Organization
[August 09, 2024 4:10 PM]
Ontario Medical Association (OMA)
 
Please see attached the OMA's submission on the CPSO's draft Reporting Requirements policy. 
 
Response in PDF format:
OMA Response_20240809.pdf
Organization
[August 06, 2024 7:04 PM]
Professional Association of Residents of Ontario (PARO)
 
Dear CPSO Policy Department,

Thank you for the invitation to provide feedback on the CPSO Reporting Requirements policy draft. 

We offer specific suggestions and questions for clarification on both the Reporting Requirements & Advice to the Profession documents further below.

Feedback on: Reporting Requirements

We suggest adding a statement or guidance to physicians on working with residents and other learners – i.e. how to approach disclosure with your resident.

Under General (2), the draft policy states:

“Unless doing so would pose a genuine risk of harm to themselves and/or others, physicians must notify patients about their duty to report at the earliest opportunity, and where possible, before making a report."

We wish to highlight that hospitals and other healthcare centres also have a responsibility to create a safe environment that minimizes risk associated with physician reporting. For example, by providing adequate support systems, training and protocols that protect both patients and healthcare professionals. We acknowledge that the duty to report, where required, is a core ethical and professional responsibility that should not be compromised and suggest that the policy emphasize the primary course of action is to report, with hospitals and other healthcare environments facilitating a safe process to do so. Flowing from the responsibility for managing risk associated with reporting, the policy will be strengthened by articulating how hospitals will provide the necessary support and safety measures to ensure that reporting can be carried out responsibly and safely.
 
Feedback on: Advice to the Profession: Reporting Requirements  
 
The section discussing the balance between reporting requirements and maintaining patient confidentiality could more explicitly address the hospital's role in managing risks. It would be beneficial to include guidance on how hospitals can support physicians in these situations, such as providing legal advice, psychological support, or security measures.

The section of "what if I suspect my patient is a victim of abuse?" can be expanded to include trauma informed approaches, additional warning signs, how physicians should respond to suspected abuse and follow up care. For example:
 
Trauma Informed Principles:
  1. Safety: Create a safe environment for the patient to share their experiences. Ensure privacy and minimize the risk of further harm or discomfort.
  2. Trustworthiness and Transparency: Be clear about your role, the limits of confidentiality, and what you can do to help.
  3. Empowerment, voice and choice:  Respect the patient's autonomy and choices and involve them in decision-making processes regarding their care. 
Warning Signs of Abuse: 
  1. Physical indicators: Unexplained injuries, frequent visits for medical issues, signs of neglect (poor hygiene, untreated medical conditions).
  2. Behavioural Changes: Withdrawal, anxiety, depression, reluctance to speak in the presence of certain individuals, excessive compliance or passivity.
  3. Verbal Cues: Descriptions of controlling or violent behaviors by a partner, fearfulness about leaving the home or contacting certain people.
  4. Social Indicators: Isolation from friends and family, restricted access to resources, financial control or manipulation. 
How to respond to Suspected Abuse: 
  1. Ask Open Ended Questions: Gently inquire about the patient's well-being in a non-judgmental manner. Examples include "I've noticed some changes that concern me. How are things at home?", "Is there anyone in your life making you feel unsafe or threatened?", "Do you feel free to make your own decisions, or is someone else in control?"
  2. Offer Support and Resources: Reassurance (Let the patient know that they are not alone, and that support is available), Information Sharing (Provide information about local resources, shelters, hotlines, and legal assistance.), Safety Planning (Help the patient develop a safety plan, including emergency contacts and safe places to go.)
  3. Document and Report: Accurately document any findings, statements, or observations in the patient's medical record. Report to appropriate authority if required depending on the situation.  
Follow Up Care: 
  1. Schedule follow up appointments to monitor the patient’s situation and provide ongoing support
  2. Referral: Consider referring patient to specialized services (counselling, social work, legal aid). 
With respect to the section "Do I have to make a report if someone else has already filed one?"
 
This section states that physicians must make a report themselves even if they know that a report has already been made. It would be helpful to clarify how this would work in team situations with shared patients, which occurs in academic hospitals. For example, if a resident has already made a report about a shared patient, does their co-resident also need to make a report?
 
