Shoot and Tell: Mandatory Gunshot Reporting

Question 1

Shoot and Tell

Answer 1

“In September 2005, the Mandatory Gunshot Wounds Reporting Act was proclaimed in Ontario. It required public hospitals to report the name and location of anyone being treated for a gunshot wound. Representatives of health professions expressed concern that this might damage their duty to patients, while others wondered whether similar reporting requirements should apply to other violent injuries.”

Question 2

Policy issues addressed:

Answer 2

• balancing societal needs for protection with patients’ right to privacy
• ethical basis of the physician-patient relationship
• framing of policy issues

Question 3

Framing (Problem Identification)

Answer 3

• unreported gunshot wounds are extremely rare - thus a small public health risk
• the likelihood of unreported shootings may be largest in rural areas - but most are accidental vs. intentional
• disease prevention is facilitated when good data is collected, including information to help determine the root causes of episodes of ill health
• public health units are associations are, with increasing frequency, declaring violence to be an issue of concern to public health and an important determinant of health, especially in children
• In 1997, the OPHA 1997 declared that violent crime was a public health issue

Question 4

Framing (continued)

Answer 4

• fiduciary duty
• individualism vs. collectivism
• making communities safer vs. avoiding treatment
• public health concern vs. criminality
• comprehensiveness? Every other province that has similar legislation also has a stab wound reporting element - status in Ontario say violent crime is most likely to occur via shooting or stabbing (1/3 each)
• prior to the act being passed in 2005, it was up to the HCP to use professional opinion re: when it should be reported to the police
• trade-offs (e.g. reporting accidental shots would be better handled with education and safety training) for HCP

Question 5

A Public Health Issue?

Answer 5

“Public health refers to all organized measures (whether public or private) to prevent disease, promote health, and prolong life among the population as a whole. Its activities aim to provide conditions in which people can be healthy and focus on entire populations, not on individual patients or diseases.”
- “violent crime can be seen as a public health issue whose impact is especially profound among youth and other vulnerable populations”

Should gunshot wounds be classified as a public health issue?

Question 6

PROactive vs. RETROactive

Answer 6

prevention: put money towards programs and policy that help reduce gunshot wound injuries

Treatment: Put money towards treating gunshot wounds and police resources

Question 7

Mandatory Communicable Disease Reporting

Answer 7

• the Health Protection and Promotion Act (HPPA) outlines the communicable diseases that are designated reportable in the province of Ontario
• under the authority of the HPPA, Ontario Regulations 559/91, these diseases or suspected occurrences of these diseases, must be reported to the local Health Unit by physicians, laboratories, administrators of hospitals, schools and institutions
• the public health system depends upon these reports of communicable diseases to monitor the health of the community and to provide the basis for preventive action

Question 8

Mandatory Reporting Legislation

Answer 8

• gunshot wounds
• child abuse or neglect
• suspected elder abuse or death
• health conditions that make it dangerous to drive, operate rail equipment
• births, stillbirths and deaths
• communicable disease or adverse reactions to immunization
• fraud in health cards (OHIP)
• Sexual abuse

Question 9

Mandatory Gunshot Wounds Reporting Act

Answer 9

Mandatory Disclosure: “public hospitals to report the name and location of anyone being treated for gunshot wound”

the law says…
- “gunfire poses serious risks to public safety and that mandatory reporting of gunshot wounds will enable police to take immediate steps to prevent further violence, injury, or death”
- must be reported orally and as soon as reasonably practicable…without interfering with the person’s treatment or disrupting regular activities of the facility
- Facility = defined by the Public Hospitals Act, but can also be any organization/institution/clinic that provides health care services
- protection from liability

Question 10

Federal Firearms Act

Answer 10

“requires individuals to obtain a license to purchase a firearm and/or ammunition

• mandatory training program when purchasing firearms
• tougher border control

Question 11

Personal Health Information Protection Act and Regulated Health Professions Act

Answer 11

“both acts required that all regulated health care providers in Ontario had a fiduciary duty to respect patient confidentiality unless disclosure was permitted in limited circumstances established by law as being in public interest”

Question 12

Policy Options to Reduce Violent Crime

Answer 12

1. Mandatory Reporting of all cases of criminal activity
2. Mandatory reporting of certain types of criminal activity
3. Voluntary reporting of criminal acts with or without the consent of the individual involved
4. Increased educational support to address the connection between the social determinants of health and gunshot wound reporting
5. Increased support of healthcare provider confidentiality

Question 13

Shoot and Tell…A good thing?

