick and have her move from patient to patient; interact directly with the patient; see what she needs to see, whether that's looking at the patient or the pill bottle or the chart; and can offer the needed advice.
Doctor in a Box is something that can be carried to various places, such as the EMS teams when a physician will not be at the scene when an ambulance picks them up. It will be able to see not only what's going on, but will be able to receive the telemetry from the heart rhythms picked up and will be able to provide advice to them directly so that the patient is getting expert care right off the bat.
Surgical robotic systems are another thing that can perform surgery remotely using state-of-the-art robotics. Those types of systems tend to be reserved for large academic hospitals, but less impressive systems can still be employed elsewhere in remote regions where surgeons with expertise can simply monitor what's happening with the OR, using two-way audio and video capabilities. So a surgeon with a greater skill set can instruct and advise a surgeon with a lesser skill set who's physically on the scene. They can see the operative field and they can see what's happening with the patient.
Finally, there are telehealth consults. As a cardiologist, I would say 90% of the diagnoses I make are taken from the patient's history. Although performing a physical exam is helpful, it's not always so critical to be able to offer care to these patients. If I had the ability to interact with them remotely and had an echocardiogram whereby I could see the images done by a skilled technologist, I'd be able to help these patients impressively.
You'll see that most of these technologies have two-way audio-video capabilities.
Rosie and Doctor in a Box aren't as widespread as I think they need to be in a country like this. And nothing I've described here uses any technology that doesn't already exist. This would allow people like me to run remote clinics all over the province, all over the country, and I think all these patients deserve this kind of access. In a country as great as Canada is, but as vast as Canada is, I think one goal for our country is to be able to provide everybody, no matter where they live, that kind of access to care, both primary care and specialist care, and with these sorts of technologies, that can be done.
Thank you very much for your time.
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I am a specialist in otolaryngology, head and neck surgery, in Barrie, Ontario. I also work in Collingwood, Ontario, Orillia, Ontario, and two days a month I travel five hours each way north to work in Kirkland Lake, Ontario. My patients know me as their ear, nose, and throat specialist.
As a surgeon in one of the fastest growing parts of our great country, I was really delighted to be invited by the Standing Committee on Health to address this hearing.
Since my arrival in the community of Barrie almost 20 years ago, I have been involved in innovation in the health care system's delivery model at almost every level. An interest in teaching young doctors led me to volunteer my time to the rural Ontario medical program to bring medical learners, medical students and residents-in-training, to Barrie to be partnered with experienced, hard-working, front-line physicians and surgeons for what for many turn out to be life-changing learning experiences. Many of these young doctors have chosen, upon completion of their training, to return to underserviced communities like Barrie to practise their craft.
I am now an assistant clinical professor of surgery at McMaster University and an adjunct professor of otolaryngology, head and neck surgery, at the University of Western Ontario.
As a continual innovator in medical education, I am most proud of the association I forged in the past decade with the Health Services Training Centre at Canadian Forces Base Borden, where I am a preceptor and lecturer in their physician assistants training program. Working and teaching these highly professional, skilled soldiers has allowed me to indirectly impact the lives and health of many in our military, and indeed many civilians treated by our military doctors and physician assistants around the world.
I completed my medical school and residency training at the University of Western Ontario in 1993. Thereafter, I spent an extra year of training at Cambridge University, in England, where I studied and became an expert in diseases and disorders of the ear, including disorders that cause dizziness and imbalance. In my specialty, and in my community, I am known to the doctors as the “Dizzy Doctor”.
The diagnosis of a patient with a dizziness disorder is one of the toughest jobs in clinical medicine. I remember nights when my father, a small town family doctor, would come home exhausted, telling us how he'd been discussing dizziness problems with only two or three patients that day. The differential diagnosis, the list of possibilities of the causes of dizziness, can seem endless at the beginning of a patient interview.
Vestibular disorders, or disorders of the organ of balance of the inner ear, are some of the most fascinating dizziness conditions, but also some of the most elusive to diagnose. You have all heard, I am sure, of labyrinthitis, a severe dizziness disorder that is caused by a viral infection of the inner ear. You might be surprised, however, to learn that very few doctors have seen and correctly recognized this disorder, which is actually the commonest inner ear disorder causing acute vertigo. Patients with inner ear disorders can be very ill one day and very well the next day. Indeed, some are very dizzy for a few seconds every night when they go to bed and they are symptom-free every other minute of the day.
