Telemedicine Is Québec Ready?

Transcription

LE
SPÉCIALISTE
THE FMSQ MAGAZINE
Vol. 11 no. 2– June 2009
TELEMEDICINE
IS QUEBEC READY?
• FACTS
• PROJECTS
• REMUNERATION
Du nouveau
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SUMMARY
7
8
9
11
15
17
28
29
WORD FROM THE PRESIDENT
Bill 34 – and the need to change its aim
IN THE NEWS
Annual Report
IN THE NEWS
Patient Education and Compliance
DID YOU KNOW...
IN THE NEWS
More than 2,000 Canadian Researchers Criticize
the Harper Government’s Budget Cutbacks
ON COVER
DOSSIER
Telemedicine
Is Québec Ready?
MEMBERS SERVICES
Commercial Benefits
GREAT NAMES IN QUEBEC MEDICINE
Dr. Denis Marleau, On the starting line of
hepatology
30
CONTINUING PROFESSIONAL DEVELOPMENT
The Importance of Continuing Professional
Development for Affiliated Associations
32
34
36
37
IN THE WORLD OF MEDICINE
CaMos Study
SOGEMEC ASSURANCES
GROUPE FONDS DES PROFESSIONNELS
MOT DU PRÉSIDENT
Le projet de loi no 34… il faut corriger le tir !
• Facts . . . . . . . . . . . . . . . . . . . . . . . . . . 18
• Projects . . . . . . 19, 20, 25 and 26
• Remuneration . . . . . . . . . . . . . . . . 23
LE
SPÉCIALISTE
TRANSLATION
Anne Trindall (JP Coty & Ass.)
EDITORIAL COMMITTEE
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The Fédération des médecins spécialistes du Québec represents the following specialties: Allergy and Clinical Immunology, Anesthesiology, Cardiac
Surgery, Cardiology, Community Health, Dermatology, Diagnostic Radiology, Emergency Medicine, Endocrinology, Gastroenterology, General Surgery,
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L E S P É C I A L I S T E · V O L . 1 1 no. 2 · J u n e 2 0 0 9
THIS EDITION’S
ADVERTISERS:
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• Groupe Fonds des
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des services sociaux
du Bas Saint-Laurent ................ 8
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• Solutions Cliniques ................ 39
• Valeant Canada ........ 38 and 40
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WORD FROM THE PRESIDENT
Dr. GAÉTAN BARRETTE
Bill 34 – and the need to change its aim
s we go to press, we are preparing our presentation
before the Commission des affaires sociales on Bill
34, An Act to amend various legislative provisions
concerning specialized medical centres and medical
imaging laboratories. We are increasingly concerned
about the consequences this new Bill will have on
medical practice and the access to specialized and subspecialized care, when taken with the provisions in the Act respecting
health services and social services.
A
For many years, both medical specialists and the government
have set objectives designed to improve the efficiency of our health
system. Following the Chaoulli decision, the Quebec Government
went further by undertaking to open the door to a broader dissemination of private care and better quality care. The FMSQ, which
is in favour of a strong public system, pointed out that physicians
could provide many services in their offices in a more efficient
manner, and that hospitals should be reserved, first and foremost,
for more acute cases requiring hospitalization.
We hoped, at that time, that measures would be put forward with
a view to achieving all these objectives. However, we now find that
not only do the measures introduced under Bills 33 and 34 not
meet the objectives, they are in fact detrimental to them.
The FMSQ has always advocated safer office medicine. We are
therefore ready to cooperate on introducing such measures and
agree with the proposals put forward in Bills 33 and 34 that promote
safe office practice.
WE ARE, HOWEVER, IN
TOTAL DISAGREEMENT
WITH MEASURES THAT
FAIL TO CONTRIBUTE
TO THE IMPROVEMENT
OF THE QUALITY OR
AVAILABILITY OF CARE
We are, however, in total disagreement with measures that fail to
contribute to the improvement of
the quality or availability of care
and, instead, tend to impose
needless bureaucracy, undermine
cooperation between physicians,
attack their rights and professional
independence, give discretionary
powers to the Minister of Health
and reduce the general public’s
access to our medical care.
A number of measures provided for in Bills 33 and 34, with their
regulations, do not contribute to the stated objectives or are
detrimental to them. There is still time to act. The government must retain the orientation we have expressed and make
the necessary amendments.
To achieve this, the FMSQ more specifically asks for:
• A review of the list of specialized treatments, in light of the criteria
given in the Bill, and information on the Minister’s intentions
concerning access to such services.
• The repeal of all measures concerning the issue of Specialized
Medical Centre (SMC) permits by the Minister of Health and Social
Services. These cover the various applicable sections in the Act
respecting health services and social services, as well as the regulations governing the issue of Specialized Medical Centre permits.
(If this does not occur, we have suggested amendments.)
• The repeal of the ban on participating and non-participating physicians
practicing in the same centre – thus creating just one type of SMC.
• The withdrawal of the need for non-participating physicians (or
those who deliver uninsured services) to provide their patients with
all preoperative, postoperative, rehabilitation or home care services
and, instead, require them to inform their patients – consequently
repealing section 78.1 of the Act respecting health services and
social services.
• The repeal of the ban on providing, in an office, specialized treatment
not covered by the regulation.
• The introduction of adequate remuneration for treatments delivered
in SMCs and offices.
• The withdrawal of the adoption of punitive measures against physicians.
• The encouragement of a consensual approach and the review with
the Federation, through negotiated agreements, of all measures
relating to associated medical clinics.