Answer 13

two sets of arguments have been made in support of mandatory reporting of gunshot wounds:
- protection of the public
- violence prevention

the more we know about the causes and the incidence of gunshot wounds, the more proactive we can be about prevention using a broad public health approach while also aiding the ability of the police to protect the public from the perpetrator

Question 14

Shoot and tell…Some Issues

Answer 14

• fiduciary duty: Highest standards of care at law - requires physicians to act in good faith (a la virtue ethics) for the sole benefit and best interests of their patients
• confidentiality: Owe patients a physical, legal, ethical and professional duty to not disclose PHI except in limited circumstances. In the context of doctor-patient relationships, confidentiality is a prima facie right
• autonomy: patients have a right to make decisions about their care without the influence of their physician - the physician provides information, but must refrain from making decisions on the patient’s behalf

Question 15

Views on the Legislation

Answer 15

• In 2009, the OMA Emergency Medicine section reaffirmed its support for the current law - but it did not support mandatory reporting of other violent injuries
• gunshot wounds were both more lethal, and could pose “a public health risk to people in the vicinity when the trigger is pulled”
• the huge burden that knife wound reporting would place on health care workers and police is “extremely disproportionate to the minimal potential health benefit”
• current legislation in Canada for gunshot trauma has steered clear of legislating penalties for those people that do not comply with reporting requirements; mandatory is better than voluntary as it does not open possibility of coercion

Question 16

Other Stakeholders?

Answer 16

• Canadian Association of Emergency Physicians - FOR
• Ontario Medical Association - FOR
• College of Nurses of Ontario - AGAINST
• Registered Nurses Association of Ontario - AGAINST
• Ontario Hospital Association - FOR
• Ontario Association of Chiefs of Police - FOR
• Family Violence Prevention Fund - AGAINST
• General Public - ?
• Ontario Minster of Health and Long-Term Care - ?
• Mayor of Toronto - ?
• Doctors - ?

Question 17

Ethical Considerations: HCPs

Answer 17

• already bound by fiduciary duty and duty to report for other situations
• more harm than good?
• retaliation by the perpetrator and concern regarding breached confidentiality: this can damage trust relationships between the victim and the HCP
• compromise of trust deters victims from seeking help or returning; this, in turn, may jeopardize the safety of such potentially vulnerable individuals
• law removes ability to exercise judgement and make decisions; disclosure should depend on professional assessment of not only the injury, but the context in which it occurs

Question 18

What about Patient Confidentiality?

Answer 18

exceptions to the duty of confidentiality include:
- patient consent
- duty to warn - patient poses a foreseeable risk to identifiable 3rd party
- public safety exception - clear, serious and imminent threat of physical or psychological harm

Question 19

Fundamentals of PHIPA

Answer 19

• establishes rules for the collection, use and disclosure of personal health information while at the same time facilitating the effective provision of health care;

provides individuals with the right to:
- access their personal health Information (PHI)
- correct their PHI if it is incorrect
- place restrictions on their PHI - “consent directive”
- be notified if PHI is stolen or lost
- challenge an organization’s privacy practices
- request an independent review and resolution of privacy complaints (IPC)

Question 20

What is PHI

Answer 20

any identifiable information about an individual, either living or deceased and includes information about their:
- the physical or mental health of the individual
- any health service provided to the individual
- donation of any body part or any bodily substance of the individual
- results of testing or examination of a body part or bodily substance of the individual

includes information collected in the course of providing health services to the individual, e.g. demographics, health card number, identity of health care provider, name of substitute decision maker

Question 21

What is identifiable Patient Information?