In medicine, we're taught to take look at the history of a problem and then to do a physical examination of the patient to look for findings. The problem with most inner ear disorders is that when the patient is not dizzy, which is most of the time, they haven't got any findings. When vertiginous, with a disorder like labyrinthitis, a patient will have several findings—they'll get sweaty, their heart will race, they'll complain of nausea—but these are all findings that are non-specific. They're findings that are shared with other disorders. They're findings that I’m feeling right now in this committee room—
Voices: Oh, oh!
Dr. Rob Ballagh: And there are other items on that differential diagnosis list.
But one finding that's very reliable during an inner ear event is nystagmus, a rhythmic, involuntary eye movement in which the eyes dance back and forth in the patient's head. When you see it, as a diagnostician, it seals the diagnosis. Quite often it even tells us which ear the problem is arising in—not always an obvious thing. Treatment, now that the diagnosis is confirmed, can commence immediately.
The problem is the nystagmus is only visible during the event, which can be measured in minutes and sometimes a few hours. So early on in my practice, I found my inability to know what the eyes of my patients were doing during their dizzy attacks to be frustrating. I would write notes to their doctors that they would carry in their wallets and purses, asking them to document the eye movements of the patient if they presented with dizziness. But try getting in to see your family doctor in the next hour, or to see an emergency room doctor within six hours. It's very difficult.
Then one day something very interesting happened to me, and I hope to be able to share a version of it with you today. A lady came to see me for a second visit for her dizziness. I was convinced, having done my comprehensive history and physical examination on her first visit, both of which were normal, that she probably did not have a vestibular inner ear disorder. Two minutes after she sat down on the stretcher in my exam room, she did the most remarkable thing: she had an attack of Ménière's disease. She became very pale and distressed, she started to lean over at a funny angle, and her eyes started to beat very rapidly from right to left for 20 minutes
I learned a great many things in those 20 minutes, but the most important thing I learned was that my initial impression of that lady had been incorrect. Immediately afterwards I started to encourage my patients to shoot video of their eye movements during the height of their dizzy attacks.
I hope to be able to show you a version of this during the hearing.
After nine years of this pioneering work, started in Barrie, Ontario, by me, with my digital camera and now my smart phone, I have shared my observations with dizziness specialists across the country, and indeed with my Cambridge connections around the world. We have made many new medical discoveries in Barrie, Ontario, and we have seen things we could not explain, raising new questions where we did not realize we even had questions before.
If this will work, and if I am not out of time, I want to show you a very short—
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I will try to answer all three questions.
The co-operative model is interesting because the members decide on the type of services they want to offer. Most of the time, it is a physical site, generally understood to be a clinic with a doctor. Other times, it might be a mobile clinic. It could also be telehealth or a clinic that travels within the community. Therefore, the members will determine their needs during their annual general meeting or after speaking with their board of directors, and they will decide whether the service provided will be a telehealth service or whether the town clinic will be kept. It really depends on the community's needs.
In general, as we mentioned in the presentation, it will be a real physical clinic. Basically, if we want there to be a doctor in the community when there isn't one or if we are losing doctors, the community creates a co-op. It is important to understand that the co-op will be a vehicle.
To answer your second question, I would say that the member contributions will be used to fund the vehicle, meaning the building, the additional equipment, additional nurses, additional prevention or other services. The advantage for members is to ensure that these services are available in the community and that people have access, perhaps at a lower cost, to services that are not covered by the government.
Obviously, people always want to know why they would pay an average annual contribution of $60 when members do not have privileged access to doctors over non-members. It is important to point out that annual contributions are not always required. In fact, most of the time, it is really an investment for the community. This sometimes also involves adding services that are not otherwise available. Prevention services under the Japanese model are a good example. We see this often. So additional prevention services not covered by the government are created. In this case, it might be available only to members. But for government paid services, members do not have an advantage over non-members.
To answer your third question about demographics, it is interesting to note that the demographics of members of health care co-ops are similar to that of the general population. You might think that older people need medical services the most and that they would more often be members, but the opposite is true. We have members who are in their twenties and thirties, for example. We have all kinds of members.
