It seems you can’t open a magazine, turn on the TV, or even sit down to a holiday family dinner these days without hearing the word “keto.” What exactly is keto, and why should we as healthcare providers be paying attention?
Ketogenic diets fall under the broader umbrella of LCHF diets: Low Carb High Fat. Some call it Low Carb Healthy Fat to emphasize that a LCHF diet is based on healthy whole foods such as dairy, nuts, seeds, avocados, olive oil, meat, and fish. In fact, this is likely where a lot of the benefits are derived: shifting people to whole foods. LCHF diets cover a wide spectrum of carbohydrate intake, but in general, a daily carbohydrate intake of less than 130g per day is considered LCHF, and is described as low carbohydrate. A ketogenic diet is a diet in which carbohydrate intake is restricted to the point that the primary fuel source for much of the body and brain becomes fatty acids and/or ketones. Intake in the < 50g range is considered ketogenic. For context, the average Canadian eats 250-350g of carbohydrates per day, often from sources such as added sugars, refined grains, and ultra-processed foods like baked goods or prepared meals.
Historically, the first time carbohydrate restricted diets were described in the medical literature was in William Banting’s 1864 “Letter on Corpulence,” where he described his own weight loss and improved health using this approach. In the early 20th century, LCHF was the mainstay for treatment of diabetes, and endorsed by medical luminaries such as William Osler and Elliott Joslin, but interest waned once exogenous insulin became widely available. In 1921, the ketogenic diet was introduced at the Mayo Clinic for the treatment of epilepsy, and for the majority of the last century, that has been the only medical condition for which it’s been prescribed. Low carbohydrate diets gained popularity for weight loss in the 1970s through to the 1990s, the most well-known being the Atkins diet. At that time, dietary recommendations such as those published by the American Heart Association recommended keeping fat intake to a minimum as it was felt to be a major contributor to heart disease, and so LCHF diets were dismissed as dangerous.
There has recently been a resurgence of interest in low carbohydrate diets as clinical interventions for a variety of conditions. This has been fueled to some degree by patient experiences with these diets, which are then amplified through social media. The body of evidence for its safety and efficacy has also grown substantially. In April 2019, the American Diabetes Association released a Consensus Statement, which reads: “Reducing overall carbohydrate intake for individuals with (Type 2) Diabetes has demonstrated the most evidence for improving glycemia.” Several other worldwide Diabetes organizations, such as those in Europe, Australia, and the U.K., have released similar statements. Low carbohydrate/ketogenic diets, along with very low energy diets and bariatric surgery, have been shown to substantially increase rates of diabetes remission compared to standard management. A recent Western Australian government report stated that remission, rather than just management, should be the goal of interventions for Type 2 Diabetes. Given the growing prevalence of Type 2 Diabetes — currently 11 million Canadians are living with prediabetes or Type 2 Diabetes — it behooves us as health professionals to understand what constitutes a low carbohydrate/ketogenic diet, the specific considerations for patients following them, and that remission of Type 2 Diabetes is possible through the use of carbohydrate restriction.
The rationale for diets that restrict carbohydrate is the following: the pancreas secretes insulin in response to ingested carbohydrates, and to a lesser degree, to protein. Many factors affect insulin secretion, but certainly the degree of refining or processing of the carbohydrate affects the rapidity of the insulin rise, the peak insulin level, and how quickly insulin returns to normal. This is reflected in postprandial blood glucose levels. In those who are insulin resistant, we often see higher blood glucose levels, and longer times to return to baseline. We now understand that insulin resistance is present in many chronic diseases beyond Type 2 Diabetes. Among these, the most common are Hypertension, Cardiovascular Disease, Osteoarthritis, and Alzheimer’s disease. It remains unclear how large a role chronically elevated insulin levels (hyperinsulinemia) plays in the development of these diseases, but it is clear that decreasing carbohydrate intake reduces insulin secretion and decreases hyperinsulinemia. In the setting of low insulin, glucagon stimulates ketone body production in the liver. Ketone bodies, along with free fatty acids, serve as a fuel source for tissues, but ketogenesis isn’t the goal of these diets, other than in specific therapeutic circumstances.
Historically, resistance to ketogenic diets are based upon some of the following concerns:
“The brain needs glucose.” Traditionally, the minimum Dietary Recommended Intake for carbohydrates has been 130g. The brain’s glucose requirements can be adequately met through gluconeogenesis, glucose generated from fat and protein. Ingesting carbohydrates is not a requirement to meet the brain’s glucose needs. In the setting of carbohydrate restriction, ketone bodies also provide energy for the brain and other tissues.
“Ketogenic diets lead to ketoacidosis.” A ketogenic diet, and the state referred to as “nutritional ketosis,” is not ketoacidosis. Serum levels of ketones are in the range of 1-4 mmol/L, are accompanied by adequate basal insulin levels, and low blood glucose. Ketoacidosis occurs most often in people with Type 1 Diabetes, very rarely in people with Type 2 Diabetes, and results from a lack of insulin and markedly elevated blood glucose levels.
“A ketogenic diet lacks essential nutrients.” The nutrient cited most often is fibre, as cereals and whole grains are eliminated on these diets. Adequate fibre can be obtained through above ground vegetables, seeds and nuts, as well as other sources. A more liberal approach permits small amounts of beans, legumes, and fruit, which also provide fibre.
“A ketogenic diet is high protein/high in meat.” Ketogenic diets are by definition not high in protein and LCHF diets are moderate protein, in the range of 0.8-2g/kg per day, depending on the nutritional needs of the individual.
Finally, those most opposed to ketogenic diets will state, “These diets are unsustainable, highly restrictive, and/or dangerous.” The large body of evidence for the safety and efficacy of carbohydrate restriction shows the opposite, so these views should be reconsidered.
From a practical standpoint, what constitutes a LCHF/ketogenic diet? Contrary to popular myths, people eating LCHF diets are not living off of buttered coffee and bacon. Their diets include: above ground vegetables, meat, fish, dairy, seeds and nuts, avocados, and olive oil. For those adopting a more liberal approach, fruit, beans and legumes can be eaten in small quantities. Sugar and refined grains are eliminated, as are ultra-processed foods. Those in the healthcare community who promote LCHF diets promote a diet that, ideally, is based entirely on whole foods, but there is also recognition that this can be challenging for those living in poverty, or lacking food and health literacy.