Answer 21

information is identifiable when it is unique to an individual. Examples include:
- name, medical record number (MRN), or health card number

information that, when used in conjunction with other information could re-identify an individual. Examples include:
- date of birth + surgical procedure + name of surgeon + date of surgery
- postal code + diagnosis/condition (unique/rare condition in a small population

Question 22

Circle of Care

Answer 22

• a person/group of persons providing care to the individual
• episode of care
• is an informal reference and is not defined under PHIPA but can include

Question 23

Who or what is a HIC?

Answer 23

Health Information Custodian
- person or organization that has custody and control of personal health information
- is legally responsible for PHI on all of its patients regardless of the purpose for which the PHI si used (e.g. health care, research, education, quality assurance), regardless of the format (e.g. hard copy, electronic, verbal)
- can include a hospital, an independent health facility, a physician in a private practice, a physician as part of a family health team

Question 24

Who or What is an Agent

Answer 24

In relation to PHIPA, an agent is:
…a person that, with the authorization of the custodian, acts for or on behalf of the custodian in respect of personal health information for the purposes of the custodian, and not for the agent’s own purposes

can be employees, physicians, third party vendors, volunteers, students, etc.

Question 25

Use of PHI by the HIC - acceptable

Answer 25

• for the purpose it was collected (provide health care)
• obtaining payment for providing health care
• risk management/error management
• program planning/delivery
• education of agents to provide healthcare
• a proceeding where the custodian/agent or former agent of the custodian is expected to be a party or witness
• research conducted in accordance with PHIPA

Question 26

Acceptable Reasons for Disclosure

Answer 26

• within the “circle of care”
• chief medical officer
• a prescribed entity (CIHI, CCO, etc.)
• significantly reduce the risk of harm (individual/group)
• SDM or acting Power of Attorney for Care
• the parent of a child
• …and other circumstances defined in the legislation

Question 27

Disconnect Between PHIPA and the Mandatory Gunshot Wound Reporting Act

Answer 27

• provider-patient relationships
• collection, use and disclosure of PHI
• the MGWRA becomes an ‘acceptable reason for disclosure’ and supersedes PHIPA
• Police do not have to abide by PHIPA
• accidental incidents still must be reported

Question 28

Violence and a Public Health Approach

Answer 28

• Aim: prevent the loss of 60,000 lives and countless traumas each year
• violent behaviour arises from contextual, biological, environmental, systemic, and social stressors
• A “trauma-informed” approach suggests that violence is not symptomatic of “bad people” - instead it is a negative health outcome resulting from exposure to numerous risk factors
• the public health approach to violence focuses on prevention through addressing the known factors that increase or decrease the likelihood of violence.

Question 29

APHA 2018 - Basis for Public Health

Answer 29

Beyond direct injury, exposure to violence increases the risk of:
- asthma, hypertension, cancer and stroke
- contributes to psychiatric illness, including depression and post-traumatic stress disorder
- those who are exposed to violence are more likely to sleep poorly, to smoke, and to become socially isolated, all added risk factors for early death
- negative health outcomes are also seen in statistics related to HIV, maternal health, and adoption of unhealthy behaviours such as alcohol and substance abuse

Question 30

Positive Outcomes in the USA

Answer 30

• a Chicago program using public health methods to interrupt violence, reduce risk, and change neighbourhood norms reduced homicides and shootings by up to 70% and retaliations by 100%
• in Baltimore, one historically violent neighbourhood went more than 22 months without a homicide after implementation of the same model
• In new york city, the John Jay College of Criminal Justice Research and Evaluation Center released an extensive independent evaluation of the local Cure Violence program that showed a 37% to 50% reduction in gun injuries in the two communities examined, a 14% reduction in attitudes supporting violence (with no change in the control groups), and increased confidence in and willingness to contact police