Society of General Practitioners of British Columbia

As patient information gets collected electronically, this raises important questions about the privacy and confidentiality of patient health information But as we push forward with the IT agenda in Canada and the drive for the health care system to adopt electronic health records (EHRs), the issue of confidentiality often seems to be downplayed.

Physicians are concerned about the potential erosion of trust. Physicians in other nations have recently beenquite vocal in expressing concerns about approaches taken for building EHR systems that focus on creating central data storage of patient records.

In the U.K. at least two recent polls of doctors found that more than 80% have no confi dence in the government’s ability to safeguard online patient date stored in a central database. The same is true in Germany where an overwhelming number of physicians are calling on the German health ministry to halt all plans for centrally-stored electronic patient health records because of potential risks to patient confidentiality.

IPSOS REID Polling of Canadians for CMA 2007

74% believe their consent should be sought before releasing personal health information
51% remain concerned even if non-identifiable (i.e. anonymized) health information about them is released without their consent.
74% feel it is acceptable if they consent up front for their physician to provide electronic access to other physicians for the purpose of diagnosis and treatment
72% also feels it is acceptable if a patient’s personal health record is stored and managed by their physician with no information released without the patient’s consent.
33% find it very or somewhat acceptable to have some (core) clinical data from a patient record stored and managed centrally by local regional health authorities or agencies.

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Because electronic medical records have the potential to improve health care delivery and at the same time promote more efficient use of system resources and better practice management, they are being implemented across the country. However, implementation is progressing more rapidly than the supporting regulatory framework, with resulting uncertainty about accountability for the electronic record.

Information maintained in paper format is less susceptible to inappropriate access or disclosure as there are fewer users who have access and it is not as easy for information to be transmitted to others. However, in the electronic record environment users can number in the hundreds or more and may include a wide spectrum of health care providers, often from several health care regions. Each of them may have access to thousands of records. In some parts of Canada, certain information is required to be uploaded to an electronic health record managed by a health region or ministry. Stewardship in such arrangements is well beyond the capability of many hospitals, let alone physicians, and consequently third party vendors are being contracted to provide this service. However, it is still not clear who is responsible for obtaining consent from patients for the use of information and who is accountable for any errors or breaches.

Although physicians remain responsible for the confidentiality and proper use of the information they gather, policies governing access to electronic records by health care providers, health care administrators, public policy generators, researchers and patients have not been generally developed and accepted. Accountability for policy development and for safeguarding the information has also not been clearly established. Thus, until regulating authorities (Colleges, ministries, and others) clarify accountabilities, it would be prudent for physicians to have a formal data sharing agreement with any group, organization, or facility that may be involved with the physicians in implementing electronic medical records

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The June 2008 College Quarterly references the plans regarding the Core Data Set outlined in the Physician Master Agreement, and states that: "When the model was examined by the College . . . [it] voiced its concern about the potential erosion of patient privacy and the loss of control of personal health information created by this initiative. The College's position was that the scope of information included in the CDS was too wide and would include personal health information which may be sensitive and which the patient may be unwilling to share with others."

The College Quarterly goes on to outline some details regarding the safeguards it feels are required, and noted: "In the absence of such safeguards, the College would have to advise its members that participation in this project would becontrary to ethical principles and a physician's defined mandate to protect the confidentiality of patient information." The College offered the following details regarding the privacy safeguards for consideration by the Ministry of Health:

i) At the time of the initial physician/patient contact leading to the creation of an EMR which is part of the PITO project, the patient will be informed about the confidentiality of the EMR, the automatic transfer ofthe CDS to the EHR, and the potential access to this information by other healthcare providers... It isrecommended that physicians document the discussions and obtain the patient's written consent as they would for any other procedure or intervention requiring informed consent. This is a once only interactionand will not need to be repeated in subsequent interactions.