Taking all of this into consideration, there are several reasons why we as healthcare providers must increase our understanding of these diets. First, the public is looking for alternatives to medications and surgery. Dietary choices are one of many factors contributing to chronic disease, and supporting patients in making healthier dietary choices can prevent and even reverse some diseases. Second, ketogenic diets have profound, often rapid, physiologic effects, especially with regards to blood pressure and glycemia. Patients adopting these diets who are on medications for Hypertension, Type 1 Diabetes, or Type 2 Diabetes must be counselled to be vigilant, as well as on how to reduce their anti-hypertensives, hypoglycemics, and insulin. It’s important to note that SGLT2is are of particular concern, as they have been associated with Diabetic Ketoacidosis, and little is known about causal pathways. Those on ketogenic diets should be counseled on the risks, and prescribers should consider discontinuing SGLT2is in patients who are on or considering low carbohydrate or ketogenic diets.
The question of what happens to cardiovascular risk and lipids is the one raised most often by health professionals when this dietary approach is presented. With adoption of LCHF diets, biomarkers usually change as follows: TGs decrease, HDL increases, glycemic control/HbA1C improves, HTN improves, hsCRP improves, LDL atherogenicity improves (moves from pattern B to pattern A). In a minority of people, LDL does increase, and in a very small minority of people, it increases dramatically. These individuals and their physicians are then faced with the dilemma of having to address a high LDL when the diet that caused it has improved other markers. In these cases, replacing saturated fat in the diet with unsaturated fat often improves LDL. If it doesn’t, statins may be discussed in the context of other risk factors. Prior to starting a low carbohydrate diet, baseline lipid testing is very useful to enable tracking of the impact of nutritional changes.
Although social media platforms have allowed for the success of online “gurus” who perceive LCHF diets as a “cure all,” it is not an appropriate intervention for all people, and should be tailored to the individual patient’s needs and health goals. Its use in seizure disorders is well-established. With the recent ADA Consensus Statement, low carbohydrate/ketogenic diets will become a dietary pattern offered as Nutrition Therapy to patients with Type 2 Diabetes. The use of low carbohydrate/ketogenic diets in Type 1 Diabetes is growing, but robust long-term data are lacking. A very active community of people with Type 1 Diabetes have adopted these diets, and some early research has been published. The groups studied showed significantly better glycemic control with greatly reduced variability in glucose levels — fewer highs and perhaps more surprisingly, fewer lows.
These diets are also being studied in neurologic disease, including dementia, as there is interest in whether ketone bodies are an effective alternative fuel source for the brain.
There are many studies looking at the anti-inflammatory properties of ketone bodies and whether they might prevent or alleviate symptoms of chronic inflammatory diseases.
Additionally, there is very early research looking at ketogenic diets as an adjunct to traditional treatment for specific cancers, either to increase the efficacy of the treatment regimen, or to reduce side effects related to treatment regimens.
The literature has shown LCHF diets to be as effective as low-fat diets with regards to weight loss. There may be some evidence that ketone bodies reduce hunger, which may improve adherence to the diet. As is true for all weight loss diets, some people respond particularly well to one approach, while others do not. Obesity is a chronic disease, with patients often requiring lifelong support in order to adhere to their diet and avoid weight regain. Unfortunately, these types of long-term support programs are virtually non-existent in Canada.
If you’re wondering where to start in supporting patients who may be interested in or require a LCHF diet, there are an increasing number of resources available for healthcare providers to learn more about the use of carbohydrate restriction as part of a “food-first” approach to chronic disease management. Clinical Guidelines for its use were recently published and are available at https://www.lowcarbusa.org/clinical-guidelines/
Several Canadian organizations are preparing health professionals to safely provide guidance to patients wishing to pursue these diets. More information on these organizations can be found at www.therapeuticnutrition.org (Institute for Personalized Therapeutic Nutrition) and www.ccfortn.ca (Canadian Clinicians for Therapeutic Nutrition).
Miriam Berchuk, MD, FRCPC
Diplomate of the American Board of Obesity Medicine Department of Anesthesia, Rockyview General Hospital, Calgary
Things I learned in my first ten months of practice
Attention fellow new-in-practice physicians and residents: here are ten pieces of wisdom I’d like to pass on from my first ten months of practice as a family physician
1. You can never give yourself too much time for paperwork
Any assumption I had that I would only need a few minutes at the end of my day to chart and be done the day’s work was demolished by 4 p.m. on my first full day of practice. Learning how to chart as I go has allowed me to be at least somewhat finished by a decent hour each day.
2. No one looks for lost billing, and the government doesn’t care
Every physician probably under-bills during their first year of practice, and hopefully it’s limited to that. I regularly touched base with my colleagues to see how they structured their billing to ensure I wasn’t missing anything major. As a rural family physician, I had to learn in-patient, emergency, clinic, and long-term care billing. Running a billing question by my colleagues was very helpful in discovering what I didn’t know.
3. The EMR thinks it is smarter than I am
I came up against numerous glitches in our EMR that had me convinced that I was in the wrong at times — like when the EMR told me that some form of iron replacement therapy available by prescription no longer existed. Fortunately, a prescription pad and a pen with a quick documented note in the chart overcame that.
4. It is important to block off random days and half-days
I discovered how important it is to periodically book a half-day off. Whether it was to be used for wellness (read: taking my wife out for lunch to remind her what I look like) or just paperwork, it was an important part of the week. I found that if I was relatively rested and caught up, I could open it up to patient visits a few days prior, and it inevitably filled up.
5. Come out swinging
I structured my patient meet and greets with a firm but friendly approach. If the patient had a current family doctor, I asked them what exactly they expected me to do differently than their current MD. I also let patients on benzos and opioids know that if they wanted to come and see me, we would be working on tapering strategies. Unsurprisingly, some patients have not returned.
Similar to point #5, some patients arrived for a meet and greet wanting to go on long-term disability, and expected me to fill in the forms for them that same day. I declined, and suggested they return for a head-to-toe exam and an opportunity to look through their health records with me to see if they qualify. This gave me time to check their records and see them again, armed with information to discuss with them.