We once again appreciate being included in the CPSO’s consultative process.
Physician (including retired)
[August 06, 2024 2:22 PM]
1. Legal Reporting Requirements:
• Consider clarifying the definition of “sexual abuse” in the Sexual Abuse of Patients section, pulling from the definition in the Regulated Health Professions Act, 1991 and the definition of “sexual assault” in the Criminal Code.
• Consider clarifying who may complete and sign a medical certificate of death when the death must be reported pursuant to the Coroners Act (as described in s. 17(2) of the Hospital Management regulation under the Public Hospitals Act).

2. Advice to the Profession: Reporting Requirements:
• Provide additional guidance around police demands for evidence besides PHI
Member of the public
[August 06, 2024 1:55 PM]
Hello,

Thank you for continuing to invite me, a mature member of the public, to review and consider feedback for draft policies and policies considered for revision.

I read the documents as well as comments in the discussion.

The communications of July 12, 2024 from the CMPA and August 1, 2024 (draft August 6, 2024) from the OTLA should definitely be considered along with the legal requirements for reporting and advice to doctors, both in draft.

Other notes:
The location of the medical practice setting will vary from solo office to group practice to hospital, nursing home, other facility. Determining who best report for example a general hospital ER, ICU, OBS, OR or other unit.

The Patient - Physician communication on this topic - important.

The rationale for not reporting - to document this - I agree with.

Communicable disease reporting - definitely.

Data breaches - the several breaches by Life Labs prior to 2020 were given little attention although the scope was great for both doctors and patients across at least two provinces. The COVID-19 pandemic followed while privacy laws were disregarded by Life Labs with minimal consequence for Life Labs.

Whether a future data breach of any size might present in future, or not, in any health care setting, is seeming more likely, perhaps at least a brief reference on this topic.

As a patient in a long established FHT practice in Guelph, I am grateful to have not encountered an experience associated with this topic. Further the local public health unit and Dr. Nicola Mercer during the COVID pandemic years were excellent in their communication, vaccine supply, clinics in the community.
Organization
[August 01, 2024 8:07 AM]
Ontario Trial Lawyers Association (OTLA)
 
Please see the attached submission to the College.

Response in PDF format:
OTLA Response_20240801.pdf
Physician (including retired)
[July 18, 2024 5:11 PM]
I find the reporting requirements a little bit lacking in precise details. For example, under incompetence and incapacity, reporting has a risk to the individual making the report, especially if there are power differentials. How do you ensure that the reporter/whistleblower is protected. There are significant impacts in making reports ... unless it's clear.

Under Legal Reporting requirements, (being a pediatrician), Child in Need of Protection. Many times in the hospital, we work as a team, and we report as a team (or there's a portion of our hospital) that does this. The clarity on "not rely on anyone else to report on their behalf" may be inappropriate in places with hospital mechanisms to report. Similarly for births ... I have NEVER as a pediatricians given notice of births and still-births peresonally. There's some forms I fill, and then the hospital does the rest.
Physician (including retired)
[July 15, 2024 12:50 PM]
I have strong feelings about the proposal from an administrative point of view-without a lawyer or legal assistant in the office, determining what is applicable and what is not, will be a huge administrative task
Adding more time, less income and more frustration with family medicine
Organization
[July 12, 2024 2:36 PM]
Canadian Medical Protective Association (CMPA)
 
Please see the attached correspondence from the CMPA regarding consultations on reporting requirements. 
 
Response in PDF format:
CMPA Response_20240712_Redacted.pdf
Physician (including retired)
[July 11, 2024 11:55 AM]
The information that is lacking from your reporting requirements is the specific coordinates of where to submit reports to.

You are putting physicians in a double bind if you do not post the phone, fax, email of whom to submit the report to . This information should be placed adjacent to each category of report, in addition to a separate document with all the coordinates for agencies to whom reports should be submitted. This would more effectively “guide the profession, and protect the public”.

There is no point in putting a physician in a position of “professional misconduct” by telling them they have an obligation to report, if you don’t inform them of where to submit the report!!!! If the CPSO does not share the reporting coordinates, frankly the CPSO is equally complicit in failing to report.
Physician (including retired)
[July 11, 2024 11:53 AM]
I note, in reviewing the draft of Reporting Requirements, that the section on Impaired Driving ability should be amended:

Line 107 should conclude......functional or visual impairment THAT MAY MAKE IT DANGEROUS TO DRIVE.

It currently does not include any reference to why reporting should occur, as is included in all the other categories listed.