In this way, unproductive procedures will be avoided and the results
expected will be more in line with the objectives sought. Respect
of physicians’ rights will also be ensured, as well as patient access
to care. The alternative is that the government will find itself in the
unfortunate position of jeopardizing medical specialists’ cooperation, as they will have no other choice than to contest the
measures in every way possible.
Finally, we have to ask ourselves some serious questions about
the government’s recent propensity for desiring discretionary
control over care provided in doctors’ offices. The Federation is
also worried about the Minister of Health’s other ambitions in this
regard, particularly with respect to Bill 26 – An Act respecting
clinical and research activities relating to assisted procreation –
where, once again, the Minister intends to give himself a number
of discretionary powers and impose a whole host of requirements
on assisted procreation centres!
The FMSQ’s brief (in French only) can be found on the Internet at:
http://www.fmsq.org/f/publications/memoires.html
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7
IN THE NEWS
Annual Report
Dr. Maurice Boudreault, treasurer
The Delegates Assembly held on March 19, 2009 approved the
recommendations of the President of the Finance Commission,
as follows:
1. To approve the FMSQ financial statements as at December 31,
2008, as audited by the firm Raymond Chabot Grant and Thornton;
2. To approve budget forecasts for the year 2009, as submitted by
the FMSQ;
3. To raise annual union fees from $1,070 to $1,175.
With regard to returning the unused balance to members of the
special dues of $2,000 levied in 2006, we are continuing to
provide reductions for active members. You will recall that we
began this process last year by allowing every member a partial
deduction of $20 against their 2008 dues. This year, a partial
deduction of $950 (slightly more than 80% of dues for the year
2009) will be given. This means members will only have to pay
dues of $225 to the Federation this year. The remaining balance
will be used to reduce dues for 2010.
8
Something new from the FMSQ
On April 24, the FMSQ
launched its electronic
newsletter, À l’@ffût, the
latest newcomer to
Federation publications.
Designed for medical
specialists, the newsletter
contains all sorts of information that complement
the Internet site, FMSQ
nego and FMSQ en bref,
as well as Le Spécialiste
magazine.
If you have not received it, it is most likely because the
Federation does not have your e-mail address. You can
update your information by visiting www.fmsq.org or
contacting your medical association directly.
The next issue of À l’@ffût for 2009 will appear in October.
IN THE NEWS
SPECIAL COLLABORATION
Patient Education and Compliance
Specialists at the very heart
of multidisciplinary work
Philippe Boulet, M.D.*
professionals with regard to implementing
oday, when everything is
The organization of care described here by Dr.
the latest recommendations in their field,
changing at warp speed,
Boulet clearly falls within the parameters of the
and communication between general pracparticularly with regard to
Committee on Medical Specialists’ Conditions of
titioners and medical specialists must be
means of communication,
Practice. It is encouraging to see such initiatives
constantly improved.
specialized medicine, like firstbeing taken in response to the many needs of
organizations and physicians alike, and for the
line care, faces major
benefit of patients.
In addition, patients increasingly want to
challenges. These include population
- Dr. Gilles Hudon
share in decisions affecting them and seek
aging, the need to provide quality care
information concerning their particular
despite excessive workloads and
problems on the Internet or from acquaintances. Not only must
sometimes less-than-adequate resources, all accompanied by
physicians be experts on health problems per se, they must
a increase in the number of requests for information and decisionalso be effective communicators. Action by the various health
sharing by patients and their families.
professionals must be along the same lines; it is a known fact
It is obvious that, in the case of many patients, insufficient
that conflicting messages have an enormous effect on patients’
knowledge of their health problems and their treatment result in
adherence to treatment. Here is where practice guidelines
a poor use of medication, lack of compliance and inappropriate
provide a common base with regard to patient intervention.
use of resources. These factors, combined with the rapid
Many of our society’s health
increase in knowledge, a too-common silo mentality where
PATIENTS INCREASINGLY
problems could be prevented by
communication between the various parties is often minimal,
WANT TO SHARE IN
making changes in our behaviour or
and recommendations that are sometimes contradictory make
habits. One out of five Canadians is
DECISIONS AFFECTING
us wonder how to develop a better care delivery system and how
still subject to the bane of cigarette
to better explain the actions of all those involved.
THEM AND SEEK
smoking; a sedentary lifestyle and
INFORMATION
In 2002, Ibrahim and Major noted that health systems throughout
poor diet result in problems with
the world are performing at suboptimal levels, given the extent
major repercussions, such as
CONCERNING THEIR
of the knowledge available9. This observation has led to the
obesity and diabetes. Lastly, poor
PARTICULAR PROBLEMS
treatment compliance and useless
development of a number of knowledge transfer initiatives in an
ON THE INTERNET
– and sometimes harmful – “treatattempt to better integrate knowledge into medical practice and
ments” do not improve matters in
improve intervention strategies with regard to patients. Such
OR FROM
the slightest.
strategies can greatly reduce the morbidity and mortality rates
ACQUAINTANCES
of many diseases by promoting prevention, patient education or
We all know that it is essential for
rehabilitation, and the optimal use of treatments available, particpatients to be involved in their health
ularly in the case of chronic disorders.
care, to have a better understanding of their medical condition
and how to monitor and treat it.10,11 Not only can this result in
Every year, numerous published studies provide an amount of
improved observance, but the patient becomes more closely
information that is increasingly difficult to incorporate into an
involved with the health professional. It has been proven that for
overall treatment plan. Analyzing such knowledge often results
most illnesses, a clear understanding of the disorder and its
in a treatment consensus or practice guidelines, usually
treatment improves quality of life and diminishes the need for
conducted by specialists in the field but, ideally, with input from
emergency care.
first-line physicians and other health professionals. The latter
have a particularly important role to play in disseminating and
introducing such guidelines3. Their recommendations, based on
evidence and methods of producing quality guidelines, are being
applied more and more frequently3,5. Numerous difficulties arise
* Philippe Boulet, M.D., FRCPC, FCCP, Pulmonary Specialist,
when applying practice guideline recommendations, and more
Institut de cardiologie et de pneumologie de l'Hôpital Laval
efficient knowledge transfer and application is required6,7.