It felt as though I was barely breaking even financially over the first few months. Loan and interest payments were coming due and registration fees, my split, office furniture, and membership dues were coming off the top. Plus, some days were less busy and weren’t fully booked. But as days became busier, major asset purchases were finished, and I found efficiencies in my schedule, the income flow evened out.
There should be more teaching in medical school and residency on the importance of your relationship with your staff. Arriving at an established clinic made the transition relatively seamless, as staff were already familiar with each other – but the importance of fostering good relationships with staff can’t be stressed enough. It was easy to forget just how much they would go to town for me on an almost daily basis, from ensuring my schedule was just full enough, to moving patients to give me a half day to catch up, to appealing the many rejected bills I clumsily attempted to submit before I knew what I was doing.
9. Paperwork flow
During my first two months of practice, I only worked in my local emergency department and did a handful of walk-in shifts. I progressed to meet and greets in my third month. These first two months allowed me time to figure out the EMR, establish my paperwork routine, and ask the other doctors all of my inane and simple questions, without the pressure of 20 patients waiting to see me in the waiting room. By the time I was doing 15-minute appointments, my workflow was established.
10. Being a doctor
It was easy to forget amidst everything that I was officially a family doctor for many people, and that the relationship building when patients began coming back to see me was everything I had hoped for in medicine. Sure, some patients are needy, some ignore my medical advice, and others refuse to help themselves. But I discovered that for the most part, they are all grateful to have a doctor and a familiar face to return to.
And I am grateful to be their doctor. Just so long as I don’t forget all the things I’ve learned in my first ten months.
Gregory Sawisky, MD, CCFP
Family Medicine, Ponoka, Alberta
Dr. Gregory Sawisky completed medical school at the University of Alberta in 2016. He completed his rural family medicine residency through the University of Alberta’s Red Deer Regional Hospital location in 2018. He now practices full-scope rural family medicine in Ponoka, Alberta.
Read the complete June issue here
Healthcare is always an election issue in Alberta — and rightly so, as it accounts for more than 35 per cent of the provincial budget.
But in the 2019 Alberta general election, healthcare wasn’t — for once — the dominant issue. As the Primary Care Network Physician Lead for the Calgary Zone, I see that as a positive sign; maybe even cause for cautious optimism.
There was still plenty of debate and discussion about healthcare, of course. The response to the opioid crisis, access to care throughout the system, and the need for mental health services and support came up frequently. These are important issues and we need Albertans to be engaged and involved in these discussions.
Perhaps we are starting to see Alberta take small steps towards what the province’s Auditor General described in his 2017 report as the depoliticizing of healthcare and a renewed focus on patients’ needs. Merwan Saher’s report, titled “Better Healthcare for Albertans”, outlined the need for government, legislators, healthcare providers and the general public to contribute to realizing the vision of a fully-integrated health care system. This vision sees patients engaged and empowered to take an active, responsible role in their own care. We have made strong progress in recent years, but there is much work to be done.
Maybe I’m guilty of looking through rose-coloured glasses, but I think we saw a growing consensus about the importance of primary care during the recent election; of the need to build strong medical homes and create patient-centered care.
The work PCNs have done to establish Alberta as a leader in Medical Home adoption was recognized in the College of Family Physicians of Canada’s Report card on medical home implementation in February 2019.
In the Calgary Zone, our physicians and Primary Care Networks have a long history of partnership and collaboration that predates the formal governance structures implemented in 2017. The strong relationships we had already developed gave us a solid foundation on which to build. That spirit is reflected in our mission statement, ‘Better together’ — leveraging our strengths and sharing our resources to better serve patients through the integrated patient’s Medical Home (iPHM).
Some examples of the work we’ve done through these partnerships include:
Specialist LINK: Family doctors and specialists are connected through a real-time advice line and other resources that help ensure patients receive the right care by the right provider. The tele-advice line helped avoid 2,898 unnecessary consults and ER visits last year – cutting wait lists and saving the system more than $1.2 million since its inception.
Find a Doctor: The Calgary Zone helped spearhead a new provincial Find a Doctor website at albertafindadoctor.ca that has made it quicker and easier for all Albertans to find a doctor.
Supported transitions: Ensuring patients transition safely from home to hospital, and hospital to home, is central to our work in this area. In the last year, more than 60,000 hospital admission and discharge notifications were sent to help ensure better continuity of care.
Opioid response: The Calgary Zone is working hard to support family physicians and patients as part of the urgent response to the opioid crisis in Alberta. Training and other supports are central to our strategy.
As physicians and PCNs, we have a key role to play in supporting efforts to ensure patients are at the heart of the healthcare system. As the Calgary Zone Physician Lead, I am a representative of the Calgary area and advise the ministry through the provincial PCN Committee. This committee is chaired by the Assistant Deputy Minister of Health, Workforce Planning & Accountability Division, and attended by two other Assistant Deputy ministers, senior AHS leaders, Zone PCN dyads, and AHS and AMA provincial leaders. We are partners, aligned to improve healthcare for Albertans.
A new government can bring change, but it can also bring opportunity. The United Conservative Party’s platform points to the importance of primary care and recognizes the need to fill gaps in mental health services and tackle the opioid crisis. These are priorities that closely align with the work we are already doing in the Calgary Zone and, in fact, throughout the province.
I’m looking forward to working collaboratively with the incoming government, alongside my colleagues and partners, to continue to move our work forward and address the challenges we face in delivering better patient care.
It’s not easy to build a fully-integrated healthcare system. There’s no simple solution or quick fix. The government may have changed but our work continues. Let’s get to it.
Ernst Greyvenstein, MBChB, CCFP FCFP Dip. PEC
PCN Physician Lead, Calgary Zone; South Calgary PCN Board Chair; SAPCA Director; Clinical Associate Professor University of Calgary; Medical Director Circle Medical Ltd.
On April 16th, Albertans elected the United Conservative Party, led by Jason Kenney, as the new provincial government. It’s common for healthcare to be at the forefront of political debate, and this election was no exception.
