A parliament of medicine no more: @CMA_Docs changes its governance



The Canadian Medical Association (@CMA_Docs) is not immune to the dramatic changes in governance impacting governments and organizations around the world.

At its annual gathering this August in Winnipeg, the CMA’s General Council will cease to exist as “the parliament of medicine” and a major policy making body, and will be substituted with a healthcare summit aimed at attracting a much more diverse audience to advance the debate about health care in Canada.

For those who have sat through decades of often intense debate by physician representatives from across the country, on issues as important as abortion, physician aid in dying, and the future of medicare, this is a dramatic change. But, frankly it is not a surprising one as the CMA has been transitioning its policy-making processes for a few years now.

While CMA General Council often made great theatre and was guaranteed to attract front-page news for the organization, the issues discussed where often not within the strategic framework of where the organization wanted to head. The CMA has been clear it wants to broaden the funnel for collecting new policy ideas from a council of 200 plus selected representatives from its provincial and territorial associations, to the membership as a whole.

The elimination of General Council will be perhaps the most obvious but, given various announcements on the association’s cma.ca website, certainly not the only governance change being planned by the organization and voted on this year.

For instance in order to better align the CMA with its new mission statement as “empowering and caring for patients”, the CMA Board of Directors wants to add a non-physician to bring the patient representative to its Board of Directors. While a radical step for the CMA, this is in keeping with what many other medical organizations are doing.

That’s not the only change envisaged for the Board. Rather than allocating numbers of Board representatives based by number of physicians in a jurisdiction each province and territory would have just one Board member. This would shrink the size of the Board from the current size of 26 to 18 or 19 members including ongoing representation from students and residents.

The annual general meeting which was always held in conjunction with General Council will continue to expand its role for ratifying business decisions and after this year will move from August to the spring in 2019.

Those who will remember the extensive CMA governance review process that culminated in 2008 with arguably minor changes to governance will appreciate just how much and how fast the world is changing, to see what CMA will be doing this year.

Sir Charles Tupper may not be rolling over in his grave but it will be very interesting to see how CMA members do in keeping up to the speed at which their organization is moving.


Optimistic outlook and a lesson on wellness: An interview with Dr. Ali Jalali

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(This is the first of a planned irregular series of interviews with Canadian physicians who are regular users of social media)

Almost four years ago, Dr. Ali Jalali (@ARJalali) uploaded a video for the Royal College of Physicians and Surgeons of Canada dealing with the value of social media for physicians and how to get started. With more than 2,600 viewings it has hardly gone viral but in many ways it set out the rationale and standards for the professional use of social media by Canadian doctors.

Since making that video, Dr. Jalali has arguably become the leading Canadian academic physician when it comes to professional use of social media by physicians and has published several papers and studies with a special focus on the impact of social media on medical education and its use by medical students and residents.

I recently visited Dr. Jalali in his office at the University of Ottawa where he serves as director of the division of functional and clinical anatomy and we discussed the evolution in the use of social media by Canadian physicians over the past four years.

Despite the fact that use of social media remains static with only 5%-10% of Canadian physicians using channels such as Twitter for professional purposes, Dr. Jalali believes social media has become much better accepted within the profession.

“I don’t think the idea was to get more and more doctors on social media,” he said, “but rather to make them more aware of what social media is.” With more patients using social media and posting queries for physicians, he said, it was important to make physicians aware of how to deal with these interactions.

“We managed to open the discussion,” he said.

As a turning point in Canada, Dr. Jalali points to a 2014 publication by the Canadian Medical Protective Association (CMPA) – the organization that provides malpractice support for physicians – which acknowledged the reality of social media in medical practice.

“Whether doctors choose to engage in social media or not, they cannot ignore the implications,” CMPA CEO Dr. Hartley Stern wrote at that time.

Dr. Jalali said this was a huge change from the earlier stance of CMPA as being totally opposed to physicians having anything to do with social media.

“That gave a huge boost to our work in promoting the use of social media by physicians. It’s not as exclusive as it was.”

Dr. Jalali also talked about how pervasive social media has become in medical education and medical conferences with every conference now having a specific hashtag and making conscious efforts to have delegates engage in social media.

Despite some anachronistic attempts by the organizers of some medical conferences to still prevent people live tweeting, Dr. Jalali said an intelligent social media presence is now a reality in medical education and this has immensely benefited those unable to attend major conferences in person.

“In medical education, it has now become part of the conference.”

Dr. Jalali said he continues to advocate professional behavior by physician delegates at these meetings. “If someone had the conference says don’t tweet my stuff, you shouldn’t tweet their stuff. It’s as simple as that.”

Dr. Jalali also pointed to the incredibly active social media debate and discussion around the Ontario Medical Association and its interactions with the provincial government as well as its own internal politics as another indicator of the growth in influence of social media.