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I'm definitely aware of the shortage issue. I think the problem is that a cardiologist offers a certain level of expertise that requires a certain catchment area. So the more remote you go, the farther north you go, generally there won't be enough patient population to allow you to continue to function as a cardiologist full time. I am aware of some colleagues who still wanted to choose that lifestyle, so they have gone as cardiologists, but they tend to function more as general internists. They fall back to some of the skill sets they had in other branches of internal medicine, like GI or respirology.
The issue with offering cardiology services remotely is that it has to be done through this sort of remote two-way technology. For example, I could run a clinic one day a week somewhere very remote. I could do stress tests, because there would be a trained technologist there, and I would be there not only in the two-way audio and visual approach, where I can see the patient and I can see what's happening on the treadmill, but also ideally I would see the telemetry on my computer screen as it was being sent to me remotely.
Likewise I could do a consult, in which I would spend maybe 15 minutes discussing with the patient. Then I would be able to have an echocardiogram done, again by a skilled technologist, and I would actually see the images on my screen, because there's no reason that information couldn't be transferred digitally.
I think the biggest hurdle to having cardiac services out there isn't getting cardiologists there, but making sure that the adequate infrastructure is available so that the expertise can be used. I'd say stress tests and echocardiograms provide a lot of what we need to offer.
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I'll start, and I'll let Dr. Ballagh add his comments.
I think its multifactorial, just as you referred to. I think part of it is that when you work in a rural community—and I have colleagues who do that; they work very hard. They don't tend to get home in time for supper at five or six o'clock at night because they're the only ones in town. They're on call on a much greater frequency, often one in one.
The other thing is that there are greater demands on them. If they work in a larger community, they have the resources of specialists to fall back on; if something is getting a little out of their territory, they know they can pass it on to someone with greater expertise. When you're in a small, remote community, you don't have that, and it's all on your shoulders. That's a stress that a lot of people don't feel comfortable with.
I also think some people in some communities feel they don't have the infrastructure to support their needs very well medically. They fall to levels of frustration because the dollars aren't there to support something such as setting up better telehealth systems to have specialists work remotely.
I think after a while, unless they're very dedicated, they plan to go. It's a small percentage of these rural physicians, but that's what the Society of Rural Physicians of Canada has documented within the members of its group.
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I guess I'm going to frame my answer around medical education. When Brad and I went through medical school, there weren't a lot of options to go into the community and actually have an educational experience. In surgery, I had no option at all to go into any community, outside of Toronto or London or Ottawa, and train with a community surgeon like me.
The rural Ontario medical program that I'm affiliated with, and I also work with the Northern Ontario School of Medicine through my affiliation in Kirkland Lake, have opened up those kinds of opportunities. In the last month, I've had an ear, nose, and throat resident come to work with me in Barrie. I've worked with two family medicine residents in Kirkland Lake.
We have found that in rural educational training and medicine, if you have your formative training, if you have some of those first experiences treating a heart attack or a massive bleed from a laceration in the neck in a small town hospital with very few resources but very experienced and dedicated doctors, those are the experiences that stick with you, and those experiences will often draw you back to that kind of practice.
I was told when I finished my training that I had potential and they wanted me back in the university centre. I'd known nothing else. I was told that if I practised in Barrie, I would be wasting my academic talent. In fact, I would tell you that the opposite is true. I'm able to take the experience I have and hopefully infect some of the doctors who come to work with me with an enthusiasm to work in places like Barrie and Collingwood and Orillia, and even as far north as Kirkland Lake.
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If I speak specifically to having a heart attack, or a myocardial infarc, as we call it, having a good general assessment—and it doesn't always have to be with a family physician, it could be with a nurse practitioner or a very skilled nurse even—and going through a complete risk profile.... There are nine classic risk factors that contribute to about 95% of all heart attacks.
If somebody knows what their risks are—and sometimes they know they are out of shape, overweight, or they smoke, but sometimes they don't know what their blood pressure and cholesterol are, and you don't need a specialist like me to be able to determine those risks. If people get access to them, they can have their risks calculated, and then they can access the knowledge they need to make those changes, which are very often commonsense things.