Specialists must play an increasingly active role in guiding other
T
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IN THE NEWS (SUITE)
Unfortunately, overloaded practitioners do not always have the
resources or skills required to be effective educators and cannot
provide lengthy and often repetitive assistance to the patients
involved. There are also many barriers to effective communication between patient and doctor. Under these circumstances,
particularly when the patient has to assimilate various concepts
or recommendations, a second person can help the patient.
For example, there are more than one hundred educational
centres in the Quebec Asthma and COPD Network, or QACN
(Réseau québécois de l’asthme et de la maladie pulmonaire
obstructive chronique – RQAM). Their education of asthma or
COPD patients is based on the latest treatment guides
(www.rqam.ca). The QACN provides regularly updated interdisciplinary education and consulting services to members of
the health network, in addition to encouraging an exchange of
experiences to optimize the self-management of asthma and
COPD patients. Some studies have shown the beneficial effects
of this type of action. Specialists use these resources on a
regular basis, but they do not exist for many health problems
and they are not always available in the regions.
Even though the assistance provided is mainly useful for
chronic conditions, such as obstructive respiratory disease,
diabetes and cardiovascular disease, very many other health
problems could benefit from this type of action. Furthermore,
such educational intervention can improve the interaction
between specialists, generalists, pharmacists and other health
professionals involved in a patient’s care. In general practice,
family physician groups (FPG) might offer a favorable environment for such measures. Some cooperative, continuing
medical education and reference programs for both specialists and health educators have been developed between FPGs
and certain specialized centres, with very worthwhile results.
In addition, the QACN for example has offered FPG nurses’
updates and has helped ensure improved ties with the
education centres.
Unfortunately, in the past, preventive and educational
resources have often been separate or far away from health
centres, whereas it is important to incorporate such measures
directly into acute or long-term care settings. An emergency
situation often provides an opportunity to integrate the patient
and family members into an educational program so that they
can better understand the nature of the problem, its treatment
and prevention.
Knowlege transfer is exploding and these principles must be
perfected and incorporated into medical practice in an increasingly effective manner.12,13 Practitioners, whether specialists
or generalists, need to be supported in their work. Sometimes
simple practice aids in addition to the presence of human and
material resources can make a great difference in effective
care.14 The new Université de Laval Chair of Knowledge
Transfer, Education and Prevention Transfer in Respiratory and
Cardiovascular Disease in Quebec City will in fact be focusing
on these objectives over the coming years.
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References
1. Canadian Institute for Health
Information, Canadian Lung
Association, Health Canada,
Statistics Canada. Respiratory
Disease in Canada. Ottawa:
Health Canada, 2001.
2. Masoli M, Fabian D, Holt S,
Beasley R: Global Initiative
(GINA) on Asthma Program.
The Global Burden of Asthma:
executive summary of the GINA
Dissemination Committee
report. Allergy 2004 ;59:469-78.
3. AGREE Collaboration Writing
Group: Cluzeau F., Burgers J,
Brouwers M, et al. Development
and validation of an international appraisal instrument for
assessing the quality of clinical
practice guidelines: the AGREE
project. Qual Safe Health Care
2003 ;12:18-23.
10
4. Guyatt G, Gutterman D,
Baumann MH, et al. Grading
strength of recommendations
and quality of evidence in
clinical guidelines: report
from an American College of
Chest Physicians task force.
Chest 2006 ;129:174-81.
5. http://www.cochrane.org/
6. Boulet LP, Becker A, Bowie D,
et al. Implementing Practice
Guidelines: A workshop on
guidelines dissemination and
implementation with a focus on
asthma and COPD. Can Respir
J 2006 ;13 Suppl A:5-47.
7. Davis D. Clinical practice
guidelines and the translation
of knowledge: the science of
continuing medical education.
CMAJ 2000 ;163:1278-9.
8. Schattner A, Bronstein A, Jellin
N. Information and shared
decision-making are top
patients’ priorities. BMC Health
Serv Res 2006 Feb 28 ;6:21.
9. Ibrahim J, Major J. Corruption
in the health care system: the
circumstantial evidence. Aust
Health Rev 2002 ;25:20-6.
10. McDonald VM, Gibson
PG.Asthma self-management education. Chron
Respir Dis 2006 ;3:29-37.
11. Boren SA, Fitzner KA,
Panhalkar PS, Specker JE.
Costs and benefits
associated with diabetes
education: a review of the
literature. Diabetes Educ
2009 ;35:72-96.
12. Grol R, Grimshaw J. From
best evidence to best
practice: effective
implementation of change
in patients’care. Lancet
2003 ;362:1225-30.
13. Boulet LP. Improving
knowledge transfer on
chronic respiratory diseases:
a Canadian perspective.
J Nutr Health Aging
2008 ;12:758s-63s.
14. Renzi PM, Ghezzo H, Goulet
S, Dorval E, Thivierge RL.
