Week 11 (Nov 19th)

Question 1

PROactive vs. RETROactive

Answer 1

Proactive is the public health approach

Question 2

Mandatory Communicable Disease Reporting

Answer 2

• 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 3

Mandatory Reporting Legislation

Answer 3

• 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 immunizaiontion
• Fraud in health cards (OHIP) Sexual abuse

Question 4

Mandatory Gunshot Wounds
Reporting Act

Answer 4

Mandatory Disclosure: “public hospitals to report the name and location of anyone being treated for gunshot wound” (p. 455 Deber, 2014)
- Location where they were shot, where they were treated.

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 5

Federal Firearms Act

Answer 5

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

Question 6

Personal Health Information Protection Act and Regulated Health Professions Act

Answer 6

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

Question 7

Ontario vs. Saskatchewan

Answer 7

See slides

Question 8

Policy Options to Reduce Violent Crime

Answer 8

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 9

Shoot and Tell…A good thing?

Answer 9

• 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 (see
  Chapter 1, section 6.3.1, Public Health) while also aiding the
  ability of the police to protect the public from the
  perpetrator

Question 10

Shoot and Tell…Some issues

Answer 10

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 influence of
their physician – physician provides information, but must refrain from making decisions on patient’s behalf

Question 11

Like it?

Answer 11

• 2009, OMA Emergency Medicine section reaffirmed their support for current law – but they 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 12

Other Stakeholders for or against the legislation

Answer 12

• 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 Minister of Health and Long-Term Care-?
• Mayor of Toronto -?
• Doctors-?

Question 13

Ethical Considerations: HCPs

Answer 13

• Already bound by fiduciary duty and duty to report for other situations
• More harm than good?
• Retaliation by the perpetrator and concern re: 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 judgment and make decisions; disclosure should depend on professional assessment of not only the injury, but of the context in which it occurs.

Question 14

What about Patient Confidentiality?

Answer 14

• Exceptions to duty of confidentiality include:
• Patient consent
• Duty to warn - patient poses a foreseeable risk to
  an identifiable 3rd party
• Public Safety exception – clear, serous and
  imminent threat of physical or psychological harm

Question 15

Fundamentals of PHIPA

Answer 15

• 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 stolen or lost;
   challenge an organizations’ privacy practices;
   request an independent review and resolution of privacy complaints (IPC).

Question 16

What is PHI?

Answer 16

• Any identifiable information about an individual, either living or
  deceased & includes information about their:
• 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 17

What is Identifiable Patient
Information?

Answer 17

• 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 18

Circle of Care

Answer 18

• 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 19

Who or What is a HIC?

Answer 19

• a person or organization who has custody and control of personal health information
• is legally responsible for personal health information (PHI) on all of its patients regardless of the purpose for which the PHI is 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 20

Who or What is an Agent

Answer 20

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 21

Use of PHI by the HIC - acceptable

Answer 21

• 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 health care
• 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 22

Acceptable Reasons for Disclosure

Answer 22

• within the “circle of care”
• chief Medical Officer
• 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 23

Disconnect Between PHIPA and the
Mandatory Gunshot Wound Reporting Act

Answer 23

• 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