I remember Canada's Food Guide was very helpful in telling people how to eat healthy. I think there should be a Canada health guide for how to live healthy in general, to make sure people are doing the amount of exercise they should and not smoking. Everybody hears that, and it falls on deaf ears a lot of the time because sometimes lifestyles are hard to modify. I think a basic risk assessment will help predict many heart attacks. The real challenge, I would say, is not finding out what the risk is but making people make the necessary changes so they reduce that risk.
I've been dealing with that for 20 years, and it's a struggle.
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Let me give you a concrete example. In my village, we have a health co-op. The doctors are paid by the government and they also belong to the FMG. The health co-op members create a whole environment for doctors. Perhaps the rent for the health clinic is lower, perhaps there is more equipment and perhaps they have better people around. Doctors get a platform for free or that is significantly cheaper for the health care system. That makes it possible for them to move to the village.
For example, Mr. Ballagh said that people did not want to move to Barrie, Kirkland Lake or other remote places. Co-ops are an attractive workplace for doctors. So they will move to work there. They continue to be paid by our health care system. They continue to be part of an FMG and to work as an FMG.
There is another difference. For instance, a co-operative can decide to hire another nurse, in addition to the one paid by the FMG. The FMG nurse will then be able to take on additional work, which will reduce the doctor’s workload and give him or her time to see more patients.
Basically, people in the community come together to add more services. This creates an environment that will attract doctors.
It really complements the public system. There is no competition. This is especially important for places or areas of activity where the private sector would not benefit from investing in low-priced buildings for doctors, and things like that. Perhaps this answers other questions. When the private sector cannot provide those types of services, the community will decide to do so by creating a co-operative.
The same goes for telehealth. In Nova Scotia, one co-op provides a telehealth service. No private investors were interested in that type of service, because there was no profit to be made. So the people in the community decided to form a co-op in order to have access to the public services they were already paying for as taxpayers. By making an additional investment, they improved their access to health care. They took a real good look at what their needs were in terms of having easier access to public services. They decided to put money on the table, because the private sector found that there was no money in it, basically.
I just want to make a comment on the co-ops. I understand maybe why there's confusion, but I'll give you an example from my community.
In Goderich there was really no clinic. Instead of a co-op, they created basically a not-for-profit organization. Basically people from the community donated money, the municipality donated money, and surrounding municipalities donated money so they would have a clinic.
They had a doctor shortage in Goderich. They built a state-of-the-art facility, because there was nothing there before, really, and now they don't have a doctor shortage. People love going there. A lot fewer people in the area don't have doctors.
So one is a not-for-profit corporation. You guys call it a co-op; it's still the same thing. People who didn't donate money can still go to the clinic and receive service. It's just a way of making things happen in a small community. It's not like there's a clinic on one corner and across the street they put up another thing. There's nothing doing; this is why they have to do it.
This is just so we're all on the same page here.
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Ours is the largest family health team in the province of Ontario. As such, the family health team went out and kind of led the charge on electronic medical records in our community. They looked at all the vendors and all the products, and they chose one through a very aggressive and big due diligence process.
One of the family doctors is actually their IT lead, their electronic medical records lead, and he's a good friend of mine. When I decided what I was going to get in my practice, I talked to him. I did my own due diligence in an abbreviated fashion, and I ended up using the same one.
In our community, many of the doctors, although not all, use the same system. They all communicate with each other to a greater or lesser extent.
My biggest challenge with electronic medical records is that the patients I see...particularly this lady with dizziness, the complicated case that I presented today. Often the initial consultation request comes with a letter that says “Vertigo?”
By the way, “vertigo” is a symptom, not a diagnosis, so I know, when I get that letter, that I'm really starting from scratch. What I often don't know until the patient is in the office is that they've had two other consultations with other specialists. They have seen a neurologist as well as a cardiologist, and they've had these six tests.
One day I'd like to see an electronic medical record that is available on a memory stick that I can just put in this computer. The patient's electronic medical record can be portable with the patient, and we can actually get that information right in our offices.
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Thank you, Madam Chair.
My colleague Mr. Lobb had a good question. So I am going to continue along the same lines.
Not too long ago, when I did my chiropractic training, we weren't using the new technologies much, especially when we had to practise in real life. I would say that I am a fan of technology at home and outside work, but at work, I cannot bring myself to use technology such as the video for the nystagmus.