Paper stamp checklist
tool enhances asthma
guidelines knowledge and
implementation by primary
care physicians. Can
Respir J 2006 ;13:193-7.
DID YOU KNOW...
Prizes and Awards
QMA’S Honorary Members
Prix d’excellence – Quebec Medical Association
(QMA)
The Association also gave honorary titles to medical specialists
over 65 years of age, who are recognized for their work and are
model humanists who have put the highest aims and ideals of
the medical profession into practice.
At its annual congress, the QMA rewarded a number of medical
specialists for career achievements and their activity within the
medical community.
Dr. Serge Beaulieu, a psychiatrist at
Douglas Hospital, received the TeachingClinician Award, which recognizes the
exceptional contribution of a physician who
also teaches at a faculty of medicine. Dr.
Beaulieu has been an Associate Professor
in the Department of Psychiatry at McGill
University since 2003, Medical Chief of the
Mood, Anxiety and Impulsivity Disorders
Program and the Medical Chief of the
Bipolar Disorders Program at the Douglas
Mental Health University Institute.
Dr. Jean L. Rouleau, a cardiologist and
Dean of the Faculty of Medicine, Université
de Montréal, received the Prestige Award
for excellence and for his contribution to
the advancement of medicine and society
in humanitarian, ethical, scientific, socioeconomic and educational fields. Dr.
Rouleau influenced a whole generation of
medical students as Professor of Medicine
and Director of Cardiology at Sherbrooke
University, as well as Associate Clinical
Research Director and Director of Intensive Care at the Montreal
Heart Institute.
Appointment
The QMA named the following medical specialists as Honorary
Members:
Dr. Gilles Hudon
Diagnostic Radiology
Dr. Hudon is director of the Professional Development
Office and Health Policies at the FMSQ
Dr. Michel Bureau
Dr. Samuel O. Freedman
Pneumonology
Allergies and Clinical Immunology
Dr. Gilbert Pinard
Dre. Micheline Ste-Marie
Psychiatrist
Pediatric Gastroenterology
An internist at the head of the Quebec Medical
Association
Dr. Jea n-F ran çois L ajo ie, an internal
medicine specialist and Clinical Professor
at Centre hospitalier universitaire de
Sherbrooke – Hôpital Fleurimont has been
elected President of the QMA for a twoyear term. Dr. Lajoie succeeds to
Dr. Jean-Bernard Trudeau.
Clinical Bursaries
The Quebec Chronic Pain Association is offering bursaries to candidates interested in clinical training on
chronic pain. Several medical specialists took advantage of these bursaries last year. For more information, please visit www.douleurchronique.org.
11
DID YOU KNOW... (SUITE)
POUR TOUS VOS
BESOINS D’ASSURANCES
New books
Le trouble bipolaire
La direction de Sogemec
Assurances a le plaisir de
souhaiter la bienvenue à
Madame Catherine Boily,
notaire au sein de son
équipe. Me Boily se joint
à Sogemec Assurances
Dr. Marie-Josée Filteau, a psychiatrist
and associate researcher at the Centre
de recherche Université Laval RobertGiffard, in collaboration avec Jacques
Beaulieu, a medical writer, has
published Le trouble bipolaire pour
ceux qui en souffrent et leurs proches.
This book explores the different
aspects of this disorder (previously
known as manic-depressive disorder)
which affects 1 to 5% of the population and, because of its often poorly
understood consequences, also affects the families and those
near to the patient.
à titre de Conseillère,
développement des
relations d’affaires.
Me Boily possède plus de 10 années d’expérience
en enseignement, en droit notarial et en assurances.
En plus de son baccalauréat en droit et de son diplôme
de 2e cycle en droit notarial, Me Boily détient un
diplôme d’Études supérieures spécialisé en gestion
des HEC. Sogemec Assurances tirera parti de sa vaste
expérience et de sa facilité à communiquer, à vulgariser
et à entretenir des relations d’affaires.
Sogemec Assurances, courtier en assurances de
personnes, est une filiale de la Corporation de services
de la Chambre des notaires du Québec ainsi que de
la Fédération des médecins spécialistes du Québec.
Outre les deux actionnaires, plusieurs groupes de
professionnels ont fait appel à Sogemec Assurances,
depuis sa création en 1978, pour offrir de l’assurance
collective à leurs membres, dont : la FMRQ (Fédération
des médecins résidents du Québec), la FMEQ (Fédération médicale étudiante du Québec), l’AMLFC
(Association des médecins de langue française du
Canada), et le RéseauIQ (Réseau des ingénieurs
du Québec). Aujourd’hui, l’ensemble de ses groupes
totalise plus de 12 000 assurés.
12
Tous responsables de nos enfants
Dr. Gilles Julien, a pediatrician and founder
of the social pediatric movement, has
published a book with his wife, Maître
Hélène Sioui-Trudel, presenting their
approach in which all the needs and rights
of a child are considered. For the authors,
the key to this model is the mobilization
of all those involved in the community,
creating a real social pact for children.
Mieux connaître la syncope
Two cardiologists, Dr. Teresa Kus of
Hôpital du Sacré-Cœur de Montréal and
Dr. Bernard Thibault of the Montreal Heart
Institute, have together created a training
DVD entitled La syncope : enjeux
médicaux et psychologiques.
This DVD is a complete tool intended for
all present and future caregivers in the
health sector. It portrays a full picture of
syncope, both from a medical and
psychological point of view. Various
treatment approaches are suggested,
and it emphasizes the importance of intervening if there is a psychological comorbidity.