“The younger generation is saying I can use this tool to my advantage.”

Despite this growth, he said it remains uncertain whether social media has actually done anything to improve health outcomes or the health status of the public as a whole.

For his own part, Dr. Jalali took a conscious break from social media earlier this year when he took paternity leave. He said this was a very positive move which made him realize how important it is for the purpose of wellness and personal relationships to maintain a balanced approach to social media use.

“It definitely was a good thing to do.”

He has now returned to use of Twitter and other social media tools but acknowledged he is not as active as it was.

Dr. Jalali says in talking to students and residents about social media now in addition to discussing professional use, he also talks about wellness and how to manage time properly by not letting social media dominate one’s life.

“FOMO – the Fear of Missing Out – is real,” he said, and must be consciously addressed.

(Picture by @pathologistmag – Dr. Jalali delivering closing plenary at #CAPACP2017)







Is failing to use an EMR unprofessional conduct?


It has come to this.

Some hospitals in Toronto are starting to use virtual reality in patient care (to help ease pre-operative anxiety). Yet, there are still family physicians in the province using paper charts to record and monitor the health of their patients: Not many for sure and far, far fewer than a decade ago an (an increase from 37% to 73% between 2009 and 2015).

But nonetheless, in an era where the health technology envelope is being pushed harder and faster than ever before, the most recent international comparison of use of electronic medical records (EMRs) by family doctors shows Canada continues to lag behind countries such as the U.K. and New Zealand where use is almost universal.

This finding comes from a study released earlier this year by the Canadian Institute for Health Information (CIHI) in partnership with the Canadian Institutes of Health Research, and with co-funding from Canada Health Infoway looking at data from the Commonwealth Fund 2015 survey of 10 countries.

Maybe the time has come to seriously ask whether the acceptable standard of care for family doctors practising in Canada involves using an EMR and that failure to do so could be seen as failing to maintain that professional standard.

It is a question that was first asked quietly more than a decade ago, back in the twilight era when only the most forward looking physicians and jurisdictions were using EMRs routinely. Now, when EMRs have hugely increased functionality and proved their value in efficiently managing the health of populations, the question can surely be asked with more authority.

Of course, nobody wants to force some physicians to use technology they don’t like, don’t understand, and which can sometimes lead to gross inefficiencies in the use of their time. In fact we can imagine there may be parts of the country where a physician still cannot even purchase a reliable EMR. And we in Canada still struggle with interconnectivity and many family doctors remain stranded on ‘electronic islands’ unable to use their EMR to communicate effectively with others in their community.

But the reality is that electronic storage of patient data is here to stay whether the medical profession likes it or not.  With almost three quarters of Canadian family physicians now using EMRs for patient care the time has to come to ask medical licensing authorities whether they need to apply more diligence to observing those doctors who choose not to rely on paper records.

The failure of family doctors to totally embrace electronic records is hindering both patient care management and population health management. Even of those who use EMRs, the CIH report notes fewer than half routinely use the system for at least 2 of the following: electronic alerts or prompts about a potential problem with drug dose or drug interaction; reminder notices for patients when it is time for regular preventive or follow-up care; alerts or prompts to provide patients with test results; and/or reminders for guideline-based interventions and/or screening tests.

Surely the time has come for this to change.

Social media and hospitals: Now more than just pretty pictures

Lakeridge Health report_cover

For leading hospitals, the use of social media tools and platforms has moved from giving in to the demands of the head of marketing to at least have a Facebook page, to a recognition that use of social media can add value throughout the enterprise.

This evolution beyond using social media to post nice pictures and videos of hospitals doing good things has occurred rapidly since the emergence of the first social media platforms a decade ago and holds great potential for health care institutions who want to communicate effectively with their patients.

This is my conclusion following an extensive review of the literature on social media use in North American hospitals and interviews with experts both in Canada and the U.S. who confirm this trend. This work was done on behalf of Lakeridge Health in Oshawa, Ontario as part of a review to improve patient experience at that institution.

While they acknowledge the huge potential for social media in the health care setting, leaders in health communications also recognize that social tools and channels represent just another series of communications options and should be used only as appropriate.

The only comprehensive survey of social media use by U.S. hospitals published by University of Pennsylvania researchers in 2014 showed 94.4% of the more than 3,300 hospitals polled had a Facebook account and just over half had a Twitter account. Anecdotal evidence suggests the same is true of Canadian hospitals.

“There are some really creative people out there who are finding ways to use these tools to engage patients and get their messages out,” said Christina Thielst, a Santa Barbara, California-based hospital administrator, consultant and author who has been following the use of social media by health care organizations for more than 30 years.