One of the reasons why health professionals in general do not use those technologies in their practice is the confidentiality issue. Just think of X-rays on the computer, for instance. That poses a risk of data leakage and, therefore, a confidentiality problem. I would imagine that the same goes for that video. It is part of the patient’s record. So it has to be in a secure place.
Dr. Ballagh, could you tell me what you think about that and give me an example of where you need to use new technologies more and still be very careful about the confidentiality of patients?
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I certainly can, and I should preface this by saying I'm married to a civil litigation lawyer. Confidentiality has been an obsession of mine since the day I met her, and actually since the day I walked into first-year medicine.
To give you an example, I was quite concerned about the confidentiality of the lady in the video that I showed today. I had reassurance from the committee that it would not be archived or shared on the Internet, and in fact that it would be shared only by the people in the room. I also went to the extent of calling her last Sunday afternoon and explaining to her what I was going to be using it for and got her permission to use it. She is an educator as well and she really wanted you to be part of that experience.
In my practice, with regard to these confidential details, they are not archived; they are simply documented. When I see that, I know what it is and I write it down. I don't need to keep that information, but some things do need to be archived and kept. For instance, if someone had a CAT scan five years ago and this year we find a tumour, we often go back and look at the CAT scan to see if that tumour was there. Did we miss it? How small was it? How could we have avoided that error?
So I think it's important that the information be available, but it has to be available only through the most secure firewalls. Getting through those firewalls, particularly if you're not in the hospital and in the facility inside, can be very difficult. From my office, it can be very difficult. Even though I share an electronic medical record with 85% of the doctors in my community, I can sometimes have a hard time getting that neurology consult, that CAT scan from last year.
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It's a complicated question because it is the patient's information.
First of all, this is a dream, the memory stick; this is not a reality yet. And it's a dream that we can collectively, hopefully, have together this afternoon. There needs to be a comprehensive medical record on that medical stick, and it should include, very quickly after the patient sees me, the record of my visit with them that day, and it should be contiguous with all the records, hopefully dating back right to their birth.
In terms of who can access it and to what depth they can access it, and can the patient access it, these are very difficult questions that have to be hashed out. Patients, when they read their own records, can sometimes misinterpret things or be offended. We're very careful in our language, but sometimes they can come back in with concerns about the way things were documented and things like that.
At the same time, not having that information, and particularly if I can't get that information during that very short patient visit—our patient visits are not long, and in my specialty they're 20 minutes—sometimes that guarantees another visit. Many of my patients come from miles and miles away to see me for that critical first visit, so we try to get as much done as can. But if we had that extra information, it would just be so much easier to get more done in a single visit.
:
Thank you very much, Madam Chair.
Thank you, folks, for coming to see us today.
There has been lots of talk today about access to doctors in rural and remote communities. I never actually thought of Barrie as being particularly rural. Since I come from Toronto, it's just kind of up the road, with lots of suburbs in between.
Setting that aside for the moment, I was watching The National last night and there was a story about paramedics in Toronto being rerouted seven times in the course of three hours and a woman eventually dying over that period of time.
If I may, I'll share my own personal experiences with trying to access a doctor. I've had the same doctor for almost 20 years in Toronto. I thought I could book an appointment for a checkup with two months' notice, but apparently that's not correct. It required six months' notice. Then I had to miss that one, so that set me back another five or six months. By the time I got my annual physical booked, a whole year had gone around. In my family, my son and I—the boys in the family—have stuck with this particular doctor. Once my girls grew up, they decided to go to a female doctor in our neighbourhood, and it's really just this constant rotation of doctors through a clinic where you never see the same doctor twice.
With all of that, I accept the issues of remote and rural communities, but in our cities we have a huge problem with accessing health care and doctors on a consistent basis as well.
I should add that even in downtown Toronto, because of this condo boom we've experienced, even though there are a whole bunch of hospitals up and down University Avenue, as you know, they have simply been overwhelmed with the population in downtown Toronto.
My first question, after that lengthy introduction, is to the cooperative folks. You talked about pretty much all rural cooperatives. Is there any application of this model in an urban context?
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Thank you very much, Madam Chair, for the opportunity to ask a question.