For more information, to view a short extract or order a copy, visit
http://www.clipp.ca/servlet/dispatcherservlet?selectedContentID=1
2942&lang=1&action=2.
Dr. Jacques Lacroix, Recipient of the Prix Letondal
Prizes and Awards (suite)
r
D Jean-Claude Fouron récompensé lors du Colloque
annuel du Collège des médecins du Québec
Dr. Jean-Claude Fouron, a pediatric cardiologist at Saint Justine University Hospital
Centre was awarded the Grand Prix 2009 of
the Collège des médecins du Québec.
Founder and Director of the Fetal Cardiology
Unit of the Saint Justine University Hospital
Centre, Dr. Fouron has devoted many years
to research, teaching and to the development of fetal cardiology while maintaining his
clinical activities.
This prize is given each year to a physician who has distinguished
himself by his remarkable contribution to the development of the
medical profession and the improvement in the quality of medicine,
his humanism and professional ethics.
The Association of Pediatricians of Quebec
awarded the Prix Letondal to Dr. Lacroix in
recognition of his contribution to pediatrics.
Dr. Lacroix is the co-founder of pediatric
care at Sainte Justine UHC, a pioneer of
clinical research, an author, professor and
man of action. Among his achievements
are a study on the transfusion of children
hospitalized in the pediatric intensive care
unit and a reference book on pediatric
emergencies and intensive care, which is now required reading
in his field.
The Prix Letondal was created in 1989 to mark the exceptional
contribution of a pediatrician to the development of his profession in Quebec.
Le 4e Tournoi de golf des fédérations médicales
Merci à nos commanditaires
au profit de la Fondation du Programme
d’aide aux médecins du Québec
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et New Star Canada Inc.
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(meilleure balle), une voiturette, le brunch, le lunch, le cocktail ainsi que le souper.
Les places sont limitées et s’envolent rapidement ! Le formulaire d’inscription et tous les détails de l’horaire de la journée sont disponibles
sur notre site Internet au www.fmsq.org. Quelques occasions de commandite sont encore disponibles. Pour connaître tous les détails
concernant les options, les disponibilités et les tarifs, contactez Geneviève Roberge au 514 350-5028 ou par courriel au [email protected].
Informations et formulaires d’inscription disponibles sur le site Internet de votre fédération :
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13
DID YOU KNOW... (SUITE)
Grand défi Pierre Lavoie, 2009
The FMSQ beats its objective!
Palais des congrès de Montréal
LE VENDREDI
6 NOVEMBRE 2009
Réservez cette date à votre agenda !
Au programme : 6 thèmes
LE RÔLE DE L’EXPERT PSYCHIATRE DANS NOTRE PRATIQUE
Partenaires :
• Association des médecins psychiatres du Québec
• Société des experts en évaluation médico-légale du Québec
Mission accomplished! The final count is 17 teams
from the medical associations who will be at the
1,000 kilometre starting line at Ville de La Baie
(Saguenay―Lac-Saint-Jean) on June 12 to
undertake the Grand défi Pierre Lavoie. The FMSQ
had set itself an objective of 15 teams. With 85
cyclists, the FMSQ delegation alone represents
one-fifth of all participants. In terms of support
and personal engagement for this cause and the first event of this
kind, this is a real success! Quebec medical specialists quite simply
knew how to make a difference by a large number of them being
present and all of them must be extremely proud of having taken
part in this great adventure, which has a dual purpose: to raise
money to fund research on orphan diseases and to make young
people and the general population aware of healthy eating habits
– and get them moving!
Our courageous cyclists will be highly visible all along the route
because each participant has been given a distinctive sweater in
the FMSQ colours, specially designed for the occasion.
Provenance and leaders of the 17 teams from
FMSQ associations:
• Équipe FMSQ “Les Doctopus”, Dr. Michel Lallier
MALADIES HYPOPHYSAIRES
Partenaires :
• Association des médecins endocrinologues du Québec
• Association d’oto-rhino-laryngologie et de chirurgie cervicofaciale du Québec
• Société canadienne-française de radiologie
• Association des neurochirurgiens du Québec
• Association des radio-oncologues du Québec
• Geneticists, Dr. Jacques Michaud
• Radiologists, Dr. Frédéric Desjardins
• Orthopedists “The Cyclopedists”, Dr. Dominique Fleury
• Surgeons (AQC), Dr. Pierre-Yves Garneau
• Plastic and Cosmetic Surgery (ASCPEQ), Dr. Michèle Tardif
• Cardiologists, Dr. François Delage
• Nephrologists I, Dr. Robert Charbonneau
• Nephrologists II, Dr. Nathalie Langlois
IMPACTS DES INÉGALITÉS SOCIALES SUR LA SANTÉ DE NOS
ENFANTS AU QUÉBEC
Partenaires :
• Association des pédiatres du Québec
• Association des médecins spécialistes en santé communautaire
du Québec
• ENT, Dr. Frédéric Hélie
LA PLANIFICATION DE LA RETRAITE
(POUR TOUS)
• Orthopedists, Dr. Jacques Desnoyers
LA LECTURE CRITIQUE DE LA LITTÉRATURE
(POUR TOUS)
COMMENT ORGANISER UNE ACTIVITÉ DE FORMATION
CONTINUE POUR LES MÉDECINS
(POUR TOUS)
Cette activité est rendue possible grâce à une contribution
financière de :
• Urologists, Dr. Paul Ouellette
• Anesthesiologists “Sevo-Velo”,
Dr. Jean Brassard
• Hematologists/oncologists,
Dr. Raynald Simard
• Orthopedists “Vel-Os I”, Dr. Rémy Lemieux
• Orthopedists “Vel-Os II”, Dr. Marc Lemieux
• Pediatricians, Dr. Pierre Tremblay
The start for the 1,000 km will be Ville La Baie on June 12. Passing
through the Parc des Laurentides, the caravan will reach Quebec
City and then move on to Trois-Rivières, Drummondville and
Sherbrooke. During this endurance test, the cyclists will pedal on
under sun or rain, night and day. There will be a great welcome
awaiting them at the Circuit Gilles Villeneuve in Parc Jean-Drapeau
on June 14. From there, all participants will go to the Olympic
Stadium for the Grand Finale which will be held in front of the
5,000students who won the school challenge “Get up and Move”
organized in all Quebec schools.