As is the nature of politics, promises made during campaigns don’t always translate into visible, concrete changes. However, official platforms and statements provided throughout the course of the election can give us a sense of the UCP’s priorities, and their stance on key issues in Alberta healthcare.
As physicians, it’s important to stay informed when it comes to politics, no matter who is in power. Below is a brief evaluation of where Jason Kenney and the UCP stand on some major healthcare points, as well as specific promises that have been made thus far.
Universal & private healthcare
“Supporting a universal, comprehensive healthcare system is a core part of the UCP’s policy declaration agreed at our founding conference,” Kenney stated at a news conference in Edmonton in February. He also promised to maintain, but not necessarily increase, current spending on healthcare — which was $22 billion last year, or about 40 per cent of the provincial budget.
Kenny also said the UCP is open to exploring private healthcare options, noting that private care for minor procedures had reduced wait times in provinces like Saskatchewan. The UCP’s platform (available in full online) gives the example of inviting third-party surgical clinics to bid into the publicly insured system, meaning surgeries would be contracted out to these clinics.
Alberta Health Services
One of Kenney’s main campaign promises was that within his first 30 days in office, the UCP would “commission a comprehensive performance review of Alberta Health Services,” with the purpose being to “identify possible savings and efficiencies and to reallocate significant resources away from administration to front-line service delivery.”
The UCP projects that this review will cost between $2-3 million, and is aiming to have it completed by December 31st of this year. According to the UCP’s official platform, “subject matter experts from an outside consultancy firm will be assigned to employee teams.” These employee teams will then, “solicit cost-savings, best practices, innovative delivery mechanisms, etc. from front-line employees and recommend ways to cut costs and improve service.”
Addiction & mental health
Speaking in Calgary at the end of March, Kenney said the UCP would conduct a review of operating safe consumption sites throughout the province to see if there are better locations, “that could provide the service without creating a serious crime problem.”
Kenney also promised to appoint an associate minister of health focused solely on addictions and mental health. This part of the UCP’s platform also includes: expanding support for opioid treatment centres, adding detox beds and mobile detox programs, and a $5-million per-year investment for drug treatment courts. Mental health funding was promised at $100 million over four years, and Kenney said this funding would further support First Nations and Metis peoples in accessing mental health and addictions treatment.
The UCP promised to lift the cap on midwifery services in Alberta, with Kenney noting that midwives are cost-effective and help relieve burden from the primary healthcare system.
The official platform also promises $20 million over four years in palliative care funding, and $5 million per year to sexual assault centres.
What has been done so far?
As promised during the campaign, as of April 22nd, the UCP halted construction at the site of the proposed “superlab” in Edmonton. The $590-million project was aimed at consolidating lab services at a site in south Edmonton. Kenney previously called the project “unnecessary” and said cancelling it would save important funds for the province.
Vital Signs Staff
Show Me The Money
This memorable line from Jerry Maguire danced in my head as I ruminated after the CMA presentation given at the most recent AMA Representative Forum this past March. The activation of my irritated emotional quotient highlighted the fact that the residue from the MD-Scotia transaction had yet to wash away. And, judging by the pleasant feedback given by many of those in attendance, the same may be said for them.
Despite the passage of time, the harm from the CMA Board’s mishandling of the messaging following the sale seems to be slow in its healing. In fact, scars of mistrust are likely to remain. From a personal perspective, I hold no grudge on how the process had to unfold to allow for the sale to conclude successfully for all parties. As a Board member of the Calgary West Central PCN, we received a polite ‘request’ from Alberta Health to enact a hard turn on our business plan, which would fundamentally shift the landscape of the embedded allied health services working in our member clinics. Due to the sensitivity of this process and the bureaucratic machinations associated with it, we did not inform the members until the deed was done. Needless to say, despite our best efforts to qualify what had to be done and why, the physician response was robust. And, as part of a cautionary tale to my fellows in Ottawa, the looks we still get from the gallery at subsequent AGMs could turn those of us at the head table into fine looking statuary to adorn any local garden. This, even though the changes were made almost four years ago! It seems hurt can linger and memories can be sharp.
Given the above experience, I feel empathy for the CMA Board, as I know all too well how one’s hands are tied when working within particular constraints on complex processes. However, it has been the patronizing tone and outright dismissal of CMA member concerns that continues to breed conflict within the national organization. Exemplifying this is the debate within our own province to cease conjoint dues that, when collected for AMA membership, allow physicians to voluntarily join the CMA. Some colleagues have lobbied hard to have their fellows continue to be part of the CMA, stating that it is easier to court change in an organization when one is a member of the organization. This is particularly true if the leadership appears to receive and act upon reasonable insights from the membership at large. In this case, it has been demonstrated repeatedly that the leadership is willfully ignorant to address poignant requests to listen to the needs of its members.
Whoa — pretty heavy language there, right? Well, prove me wrong. Since the MD-Scotia deal, the CMA has transformed its title in a self-congratulatory form, by proposing to use the money received to fund grand (and optically favourable) programming, which will come at the expense of refusing to enact thoughtful forms of programming to support the members on which they stand. Some food for thought on alternatives:
1. The Canadian Medical Subsidy Association: Member physicians (by report) pay massive amounts of taxes to assist in funding the system that plies our trade, a system we should not be responsible to subsidize, even as we are aware of its deficits.
2. The Canadian Medical Charity Association: Member physicians already donate personal time and money to multiple causes that speak to them at a personal level. Seems the Board has tapped into the hive brain to figure out what priorities all members would want the money to go to. Amazing.
3. The Canadian Medical Advocacy Association: Prior to the windfall, the CMA and Boards (both past and present) had successfully taken part in many dialogues at the national level on issues important to member physicians and their patients. Again, this all happened successfully without billions in hand.
Now, the Board would likely protest by saying that they have members’ best interests in mind. They would be quick to point to the newly incepted Physician Wellness Program, ostensibly derived to explore methodology to offset physician ill-health and burnout. Here’s a thought: a WELL doc is a WEL-FUNDED doc. (Take note I said well-funded, not wealthy doc… that term seems to be reserved for barbers only). In talking to my colleagues, beyond patient and system stressors, financial challenges to taking adequate time away from work while also attempting to create a war-chest to retire from are near the top of the list. The sticking point around creating a pension fund for member physicians continues to galvanize conflict, as the Board seems oblivious or unwilling to address this need.
