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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.

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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 

Story from Vital Signs February 2019 Issue

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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.

References
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.

Story from Vital Signs February 2019 Issue