S
L
14
IN THE NEWS
More than 2,000 Canadian Researchers Criticize
the Harper Government’s Budget Cutbacks
In its last budget, Stephen Harper’s Conservative Government slashed nearly $150M from
research funding, with the result that whole teams of scientists will be affected or dismantled.
by President Obama, you wonder why you’d want to stay on
here. As scientists, our work reaches far beyond our daily life.
The results of our research have an impact worldwide, and
research carried out by our colleagues also has an impact on
us,” said Dr. Richards.
To learn more, visit www.dontleavecanadabehind.wordpress.com.
Dr. Brent Richards, an endocrinologist at the Sir Mortimer B.
Davis Jewish General Hospital, Montreal, is one of the
researchers who signed the letter. Dr. Richards is a CIHR Fellow
Canada recruited from the U.K. He is working on various clinical
research projects and, in particular, the Canadian Multicentre
Osteoporosis Study (CaMos). Until now, the funding he has
received from sponsor organizations such as the Canadian
Foundation for Innovation or the Leaders Opportunity Fund have
enabled him to obtain equipment, tools and the other items
required to continue his research work. The money cut by the
federal government will deprive him of the services of laboratory
personnel, greatly compromising the continuation of his work.
Other medical specialists are also facing major cuts. “When you
look at the difference between what Canada is doing with regard
to scientific research and what is being done in the United States
You think Dr. Richards is an alarmist?
On May 4, we learned that an eminent
immunology researcher, Dr. RafikPierre Sékaly, was leaving. Known for
his research on HIV/AIDS, Dr. Sékaly
has decided to leave Quebec and go
to Florida, where he will join the
Vaccine and Gene Therapy Institute.
And he will not be going alone: twenty
or so researchers from his group will
also be leaving their research laboratory at Université de Montréal to
continue their work in Florida.
Source : www.iforum.umontreal.ca
S
cientific researchers from all fields (engineering,
physics, chemistry, mathematics, etc.) have questioned these cuts at a time when the new President
of the USA has taken the opposite route, increasing
budgets to stimulate research activities and, consequently, the American economy overall.
Dr Rafik-Pierre Sékaly
S
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8m\q$mflji\eflm\cmfki\Zfk`jXk`fe6
Votre avis de cotisation accompagné du paiement doit être reçu
au Collège des médecins du Québec au plus tard le 30 juin, à 17 h.
Pour éviter tout retard pouvant entraîner la radiation au tableau
des membres à compter du 2 juillet, effectuez votre renouvellement
en ligne à l’aide du mot de passe qui vous a été transmis par la poste
le 12 mai : www.cmq.org/fr/medecinsmembres.aspx
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,(+0**$+'/.fl(///-**$*)+-
15
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TELEMEDICINE
IS QUEBEC READY?
id you know that the very first demonstration of
telemedicine (or remote medicine) was carried
out in Quebec? On November 8, 1994, a patient
at the Hôpital Cochin, in the 14th arrondissement
of Paris, had an X-ray scan guided more than 5,500
kilometers away by the Radiology Department of
Hôtel-Dieu de Montréal.
D
Who would have thought that the cyber tools in 1970’s films and
science fiction series would become commonplace, in fact
outdated, today? Think of the possibilities created by the
miniaturization of electronic components, the advent of new
technologies, 3D modeling, etc. Technological development has
also advanced our knowledge, particularly with regard to
sequencing of the human genome and its current applications. In
short, technology allows scientists to achieve more, push the
envelope of current practice, and offer still more.
The pace at which science has evolved over the past few decades
would indicate that telemedicine has taken giant strides forward,
even in everyday use. The technology is omnipresent, increasingly
easy to access, and forms part of our daily lives: portable access
to the Internet (laptop, telephone and other mobile devices),
information or data transfer at a simple click, audio video
recording or digitization, home entertainment systems, etc. Plug in
anywhere in the world and you’re in cyberspace.
But how far have we traveled since the very first use of
telemedicine 15 years ago? We asked this question of various
people. For some, it offers the hope of a new form of medical
practice, which does away with borders and administrative
barriers. For others, it is a dead end, the disillusionment of seeing
such a marvelous tool at the centre of administrative and legal
problems. Can these two points of view be reconciled? That is
what Le Spécialiste asks you to consider in this special report.
17
Jean-Paul Fortin. M.D.
Medical specialist in Community Health*
TELEMEDICINE
IS QUEBEC READY?
Telehealth in Quebec:
A Lot of Catching Up To Do...