I’ll anchor the end of my frustrated diatribe on two quotes from the film Cinema Cruise: ‘Help me help you.’ What I suggest is the Board put a hold on any more dispersements of funds from the sale into programming it presumes the members wish to support, and hold formal discussions with stakeholders to address the true potential for creating pension programming for member physicians. Remember, all investments start from nothing, but given the chance, can grow to be quite something (RE: ‘You complete me’). It behooves the Board to remember that the value of MD came from the investments of their fellow physicians and their families. It also behooves the Board to remember that the CMA exists due to its member physicians — the member physicians do not exist because of the CMA. All organizations must pay heed to this, as discounting member feedback and dismissing member needs is something any Board would do at their own peril. Trust me, I know.
Scott F. Beach, MD, CCFP
Medical Editor, Vital Signs
Keep the Story Flowing: A Family Doc Perspective on the Coming of Connect Care and CII/CPAR
Connect Care and CII/CPAR will be a transformational change for the health system in Alberta. Connect Care will bring under one umbrella all of the varied health information systems working within Alberta Health Services, and whether you work in an AHS facility or not, this change will impact all health care providers.
As a front-line family physician and working on the Connect Care project, I have had to reflect on how this initiative will impact my practice and my patients, as well as answer some questions many doctors may have.
How will Connect Care and Community Information Integration/Central Patient Attachment Registry (CII & CPAR) impact me?
More relevant to community family physicians, the CII/CPAR project will impact many family doctor offices, especially those who are in the midst of, or have completed, their transition to the Medical Home. All of us are aware of the informational gap that occurs when an Albertan transitions from an AHS facility back into the community. The health story generated from their journey is often complex, convoluted and fragmented. On the same footing, an Albertan who needs to enter an AHS facility does not have the benefit of a curated and clinically relevant information that is housed in the various EMR’s used in the community. Some readers may be wondering if Connect Care will facilitate this transfer of information, and what will be required to keep the patient story going. At this time, these questions remain unanswered.
But within the midst of this transformation, remember: history has taught us that things change slowly in health care. I expect my day on day one of Wave One will look pretty similar to my other clinical days. Community docs adopt change in an incremental way, and only if there is some sort of value add to the care of their patients and the efficient workflows in our respective community clinics. Once a particular functionality of Connect Care impacts one of my patients, I will probably react somewhat skeptically and test the added value of a certain feature of Connect Care. Like most community docs, those aspects of Connect Care that prove useful to me in my day to day work will be those features I will continue to use, and I will not use features that do not provide any visible benefit.
I can only ask that the introduction of these features be done in a way that engages community providers in a collegial and thoughtful manner. I also ask of my community colleagues to realize the importance of sharing the relevant portions of those curated, up-to-date, and insightful EMR patient stories with our often equally beleaguered AHS colleagues, who also take on the task to care for our patients. If we can leverage technology to make this job easy and manageable, then is this not better for both physicians and patients?
In the end, I realize that the Connect Care implementation is a huge deal for our colleagues within the AHS fold, but for those in the community very little will change on the first day of Wave 1. But things will change, and hopefully the introduction of Connect Care to the community will be constructive, beneficial and, at worst, tolerable. I do hope this endeavour will inform us on the importance of the patient story and the need to keep that story flowing.
What WeNeed to Make it Work
It is clear that when a patient story flows easily and efficiently across the continuum of healthcare in Alberta, it is beneficial to patients. To this end, a list of principles has been developed to serve as a guide for those tasked with the construct and implementation of Connect Care in the hopes to maintaining, at a minimum, the current work environment for community physicians and to act as a blueprint for the future.
1. Keep what is present and move forward (i.e., no backwards steps).
2. Maintain eDelivery of lab and reports, as it is the main way community physicians see their health information
3. Engage patients in this process of implementation
4. Netcare and Connect Care must co-exist after Wave 1
5. Work smart to move forward
6. Watch for unintended consequences
7. Don’t make things worse when Connect Care comes.
8. Maintain information flow across the continuum.
9. Patients need access to their information
10. Maintain current levels of EMR integration and move forward positively
11. Change management for physicians (that means support and acknowledgement of the impact of Connect Care on community physician workflows)
12. Evaluation – it is important to know how we are doing
What About Community Docs Sharing?
I think by now, most of us have heard about this Community Information Integration (CII) project that has been coupled with the Central Patient Attachment Registry (CPAR) initiative. This project is an important component of the Medical Home initiatives being implemented in all parts of the province. Many of us are not in the mindset of continued sharing of health information with the health system outside of our clinic walls, but the CPAR project actually offers us a route to providing a key piece of information for AHS physicians and providers. At present, finding a patient’s family doctor happens in an informal process of directly asking our patients. What happens if the patient does not remember, is mistaken, or may be too sick to respond to this standard question? Needless to say, this ad hoc process is not overly reliable on a system level but imagine the benefits of reliably attaching an Albertan to a particular physician in a way that is continually updated and verified. It would be a significant step to maintaining flow of health information, and this is the potential power behind the CPAR project. Take a minute to reflect on if there is a way to link your patients to your name in a reliable and continually updated fashion, and how it would benefit the care of your patients when they end up in an acute care facility.
Linked to CPAR is the CII initiative, which will enable the sharing to Netcare of particular parts of the clinical information held in the patient records housed in our various community EMR’s. CII also provides a route to allow curated and updated health information and makes it visible to other Netcare-enabled physicians and providers. Again, only specific parts of our EMR information (and not progress notes) is shared. In the very near future, CII will also begin to provide notifications in a push fashion of when ou patients seek out emergency care.
At the present time, the CII/CPAR initiatives have not yet formed strong information flow linkages to Connect Care, but this does need to happen. As we move past day one of Wave 1 of the Connect Care implementation, keeping this vision of bidirectional flow of information by integrating CPAR information with Connect Care needs to be a key foundational goal for our healthcare system.