Ann Fuller, VP for volunteers, communications and information resources for the Children’s Hospital of Eastern Ontario, was quoted in 2013 as saying: “In Canada, in health care we’re at a point where most hospitals accept the role of social media for branding and communication, but only the lead adopters are using it for patient engagement and for clinical use.”

Since that time, she says “a lot of the perceived risks and threats of social media have lessened” yet, she adds, while “everyone agrees that social media can and should be used, and there are benefits to it, some of that stigma still exists.”

“It’s not about creating a community and trying to integrate those experts into it. It’s using social media to come up with a new platform for doing what they already do—such as engaging patients. It’s another way of bringing people together,” said Dave Bourne, a former communications director for Baycrest and the Scarborough Hospital and now director of communications for Sienna Senior Living.

But despite the most popular social media tools having been around for a decade or more, the optimal use of these tools in hospitals has yet to solidify.

“I don’t think anybody has nailed it to the point where there are best practices,” said Bourne.

Those looking for a leading Canadian hospital with regards to social media could do far worse than to study the experience of the Michael Garron Hospital in Toronto. That institution has taken an incremental approach and changed the hospital culture to slowly integrate social media into many of the hospital’s functions. Elements of that approach include

  • Publication of a policy or guidelines to assist hospital staff in the appropriate use of social media
  • Training of the senior management team as a group in how to use common social media tools such as Twitter.
  • Ongoing education and support from the communications team to assist any staff in using social media
  • Integrating social media tools into a new proactive approach to patient engagement which included aggressive timelines for dealing with patient concerns.
  • Integrating social media use into a new, more responsive approach to leadership

While social media remains an important and innovative set of tools for telling stories about the good things a hospital can do, it is clear that the most innovative institutions are also using those tools to facilitate both internal and external engagement with the communities they serve.

As Isabel Jordon, a BC-based patient advocate and chair of the Rare Disease Foundation, says: “the way I would like a hospital to use social media is to reach out to people to find out what we want from them; if there are going to be changes or something new coming down the pipe—to reach out and engage us before something is going to happen.”

(P.S. Anyone interested interested in publishing a more extensive analysis of this research please feel free to get in touch)




#HIMSS16 A passing unpleasantness?Physicians and EHRs


Finding out what US physicians think about electronic records at HIMSS16 took no longer than hearing the first speaker in the first pre-conference satellite session on Sunday titled: “The Electronic Health Record: What went wrong? Can it be fixed?”.

“The number one complaint for the quality of life and for practice is the EHR in its present form,” said Dr. Ed Livingston, Deputy Editor, Clinical Review and Education, for JAMA.

He was quickly followed by session moderator John Nosta who noted “the EHR seems to be ill. Should we put it in the ER, the ICU or the mortuary?”

This less than cheery outlook was then reinforced by Dr. Christine Sinsky, VP of Professional Satisfaction for the American Medical Association (AMA)who repeated results from a 2013 survey suggesting the number one reason for burnout among physicians was the EHR.

Sinsky then became the first of several speakers at HIMSS – including Andy Slavitt, acting administrator for the Centers for Medicare & Medicaid Services (CMS) – to quote individual US physicians and their angst in dealing with EHRs.

For a Canadian observer of the physician community, all of this initially seemed a little overwrought.

Sure, many Canadian MDs complain about their electronic records systems as well, especially during the implementation phase. But being driven to burnout or actually leaving medicine because of the EHR?

What seems to be at the core of the problem for most US physicians are the data recording requirements – the sheer number of clicks required to perform and document clinical interactions.

Thirty-two clicks are required to order and record a flu shot, Sinsky notes. Eight clicks to order an Aspirin, quoted Slavitt, 16 if its full strength.

Dr. John Halamka, chief information officer at Beth Israel Deaconess Medical Center in Boston, noted physicians at Beth Isreal must make 450 clicks and enter 141 structured data elements during a 12-minute patient encounter “and make eye contact with the patient.”

Slavitt said the message from the physician community is clear: “Stop measuring clicks, focus instead on allowing technology to become a tool and focus on the results technology can create. Give us more flexibility to suit our practice needs and ultimately more control.”

The good news from HIMSS is that there appears to be a willingness to make this happen. With legislative changes in the US and a move towards outcome-based care and population health, the rigid process-based requirements – what AMA President Dr. Steven Stack terms the false sense of precision where accuracy really doesn’t exist – may fade into the background.

Furthermore, the EHR itself may become a relic as multiple platforms for providing virtual care and the growing movement of patient engagement and empowerment move the locus of patient data from the physician to the patient.

Halamka proclaimed the growth of mobile means “the desktop is dead” and he talked of Facebook-like social networking applications being better for capturing the physician-patient interaction.