Last year, an article indicated that Quebec was losing a great deal of ground in the field of
telehealth, and suggested possible solutions1. The situation is still continuing to deteriorate
despite the efforts of highly motivated individuals and teams.
re we experiencing what the Director General of
the Institut du Nouveau Monde calls “Years of
Indecisiveness”, a period characterized by
society’s inability to consolidate the individual
energies created in order to move society forward
as a whole2? It would seem so, but there are some
encouraging signs, related in particular to the preparation of
major projects, partial reorganization at the MSSS, steps taken
to draw a more complete portrait of work in progress, a
somewhat more inclusive vision of information and telecommunication technologies (ITTs) and their use, as well as the
recognition that synergy between actors from various levels of
intervention (local, regional and central) is important. Will Quebec
regain its leadership position in telehealth? It is still possible, but
the challenge is somewhat daunting.
A
Telehealth
In its White Paper, the Canadian Society of Telehealth (CST)
described telehealth as a new way to deliver health care, health
services and health education in order to improve the health
system's efficiency, access and the maintenance of quality
services, to promote professional support and also enhance cooperation between persons, organizations and regions. Telehealth
also allows individuals and communities to play a more active
role in this field. The White Paper highlights the fact that we have
reached the third generation of telehealth, where various ITT
components become integrated.
Technological integration is revolutionizing how we do things.
Think of cell phones, which are central to the economic development strategies of so-called emerging countries3. More than
8 billion cell phones are in circulation and, in twenty countries or
so, there are more of them than inhabitants. Cell phone communications use a wireless system that is more accessible and less
costly. And the network is spreading at impressive speeds. With
the arrival of Web 3.0, semantic maps, intuitive artificial intelligence applications, nanotechnologies and all kinds of sensors,
future systems will be truly transformed, conferring greater
mobility that will be at the heart of future health services.
18
These rapid developments require an overall view of our health
systems and of the role that ITTs will play in reaching our clinical
and organizational objectives. But there are no miracle solutions,
and our approach must therefore remain innovative and flexible
in order to evolve. Technologically, we must look without further
delay at the connections that will need to exist between telehealth, electronic records, clinical/management/research
databases and links to the Internet. It is therefore important that
ITTs are not only developed on a case-by-case or silo basis.
With technologies becoming more user-friendly and intersecting
even further, existing silos must change and telehealth will need
to be incorporated into medical practice, health care and health
service organizations as well as living environments, particularly homes. Telehealth will form the core of health prevention,
promotion and protection, as part of increasingly interdisciplinary projects4. It will be used by family caregivers, social workers
and communities to manage social isolation or to strengthen
social networks in both outlying regions and large urban centers.
It will be possible to further integrate telehealth into the daily lives
of individuals through alliances between municipalities, communities, education, environmental and other sectors that may have
an impact on health. It should be noted that projects with the
best performance are those which have integrated various ITT
components into their clinical and organizational processes.
The Development of Telehealth in Quebec
Telehealth came into being through the will and initiative of a
certain number of clinicians, managers and passionate and innovative technology specialists. The first applications were clinical
in nature and introduced by committed physicians. Success was
also due to alliances with management and technical teams
within their organizations. They benefited from financial and other
support from health facilities, the federal government, the MSSS,
the industry and sometimes even personal contributions. The
significant role played by teams from university and local health
* Medical specialist in Community Health; Professor, Department of
Social and Preventive Medicine, Université Laval; Medical Expert,
Institut national and Direction régionale de santé publique (Québec);
Researcher/Evaluator, Centre affilié universitaire CSSS-Vieille
Capitale; Medical Coordinator, Réseau québécois de télésanté (RQT)
centers should be noted. Their competence was recognized in
one case by the Canadian Council of Hospital Accreditation.
The network has changed profoundly in the past few years, and
decisions have become increasingly centralized. In the case of
ITTs, the Canada Health Infoway (CHI) was set up and rapidly
influenced the choices made by provinces. Great importance
was also given to the simultaneous development of Quebec
Electronic Health Records (EHR) and medical imagery solutions
(PACS – Picture Archiving and Communication System). Because
of these major changes, conditions were less favorable for the
network to develop or disseminate the concept of telehealth –
and this is when Quebec started to lose ground.
Start-up was encouraging with a number of promising projects.
A pediatric telecardiology project opened the way, allowing familiarization with telehealth which was spreading and was intended
t serve as the basis for the development of other applications.
A second project in Îles-de-la-Madeleine aimed at gaining a
better understanding of the realities of client sites and of their
needs with regard to care and services, organization and
technical support. Another project – Themis first-line care in the
Témiscamingue region – opened up new avenues with respect
to professional cooperation for more remote regions, while
others, such as home telecare, increasingly highlighted the
impact of ITTs on care and services, and on patient and family
involvement in health care processes. Teledialysis was directed
more to living environments (see insert in page 20). During this
period, the Mother-Child Network, a supraregional project, was
being established. Rehabilitation, speech therapy, nutrition and
many other projects were then developed at sites that already
had a history of collaboration. At the same time, numerous
services were developed for populations in Quebec's Far North
(more than 1,500 videoconferences in 2008-2009).
Telemedicine and Ophthalmology
Dr. Jean Daniel Arbour, President,
Association des médecins
ophtalmologistes du Québec
The many technological advances in
ophthalmology have led to the introduction of new applications and procedures.
Telemedicine is mainly used for eye
examinations today:
systems that
include a microscope can be connected
to an imaging network; the slit lamp used
in the external and internal examination of the eye; and indirect
ophthalmoscopy to enable a more complete examination of
internal eye structures. To capture and store images, digitized
imaging systems can be linked to a network similar to those found
in hospitals – i.e., photography of the exterior and interior of the
eye, ocular echography and retinal angiography.