Thus, a patient panel which is curated, regularly updated and is dynamic has the potential to be a key enabler of health information flow. On the community side, it serves the Medical Home model of care, and to those who provide care in AHS facilities, there will be increased certainty that information will get back to a patient’s family physician. Ultimately, this can only lead to improved patient care and safety. The CPAR project offers the health system a technological solution that links a primary care provider with an Albertan, and making this information visible to all physicians involved in the care of our common patients.
When it comes to Connect Care and its related systems, patients will need to be key partners in each endeavor. Providing patients with an ability to see and add to their story, along with interacting with providers, will prove an important part of keeping the story flowing.
Wayne Chang, MD
South Calgary Medical Clinic, Calgary
Urgency and the Hot Hand
Sounds like a fantastic name for an Arcade Fire tribute band. Unfortunately, this sentiment rings true for an ongoing challenge: continuity with patient flow between care in the Acute setting, to follow-up in the Community clinic.
A thousand years ago (timescale used to make a point that it was a while ago) I started my journey here in Alberta pro-viding locum ER and inpatient coverage for small town hospitals throughout the province. During this time, I became exquisitely familiar with the CTAS triage system of urgency when addressing the wide variety of care concerns that would grace our ER from the rural setting. After my time in the field, I formulated a similar approach in my community clinic with the hope of addressing my patient’s con-cerns in a timely fashion, based on their acuity needs. Nowhere near as fancy as CTAS, I, with my care team, derived a colorimetric scale vis-à-vis a traffic light to guide our appointment strategy and weekly scheduling.
Day to day, our Red-Orange-Green algo-rithm works fairly well, with fit-in spots available each day for red zone needs, and a grouping of slots for orange zone folks who I then address within the week. Although it runs pretty smoothly overall, I’m sure from the patient’s perspective on urgency, it isn’t perfect. Over the years, where I’ve found this to be most conflicted is when a patient completes his or her journey in acute, and I receive either an earnest call or a template-based discharge summary regaling me on their adventures. The scenario that unfolds in these cases has evolved as I’ve grown my practice over the years. It’s looked something like this.
Years 1-5 (Fresh and Eager): Call from patient
“I’ve just been discharged from hospital and doctor X here says I have to be seen in one week.” Okay. Do you know why? “Nope. They just told me to tell you.” Go to (if available) D/C summary. Follow-up: To be seen by FP in one week. Patient to arrange.” No help there. Must be something urgent though. Move time, shuffle space. Await with bated breath. See patient. How are you? “Looking good and feeling fine. How’s by you?” Hmmm. Where was the fire?
Years 5-15 (Busy and Harried): Call from patient
Same opening as above. Rant to staff that Acute has no clue about how Community runs. Stomp around office until calm. Move time, shuffle space. See patient. Diatribe to patient on how Acute doesn’t get to tell me when I should see my patients and how sneaky it is to use the patient as the messenger (for I tradition-ally don’t shoot same). Rant to spouse at end of day. Move on.
Years 16-onward (Even busier and more Harried): Call from patient
Same opening. Resigned sigh. Move time and shuffle space. Play out with my inside voice my poignant quid-pro-quo for my next referral:
Dear Dr. X,
Please see patient Y with problem Z. Must be seen in one week. Patient to arrange.
Give patient Dr. X’s office number. Stand back and watch world go all Purple Minion. Now, this will always remain an internal dialogue as I was once read something by a colleague that said “You are the professional. Be the professional.” From this, I know my compatriots in Acute are exemplary as embodiments of professionalism, but the scenarios above reflect the frustra-tions that have challenged the keystone to the collaboration required for contin-uation of care: communication.
As a resident, my attending believed that inter-collegial communication was an important element for the care of the patient. Thus, she expected that I and my fellows would call the patient’s FP at the time of discharge to close the loop on care in-house, and bring community up to speed on what the patient may need going forward. Each call was well received and put a positive tick mark on my clinic day. To this day (contrary to what has been written here might suggest) contact with one of my colleagues from acute is still a high point in my day.
As a resident, my attending believed that inter-collegial communication was an important element for the care of the patient.
First, it allows me to put a voice to what would otherwise be just a name at the bottom of a sheet (and vice-versa). Second, it allows me to understand my patient’s care needs going forward, and learn something that will enhance the care of others with similar concerns in the future. Finally, it closes the loop on continuity, ensuring an upward trajectory on the patient’s recuperative curve.
Aspirationally, this idealized interac-tion unfortunately conjures the theme song from our favorite medical game show: “Who is the Biggest Martyr?” From Acute’s side (which I still know pretty well as a locum hospitalist), time is precious, as making a call for rounds, clinic, teach-ing and administration responsibilities, admissions, and call consume the day almost entirely. From Community’s side, there is no time to take a call, for the clinic is an hour behind, there are ten 3M’s from the staff that need address-ing, the carpet guy is here for a quote for the exam room flooring, and there is a PCN meeting that one is going to be late for.
Between the two settings, the common denominator that challenges connections is the rarest of non-renewable resources: time. In the wisdom of the system, to breed efficiency of communication and thus better manage time, template-based D/C summaries were created to stream-line information dispersement and bridge continuity of care. My experience would argue that in some ways these documents have challenged this, where stock statements pertaining to follow-up need have been more enigmatic than clarifying. From this, time management has been effectively hamstrung.
So, where to go from here? I person-ally have no quick answer on how the system can forgive more time to allow colleagues to connect in person or by phone to hand-over care from acute to community. I hope that great minds from both the Primary Care and the Acute worlds will examine this issue going for-ward to identify ways for connections to be made, without creating greater burdens on already weary souls. At that point, the title of my column would be something akin to a group seen at Lilith Fair: Empathy and the Clasped Hands. Until then, as the alpha and omega in my own little microverse, I will continue to bend the time space continuum and provide the best care I can.
Scott F. Beach, MD, CCFP
Medical Editor, Vital Signs
The famous writer Robert Louis Stevenson once said, “Politics is perhaps the only profession for which no preparation is thought necessary.”
There is an upcoming election here in Alberta, and a number of doctors have added their names as candidates. There are a reported 234 physicians per 100,000 people in Canada (1), and when statistics show that only 6 per cent of Canadians would consider running for political office (2), it’s no surprise that physician politician numbers in our country are so small.