The document was otherwise quite clear to me.
Physician (including retired)
[July 11, 2024 7:56 AM]
The reporting requirements are well laid out

There is one thing that i think should be added to the OHIP fraud portion is physician fraud. It seems to me that a physician who is aware that another physician is defrauding OHIP via billing or other arrangements (such as through alternate funding plans) the physician should be required to report this to the General Manager of OHIP. Such conduct is dishonourable in the extreme and a discredit to the profession as well as theft of public funds which would be used for patient care.
Physician (including retired)
[July 10, 2024 7:05 PM]
I wondered if applicable specific legislation shouldn't be explicitly noted. For example, I wondered why Ontario's Health Protection & Promotion Act wouldn't be specifically noted because of its requirements for physicians (and others) to report instances of diseases designated for mandatory reporting?
Thanks!
Physician (including retired)
[July 10, 2024 6:26 PM]
Thank you for the documents, they are thorough and helpful.

In the advice document, it explains that we have to make a report even if another report has been filed. I am wondering how this pertains to MTO reporting. In our busy ED/hospital setting, multiple physicians may interact with a patient over the course of an admission. Would each be required to make a report? This feels excessive and not the best use of resources/billings, with a single patient being reported potentially several times a day. If another report has been made and documented during that episode of care, could that suffice? Thanks again!
Physician (including retired)
[July 10, 2024 4:14 PM]
It's a good way to triage which areas need closer attention/governance.
Physician (including retired)
[July 10, 2024 3:55 PM]
The part about reporting preferential treatment is incredibly draconian and not our job. I'm surprised nobody is shocked by that.
Physician (including retired)
[July 05, 2024 10:23 PM]
Agree with other comment that the reference to "communicable disease" without associated reference is too broad - we need more specifics on reporting requirements.
agree with comment that "significant" with respect to privacy breeches it too vague wording.
in the Q&A document the section on victims of abuse lines 174 and 175 is unclear to me - my understanding is we remain unable to report to police the suspicion or knowledge of physical abuse (but can help/encourage patient to report) but the way this reads is that we cannot file a report without consent unless “patient is at significant risk of serious bodily harm, and disclosure is necessary to eliminate or reduce risk of harm”. One could imagine a scenario where you treat someone presenting with physical injuries consistent with abuse, their story corroborates this and they tell you the perpetrator lives with them and has a gun and has threatened to kill them. This would appear to meet the threshold of significant risk of serious bodily harm and presumably reporting to the police would reduce the risk of harm as perp should end up in custody. However, my understanding is that we actually cannot report without patient consent, despite what this wording says. This needs clarification
Physician (including retired)
[July 02, 2024 5:56 AM]
Thank you for the opportunity to comment on this.

Line 97 from "Legal Reporting Requirements" might be reasonable in a solo practice environments e.g. a doctor should not delegate this to a clerk in their office. However, in complex and specialized environments where care is team-based and is provided through structured teams of specialized health care professionals, it is quite reasonable to have reporting structured so that it is done by a certain professional member of the team providing care for the patient.

Examples:

1. In an emergency psychiatric unit, there is no benefit from the duplication of reporting to have the emergency physician, psychiatrist, psychiatric nurse and social worker all reporting the same issue to FACS about the same event, There only needs to be one report from one member of the team.

2. In an academic learning environment, the act of reporting is also an opportunity for a learner to practice their reporting duties (supervised to the degree of their training). It would make no sense for a medical student, junior resident, senior resident and staff physicians to report the same incident to FACS.
Physician (including retired)
[June 29, 2024 10:52 AM]
I question the recurrent use of "must" and "mandatory" requirements. It sounds quite like a medieval dictate. Could you not "remind" or "urge" a responsible physician to seriously consider the option to report as a matter of "responsibility" rather than submissive obedience to an authoritarian regulator? Would this not be more like collegial collaboration than deadly threats?
Physician (including retired)
[June 27, 2024 10:29 AM]
Both documents articulate clear and reasonable policies. Some items to consider for further clarity:

1. In the Legal Reporting Requirements document, line 167 states that reporting is required by health information custodians when a “privacy breach is significant”. What is the threshold for significance? If it is defined in the referenced legislation, then at a minimum, the policy should state so i.e. “ …privacy breach is significant as defined in <PHIPA or other source>” (with hyperlink to the specific text). If possible, it would be even better to list explicit criteria to reduce subjectivity in judging “significance” and mitigate the risk of under-reporting.