I do want to thank my colleague Mr. Lobb.
I think you do have a future in consulting.
You know, when I look at the co-op model, I can see how the model would give control to local communities. In Canada we have such diverse communities.
We've heard about first nations communities. Different communities, like first nations, for example, might want aboriginal healers. They might want chiropractors, more natural healers. They may have issues with respite care, home care.
Could you maybe give an example to the committee of how a cooperative model might be very innovative, if these communities decide this is a way they could attract physicians, attract human health resources?
One of the things we hear over and over again is how difficult it is to attract human health resources to these communities. Could you give us an example of how the co-op model would work in a situation like that?
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I am going to try to be as clear as Mr. Lobb.
Let's take Saskatoon as an example. There is a health cooperative there that has decided to offer additional service to aboriginal persons, service that is adapted to their needs, because no public service was doing that. They decided to do so using the resources of the cooperative.
I will give you another example. In northern Quebec, there is a project to serve the needs of the Inuit using cooperatives. The local cooperatives have decided to offer health prevention services that include health education, because this is a considerable challenge among the Inuit. This is being done according to the cooperative model. The public service was not offering such services, and so they used the cooperative model in order to provide these targeted services.
I find your comment about involving citizens very interesting. To express things in the simplest way, the health cooperative model implies that citizens decide to provide additional funding in order to have additional services, or to have greater access to services. Those citizens decide how they will do that. So this is a vector for innovation. Citizens decide to look at the innovations needed to meet their own needs, since the public services alone are not managing to do that. They reinvest and go and get what they need to target the public service to the needs of the community, and they foot the bill.
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I think I'd give cardiologists' the first right to be able to say something like that.
Anyway, the funds have to be there. Most people feel that health care and education are two supremely important things. We just have to make sure we use the funds we have available for those things as wisely as possible.
Just because some people chose to live north of the French River, for example, they shouldn't have access to health care. They're Canadians, after all. We need to make it as feasible as possible.
We don't want to mandate doctors like me to go up there who won't be able to function as a cardiologist full time, but maybe they could make it so that I work from my own community back home.
If these communities can appeal for those sorts of technologies, that's great. That's money very well spent. I'd have to see the whole budget to know what else you should cut, though.
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In some provinces, the community health centres are equivalent to some degree to the CLSCs, the local community service centres. They are really a public system. It is interesting to note that Alberta is considering the creation of family care clinics and is studying the possibility of adopting the cooperative model.
Also interesting, the four Saskatchewan cooperatives are a part of the community health centres network and of the public network. The democratic process is what differentiates a cooperative model organization from one that is not built around that model. In the first case, the population, the members, are involved. Often they make a financial contribution, small or large. The fact is that members become the owners, to a certain extent, of their health development tool, in their community. And so, there is more involvement on the part of those members.
Members of cooperatives believe in the collective responsibility for health, but also believe in personal responsibility. The principle is that people should be involved in fostering their own health, and learn to manage it themselves. You can see the difference. Generally speaking, the additional services involve prevention, essentially because people want to help each other out. Rather than using a program or a standard approach that allocates funds to a specific purpose, the model trusts the communities and allows them to determine their own needs themselves. In a lot of cases, their solutions really meet their needs, since they are the ones who know what they are. That is the difference we have observed.
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In my experience within cardiovascular medicine, I think there's very good collaboration. In one way we're unique because more people die from our diseases than anything else, so we get to do a lot of studies on these patients. Clinical trials are always coming out. As a result, for example, I'm connected to CIHR, and I'm invited sometimes to participate in clinical trials if I would like.
It's very easy to be connected internationally because we're constantly getting information, usually by Internet or e-mail from all our organizations, the Canadian Cardiovascular Society, and then, in the U.S., where we tend to be members, the American Heart Association and the American College of Cardiology. We're told exactly what's going on with these clinical trials, when they're starting, when they're going to finish, and if we want to get involved, we know whom to contact.
Within cardiovascular medicine, I would say the global community has a lot of collaboration. Most good trials that answer the questions I have about how to better serve my patients tend to be multinational trials. Very few trials are done now in one community or even one country, because the question across the pond will be whether or not it applies to their patients. So these tend to be multinational, and they tend to have many thousands of patients. You can't do that without that level of collaboration.