Doctors are certainly not the most common profession elected to office. That position is taken by law, business and diplomacy. The so-called “professional politician” — someone with a career entirely in and around politics — has been on the rise in democracies like Britain and the U.S. (3).
Given the merits of experience in the medical field, should we begin to more seriously consider doctors for political office? When we vote, does the consideration rest on the politician as a person and a professional, or do we weigh more heavily on how well they will do the job of representation?
If we consider physicians as a group, we can look at how the profession might positively reflect suitability for public office. Integrity is a word often used to describe the ideal political candidate, and physicians rate high in trustworthiness — 92 per cent of people polled in one study trusted a physician to tell the truth (4). Working doctors have skills necessary to get through the selection process to enter medical school, and have demonstrated rigorous academic, personal and professional skills to complete medical training.
By its very nature, the practice of medicine involves the physician being intimately involved in the lives of other people. Dr. Bob Turner, MLA for Edmonton Whitemud, listed the crossover skills from his career in medicine: “Social determinants of health, human rights, patient autonomy, listening skills, research skills, record keeping, staff management…” (5). Furthermore, the health care budget in Alberta makes up 40% of the overall provincial budget (6), and physicians (and other healthcare professionals) have nuanced insight into a system that consumes a large number of government dollars.
While the merits and transferable skills are clear, the question becomes: can a physician do the job of representation?
A physicians’ intent in their career is to positively affect the lives of their patients, whereas a politicians’ intent is to improve the lives of their constituents. Dr. David Swann, commenting on his turn in government, stated, “As a doctor, I would affect the lives of hundreds of people, but as a politician, you influence the lives of thousands, millions of people with policies that either improve their opportunities, or, in some cases, reduce their opportunities for healthy and successful lives.” (7).
While each candidate should be judged by their individual merit, I believe doctors should be given the same measured consideration as those entering politics from other fields of expertise. This should be based on what the medical profession says not just about their personal character, but the skills they bring to the tough job of being in government.
Alayne Farries, MD FRCP(C) Anesthesiologist, Red Deer Alberta
1. Physicians in Canada: https://.cihi.ca/en/physicians-in-canada
2. Politics Anyone? Who Would Run for Office In Canada, by Bruce Anderson and David Coletto. December 9, 2014, Abacus Data.
3. “There was a lawyer, an engineer and a politician…” The Economist. (Link: https://.economist.com/international/2009/04/16/there-was-a-lawyer-an-engineer-and-a-politician)
4. Ipsos: https://.ipsos.com/sites/default/.../veracity_index_2018_v1_161118_public.pdf
5. “Transitioning from Physician to Politician.” Vital Signs. October 2017: https://static1.squarespace.com/static/568eb5bbd82d5eecf06026c4/t/5a6f5a41419202096a41b177/1517247054396/VS1017.pdf
6. “Alberta spends $2.4 million an hour on health care: here’s what’s being done to reduce it.” CBC. March 2018: https://.cbc.ca/news/canada/calgary/alberta-spends-2-4m-an-hour-on-health-care-here-s-what-s-being-done-to-reduce-it-1.4589048
7. “Alberta Liberal MLA David Swann says he won’t seek re-election next year.” Calgary Herald, March 2018: https://calgaryherald.com/news/politics/alberta-liberal-mla-david-swann-says-he-wont-seek-re-election-next-year
Open any medical dictionary and under the ‘ f ’, you will find a rich cadre of polysyllabic constructs one can use to connect with colleagues and wow your friends. Amidst all of them are two four-letter elements that, upon utterance, tend to bring on a hyperbolic adrenal response: FREE and FORM.
For my good friends recently arrived from Mars, a quick FYI: healthcare is not free. As I sat with a patient not so many days ago, she regaled me with the details of her recent journey through urgent care. At the conclusion of her narrative, she expressed her gratitude for the ‘free’ care she received. As the extolled emote of this folksy mythology grated across my dorsal root ganglia, I inhaled deeply, prepared to deliver my patented lecture on the true costs of healthcare. But at the apex of inspiration, I paused. The clinic that day was unfolding well, and I liked this nice lady, who has been a friend of the practice for a long time. I exhaled slowly and let the teachable moment pass.
In my heart, I know that she knows (like the majority of thoughtful Canadians) that healthcare is indeed not free. At the macro and meso levels, better humans than I with far greater minds wrestle constantly with the perpetual conundrum: getting high value care as a return for dollar investment. One of our former Premiers once stated that healthcare was a bottomless pit that can never be filled.
From my perspective, I feel that the Sea Captain’s observance on Homer S. summed up our system best when he described our friend from Springfield as a “remorseless eating machine.” Any way you slice it, as time goes on, the indolent grind of healthcare continues to consume greater portions of provincial budgets, challenging system stability on the grand scale. Solutions to this challenge are diligently being sought, though they remain frustratingly elusive.
On the front lines of delivery, physicians are intimately aware of the cost of providing care to our patients. For me, the notion of ‘free’ immediately conjures a need to give the listener insight into monetary investments docs makes before the lights go on and patient one has been seen. At one point, I listed to a captured soul the tolls physicians pay to pursue our craft: CPSA, CMPA, CCFP/FRCP, AMA, and a myriad of insurances well before one code is submitted or recompense received.
In a place to call the medical home, it is nice to have a light on and chairs to welcome your guests (which IKEA was happy to provide at quite a reasonable price). Additionally, that pleasant and infinitely patient young person at the front desk’s smile broadens ever so slightly every second Friday of the month. I will not go on, but suffice to say doctors have the double honor of both providing and paying for care. This does not jive with the dictionary definition of ‘free’.
FORM is the second four-letter F-word that derives a response akin to an unwelcome IBS flare. Oft clutched in our patient’s hands, these 81/2” x 11” bundles of advocacy are at best an occupational irritant. At worst, they are one more opportunity to erode our professional value. Now, to be clear the patients are merely the messengers, and I don’t make a habit of shooting same. My frustrations arise from the smug assurance of governments and insurers that do-gooder docs will happily waive the fee when small print “patient responsible for any fees associated” catches the eye. This is done knowing that many, if not all patients could not embrace the cost as charged by comparable professions — our ‘street value’ if you will.