ii) Patients will be advised that they have the option to mask their personal data, which means that the nominal information that is entered electronically will only be available to the physician who created it. In such a situation, the CDS will be forwarded to the EHR and access would be permitted with explicit patient consent only. Non-nominal and de-identified information could be used for planning and research purposes but will not be identified as specific patient information.

iii) If patients who have masked their personal health information see other healthcare providers such as medical consultants, pharmacists, etc., they will have the option of consenting to access by such a provider through the provision of a swipe card, a personal identification number or another method to bedetermined, which will unmask their data.

iv) Access to unmasked personal health information such as the CDS by other healthcare providers will be determined by their scope of practice and their need to know. At this point it is unclear how and by whom the scope of practice will be defined, and how a range of access will be determined. While the College would have a significant role in that determination, the Data Stewardship Committee, as proposed, is not the appropriate forum for such decisions.

v) Access to aggregate non-nominal data for research and health planning purposes will be subject to review by the Data Stewardship Committee, and supplemented, where necessary, by review by the Office of the Information and Privacy Commissioner."

"At the time of writing this report, the proposal is being reviewed by Ministry of Health representatives, and it is anticipated that the College's concerns will be appropriately addressed. . . . At this point the proposal is a basis for further discussion and should not be perceived as formal College policy."

(These ecerpts of the College Quarterly were previously preseented in the SGP's Oct 2008 Issues and Ideas Bulletin which is posted below. To read the full College Quarterly or the full SGP Bulletin,  please ensure you are logged in, and click on the title.)

The Primary Health Care Charter (the Charter) sets the direction, targets and outcomes to support the creation of a strong, sustainable, accessible and effective primary health care system in B.C. Primary health care provides firstcontact access for each new need, long-term comprehensive care that is patient-centred, and coordination when care must be sought elsewhere.
There is great potential in primary health care to improve the health of the population and contribute to the sustainability of the health care system. To reach that potential, all partners for a healthy population must work together. To support such collaboration, this provincial charter for primary health care was co-developed with many partners to capture the activity, experimentation and successes of the last five years, and to set strategic direction to move forward.

Starfield et al review the evidence supporting the ciritcal contribution of Primary Care to Health Systems and population health. One key excerpt:

The evidence is strong regarding the benefits of an ongoing relationship with a particular provider rather than with a particular place or no place at all. . . people who report a particular doctor as their regular source of care receive more appropriate preventive care, are more likely to have their problems recognized, have fewer diagnostic tests and fewer prescriptions, have fewer hospitalizations
and visits to emergency departments, and are more likely to have more accurate diagnoses and lower costs of care than are either people having a particular place or people having no place at all as their regular source of care

After adjustment, Ontarians with chronic conditions who said they did not have a regular medical doctor (CCHS data analysis) were 1.22 times more likely to have visited an emergency department (ED) (95% CI 1.02, 1.46) in the previous two years than those who reported having a regular doctor. This translates to an estimated 17,741 excess ED visits. People in this same sub-group were also 1.32 times more likely to have had a medical non-elective hospital admission 95% CI (0.85, 2.06) in the previous two years compared to those who reported having a regular doctor. This translates to an estimated 1,932 excess hospital admissions attributable to not having a regular doctor.

A detailed review of Primary Care Renewal by the Ontario College of Family Physicians 2005

The report notes: "The goals of primary care renewal are multiple - improved access, improved quality,improved recruitment and retention, improved provider and patient satisfaction. These end goals present as competing, rather than complementary goals, especially in light of a severe human resource crisis. While laudable, in the absence of measurable outcomes they are causing confusion, mistrust, an uncertain landscape and a belief that policy decisions regarding physician payment systems are based on ideology and not evidence."

"There is a growing belief that blended compensation models show the most promise for the future - mixing the benefits of the different compensation models to provide a variety of incentives. These models mix the benefits of a variety of compensation models to provide the most effective incentives to meet the established goal. Given the competing goals in PCR and the different priorities in each community, different blended funding models are needed to address the established priorities"