2. Re line 200. Surely not all communicable diseases (respiratory viruses etc.) warrant reporting. I would recommend listing or referencing the specific reportable conditions. Also, since most of the applicable conditions are diagnosed through laboratory testing, it’s hard to imagine a scenario in which one would report a patient who “may” have a communicable illness (who tests negative). If such situations exist, it would be helpful to elaborate on these.

3. Re health card fraud. This seems to pertain to fraud by patients. What about fraud by physicians?
Physician (including retired)
[June 26, 2024 6:47 AM]
Highly likely to be misused in strained healthcare system.
Physician (including retired)
[June 25, 2024 12:21 PM]
I find the updated document adequate and appropriate.
Physician (including retired)
[June 25, 2024 11:34 AM]
I have read your report in question and I believe “Line 200” is too broad a definition for reporting. “Communicable disease” could be any form of airway, respiratory or even skin infection and so I believe that line needs to be tightened in it’s potential scope
Physician (including retired)
[June 25, 2024 11:32 AM]
Thank you for the opportunity to respond.

Firearm Violence is a Public Health Problem, not just a criminal one. Indeed, 75-80% of all firearm deaths in Ontario and Canada are due to suicide and many people contemplating suicide access the services of a physician in the weeks before their death.

Physicians should be provided an opportunity to intervene prior to the trigger being pulled. While clearly in favour of mandatory reporting of gunshot wounds, I think we as a profession need to look upstream and prevent the firearm from ever being used in the setting of suicidality, dementia, intimate partner violence and certain untreated medical/psychiatric conditions.

The Province of Quebec allows discretionary medical reporting through the auspices of Anastasia's Law. Ontario should do the same. The CMA has somewhat supported medical reporting in their most recent policy.

Canada has introduced a new Red Flag Law, which does not allow physicians to breach confidentiality unless there is clearly expressed intent to harm. I have it on good authority that they view medical reporting as a Provincial concern which is why it wasn't included in the legislation. Time for Ontario to be bold and save lives.
Physician (including retired)
[June 25, 2024 11:29 AM]
I have today reviewed the CPSO draft Mandatory and Permissive Policy. It is comprehensive, detailed and thorough, as written.
I have no suggestions to offer.
 
Physician (including retired)
[June 24, 2024 3:04 PM]
The language in the paragraph about documentation implies that a physician should only report if the person is a patient of the doctor.
Not sure if that is the intention?
If a physician reports a health professional who is not a patient what is the recommendation in regards of documentation?
Physician (including retired)
[June 24, 2024 1:16 PM]
A few comments:
1. Mandating physicians to report other MDs as potential perpetrators of sexual abuse creates a “snitch line” model which bothers me. Sexual is a breech of privilege for sure. However, accusing a physician of the same is a very serious allegation which carries very serious consequences. I worry that having a snitch line system has the potential for abuse and huge repercussions for the accused. On my view, the process of a complaint should be initiated by the patient who believes that sexual abuse has taken place.
Another point made to be by some lawyers in the field is that the CPSO definition of the doctor-patient relationship is way too rigid (prescribe a spouse antibiotics once and renew = sexual abuse), which in turn is coupled with mandatory revocation.
2. OHIP fraud is a serious problem, but many present wanting care and have limited resources, leading them to engage in such fraudulent behaviour. We aren’t cops. Maybe OHIP should reimburse physicians for providing care to anyone…
3. Asking physicians to report on findings of civil actions makes it very difficult for the CMPA to settle cases. Perhaps the threshold for such reports should be reconsidered. Yea it can be an indicator of physician incompetence, it in some case settlements are a calculated risk where the outcome was bad and only possibly averted by a practice issue. The policy as it stands has the unintended consequence of actually depriving plaintiffs access to justice, and it prolongs the legal process for plaintiffs.
Physician (including retired)
[June 24, 2024 12:55 PM]
looks OK
Physician (including retired)
[June 24, 2024 12:27 PM]
I have reviewed the reporting policy document. It is comprehensive and useful. It would be helpful to have the reporting authority in each section and the time period of required reporting be highlighted in different colour/font for ease of access to information.

Also consider giving examples of specific scenarios like impaired physician or abuse by HCP etc...

Keep up the good work.

Best wishes
 
Physician (including retired)
[July 12, 2024 7:52 AM]
I have read all the material and am support other members comments. Have nothing to add.