One of my all-time favourites is what I call self-deflation. It goes a little something like this: Insurance Company A asks to be informed of any cost over offered price B. Next, Dr. C. gives price reflecting fair-value for service D. In response, Insurance Company A asks Dr. C. to lower their price, requesting self-deflation. My desired (and to date inside voice) response has been, “Okay my friend, I will devalue my service if you work today for free.” Quid pro quo Clarice. Quid pro quo.
In the construct of our system, we as doctors are asked to be both physician-healers and physician-advocates. Completion of what seems to be a never-ending stream of forms can instead create a harried state of physician-secretary. When governments, insurers, and at times our leadership bodies encourage devaluation of our professional services under the guise of what may be deemed an ‘occupational hazard’, the ‘death by a thousand invalidations’ ensues, creating physician-irritated. If Lotto Max were to ever deem me worthy, I may be tempted to go and explore the occupational hazards of physician-bartender in the Bahamas.
Before that windfall arrives, I, like all my colleagues, will soldier on until a solution that results in just reward for just work is found. Until then, feel ‘free’ to carry on!
Scott F. Beach, MD, CCFP
Medical Editor, Vital Signs
I recently had a dream that I was swimming — not too out of the ordinary,since this is my exercise of choice. In it, I was gliding peaceably through the water, until I turned my gaze to the matter before me. As I looked more carefully (which I usually find rather challenging, since I’m highly myopic), an endless sea of digits came into view, and I realized that the fluid before me was not water, but data, enveloping everything it touched.
In reality, this dream isn’t so far-fetched: no matter where we are or what we do, we are surrounded by data. With the expansiveness of wireless networks, we are, quite literally, awash in a sea of it. Good data management involves navigating this vast sea, charting courses through streams, and working to control and regulate never-ending flows of information.
The waters in healthcare can be a bit troublesome. There are many ships trying to navigate through the sea of healthcare data, but as they do, they risk sending waves of it crashing outside of safe confines. If these waves break beyond the banks of control, it can be disastrous for patients, their families, and the broader healthcare community. As we embark on a major change here in Alberta by adopting the new Connect Care Clinical Information System, we must be certain that data will be both secure and appropriately managed.
The AHS describes Connect Care as a “common provincial clinical information system” meant to make healthcare data more secure and accessible between physicians and their patients, as well as among healthcare providers in general. The AHS has partnered with the company Epic Systems Corporation (referred to here at EPIC) to help run this new program.
At a recent Connect Care information session, I approached Sansira Seminowich, who is a Connect Care Beaker application specialist, to ask her some questions about data management, security and privacy. I wanted to be sure that Albertans’ medical data were being stored in Alberta — not in the U.S., or in a cloud-based platform. This stemmed from my concern that EPIC data could be subject to the U.S. Patriot Act, which might theoretically violate Alberta’s information privacy laws (1). I was assured that none of Connect Care’s data would be stored within the U.S., and that EPIC would not have direct access to any of the Alberta content within the system.
But the aegis of the Patriot Act — which, put simply, makes it easier for the government or law enforcement to access sensitive data if they believe there is a threat at hand — might extend to the EPIC Care Everywhere function. This tool allows EPIC users to share data between different information centers. An example might be sending patient data for a “second opinion” to another EPIC-enabled center. In the lab where I work, we occasionally send materials for review to leading U.S. medical centers, and it would be very convenient to do this through the EPIC Care Everywhere function. Data sent to a U.S.-based EPIC center from Alberta might therefore be subject to the broad powers of the Patriot Act, which includes healthcare data (2). If and when Care Everywhere is used to pipe Alberta information to outside systems, I was reassured that such data exchanges would be subject to an AHS/Alberta Privacy Commissioner Privacy Impact Assessment.
We should also be aware of Connect Care’s mandate for clinical data dissemination to patients. The system will allow patients the opportunity to access much, if not all of, their own clinical charts, made possible through the EPIC MyChart functionality. While noble in intention, this might raise the ire of concern for both clinicians and laboratorians. For those physicians in the former category, the literature notes that “open access” medical records might impact a physician’s ability to relate medical information in a fully honest manner (3). In certain specialties such as psychiatry, in which highly sensitive information might be perceived negatively by patients accessing their charts, the concern is that clinicians may err toward less candid assessments.
In contrast, for those of us in lab medicine, patient access to their charts might embolden us and our specialty. Indeed, a well-informed patient with access to the completeness of their medical record would see their laboratory diagnoses rendered by laboratorians, rather than interpreted through their primary care-giver. Thus, we laboratorians will need to take greater care still to ensure the perpetual accuracy, contemporariness and timeliness of the reports we produce.
Turning back to an area of medicine that I find very stimulating — research — there is optimism to be found. The Connect Care initiative promises to include a breadth of research and research-related components. The EPIC system offers levels of data analysis and integration, ranging from routine quality assurance to population-based data analyses. Once implemented, the Connect Care system promises to be one the vastest seas of clinical data in North America. Notwithstanding the serious need for state-of-the art security, data integrity, and ethics oversight, I am hopeful that Connect Care will make cutting-edge medical research in Alberta all the more fruitful. But for now, the goal should be to have all the right hands on deck when it comes time to steer through the changes ahead in this sea of important data.
Etienne Mahe, MD, MSc, FRCPC, FCAP
Consultant Pathologist with the Division of Hematology of Calgary Lab Services. Clinical Assistant Professor in the Department of Pathology & Laboratory Medicine at the University of Calgary. President of the Calgary Lab Services Medical Staff Association.
1. Province of Alberta. Freedom of Information and Protection of Privacy Act. Sect. RSA 2000, c. F-25, s. 92(3).
2. Lenzer J. Doctors outraged at Patriot Act’s potential to seize medical records. BMJ. 2006 Jan 14;332(7533):69.1.
3. American College of Physicians Ethics, Professionalism and Human Rights Committee, Sulmasy LS, López AM, Horwitch CA. Ethical Implications of the Electronic Health Record: In the Service of the Patient. J Gen Intern Med. 2017 Aug;32(8):935–9.