All of this is being accompanied by a more realistic assessment of EHRs by knowledgeable physicians.

“Those who come into practice in 10 years won’t understand why people had been so unhappy,” Stack said.

(Photo: Dr. John Halamka speaking at HIMSS16)


#hcsmca: The Last Waltz (or … Not Last Tango in Vancouver)

 The National #hcsmca Symposium to be held in Vancouver, Feb. 24 in conjunction with Quality Forum 2016 represents a watershed moment for Canada’ premier health care social media (hcsm) community.

Whether attending personally (and you should) or not, attention should be paid by anyone interested in how social media tools and platforms are being used in health care. Through #hcsmca, people are striving to change how health care is delivered and challenging many of the premises behind the traditional role of patients and providers in the health care system.

The symposium not only represents the first national manifestation of this virtual community “in the flesh” but also clearly marks the end of the beginning of Canada’s contribution to the national hcsm movement.

Colleen Young, the volunteer founder of #hcsmca, and behind-the-scenes driving force for its weekly tweetchats and occasional meetups, recently announced her intent to transfer her energies to other projects.

Experience in other countries has shown that health care twitter communities that depend on one volunteer organizer eventually flounder and it can be argued that the same will be true in Canada.

But this contention is challenged by the very existence of the upcoming national symposium, with plans to produce substantive outcomes (more on that in my next blog post), organized by a dedicated team of volunteers with the support of the established Quality Forum conference it precedes.

Over its six-year history, #hcscma has seen participation by almost every thought leader in hcsm in Canada as well as many global leaders in the field. It has also introduced dozens of patients, researchers and providers to the potential benefits social media in health care.

While writing this blog post, the Council of Academic Hospitals of Ontario (CAHO) published an interview with Colleen detailing in her own words her thinking behind the initiation and evolution of #hcsmca.

A few quotes from that interview do more than I ever could to explain where Colleen believes #hcsmca has been and is going.

“In the beginning, I just wanted to learn but as participation in the weekly chats grew exponentially … I could see how social media removed traditional barriers of communication in health care, how it was a valuable tool for bringing together people interested in improving the experience for patients as well as providers.”

“As #hcsmca grew and matured, and social media became practically ubiquitous, hosting a community focused exclusively on social media no longer made sense. … With the diverse knowledge pool of its members, the community leverages social media and other digital collaborative tools in an open forum to share perspectives, best practices, new ideas and solutions.”

Whether the National #hcsmca Symposium proves to just be the closing chapter to a grand experiment or – as Colleen and others intend – the initial phase of a new open approach to sharing ideas about improving the health care experience – remains to be seen.

Attend in person or comment through social media using the hashtag #hcsmca, and don’t miss your opportunity to be part of this event and evolution because that is what community is all about.




I had a dream

Earlier this month I had a dream in which the role of social media in relation to health care was clearly laid out before me.

Of course, the minute I woke up the clarity of this relationship was lost. All that remained was a sense that the ways we frame how social media tools and platforms can and should influence medicine and the delivery of health care must go beyond conceptual models we are currently using.

(And, yes, those who think I should get a life so I dream about more interesting topics are correct).

This lingering residue of the dream leaves me convinced we must stop thinking about social media platforms in relation to health care as mere extensions of traditional media and defining social media’s impact in those terms.

It has become abundantly clear that social media are not going to become significant new channels for the delivery of health care services or even health information anytime in the near future. I can still name by name among the tens of thousands of practitioners, the physicians, nurses and pharmacists who effectively use major social media channels such as Twitter and Facebook for professional purposes in Canada – and that’s after these channels have been available for a decade.

In Canada at least the language of social media is just not part of the health care professional’s lexicon.

That being said, I do believe social media are having a transformative impact on health care in ways that are more subtle and indirect.

For example, Twitter and LinkedIn are building connections between health care practitioners, researchers, pundits and patients on a global basis in ways that would have been impossible in the past. My own experiences with doctors in the Philippines and Ireland can attest to that.

And through those connections, we now have physicians and other health care providers with an empathy for patients they would not otherwise have had because they experienced these patients’ stories through blog posts, Twitter exchanges and other social media channels.

Despite the fine work done by medical futurists such as Drs. Eric Topol (@EricTopol) and Bertalan Mesko (@berci) – we cannot predict the future direction of medicine and health care because the variables, the unknowns and the complexity of interactions between these two are just too numerous to accurately map.

But I am confident that social media will be playing a role – one that is very different from what we would predict based on past experiences with other media. The details of my dream may be lost but the fading general outline of the theoretical construct for this role remains to guide me.

Having recently parted ways with the Canadian Medical Association, I now have more scope to observe this evolving nature of this interplay between social media and health.

And so, on to 2016 and the next chapter.