Teletraining is one of the applications that has progressed the
most, helping to familiarize potential users with the concept of
telehealth. Videoconferences are being increasingly used for
administrative purposes. Despite all these accomplishments,
conditions for initiating and implementing a truly collective project
are proving slow to develop and take root. Yet a major planning
operation was launched in 2005, with the advent of the Canada
Health Infoway.
As part of their mandates, each RUIS planned two projects, the
first of which focused on a specific area: telepathology (RUIS
Laval), the National Program for Breathing Assistance at Home
(RUIS McGill), telecare at home (RUIS Montreal) and teleassistance for wound care (RUIS Sherbrooke). The second project
differed from one RUIS to another and involved several applications involving the following disciplines: cardiology,
cancer/oncology, psychiatry/mental health, obstetrics-gynecology, geriatrics, traumatology and hemodialysis.
These projects required a more global organizational approach.
Each RUIS presented its own vision and strategy for the development of telehealth on its territory. One of them proposed a
virtual CSSS project. For operational purposes, its orientation
would need to be adjusted to take into consideration the multiple
interfaces between users and institutions. Both human and
technical infrastructures need to be available at the sites
requesting or supplying services. Action plans and progress
reports differ for each project based on the characteristics of
the environments, without there being any overall planning
between RUIS.
Other equipment that allows assessment of specific portions of
the eye mainly affected by disease can also be connected to the
network: HRT and GDx scans to assess optic nerve fibers, and
OCT to scan the internal structures of the eye are some examples.
Ophthalmic telemedicine will soon take an unprecedented step
forward with the development of diabetic retinopathy (DR)
screening programs. This eye complication of diabetes is the
leading cause of blindness in active members of the population
in industrialized countries today. Using digitized imaging, it is
now easy to take films of the fundus of a patient’s eye, even
without dilating the pupil, allowing the remote diagnosis of DR
and subsequently enabling the person requiring treatment to be
referred to the appropriate ophthalmological resources. The
Association des médecins ophtalmologistes du Québec has
already begun taking the steps necessary to introduce a provincial DR screening program, and is convinced that telemedicine
will allow ophthalmology to substantially increase Quebec
patients’ access to eye care.
19
TELEMEDICINE
IS QUEBEC READY?
An overall vision incorporating that of the four RUIS still needs to
be finalized in order to encourage the coordinated development
of telehealth and ensure its integration into the traditional provision
of health services. Progress is slow, as all the pieces for a true
launching are still not in place. Stakeholder interest and motivation are evident, but so is frustration because of the obstacles to
development and dissemination, such as the time required to
make decisions, the now centralized management of available
financing, the length of negotiations with regard to remuneration,
the small number of human resources dedicated to telehealth
both at client and at supplier sites, the limited room for manoeuvre
for teams in the field, as well as the lack of information and consultation.
All the projects previously described need to be launched, but
they only represent a part of the true telehealth project in Quebec,
a lever in fact. This could prove a major motivational factor for
those who are investing so much effort and who still have faith.
So?
Addressing the main factors that impact the development, implementation, distribution, sustainability and
evolution of telehealth enables us to identify the conditions inherent in its challenges. It must be recognized at
the outset that the challenge is clinical in nature, affecting the
practice and organization of care and services, rather than
technological. It is therefore a question of changing clinical
and administrative practices, and this requires a good
knowledge and understanding of how the health system
operates and the conditions for adopting and using the technologies involved. Clinical leadership must therefore be
predominant. Physicians in particular and other professionals
need to be at the heart of these projects.
Why should that be so? Because we need to "manage" the
new division of roles and responsibilities between physicians
and also other professionals; the impact on the distribution
And elsewhere in Canada?
The problems in Quebec also exist elsewhere in Canada. The
Canadian Society of Telehealth has, in fact, recognized the need
to promote telehealth more actively to politicians, decisionmakers, health care providers and the general population who
have little information on the potential of telehealth. The media,
who have had little to say on the subject5 should not be forgotten
either. Is there a lack of information on telehealth? Is it seen only
as a technological development? Is it overshadowed by the
electronic records project? And what about the influence of the
Canada Health Infoway, which has not really demonstrated the
fact that telehealth is its first priority?
It must be admitted that the transfer of several million dollars
from the telehealth budget to the electronic records project is a
worrisome sign, and some even fear that history may be repeating
itself. Obviously, the millions of CHI dollars are important for
Quebec, but we cannot forget that this contribution will remain
marginal if we consider what is not financed: recurring expenses,
upgrading equipment in establishments and basic human
resources required in specialized and non-specialized environments. Canada Health Infoway's contribution must therefore be
considered only as a means of supporting our health system's
strategic choices6.
Despite everything, other provinces are moving more rapidly.
Back in 2005, Ontario had already totaled almost 32,000 teleconsultations with more than 800 physicians; by 2008, they were
up to nearly 48,000. In Alberta, 500 active systems are in place,
resulting in 23 sessions per 10,000 inhabitants. Since 1998, more
than 3,000 postoperative cardiac patients in New Brunswick
have been able to benefit from telecare at home, thus avoiding
recourse to the ER and too rapid rehospitalization. A similar project
was developed as part of a management strategy for chronic
illnesses. Following evaluation, it was concluded that this model
was efficient and provided a wealth of teaching.
20
Dialys – Serving the Regions by Bus
Dr. Robert Charbonneau,
Nephrologist, CHUQ
The constant increase in the number of
patients with end-stage renal failure
inevitably brings with it a demand for
renal replacement therapy (RRT) in
poorly-populated regions. Satellite
hemodialysis
units
have
been
developed to meet this need. However,
RRT patients are becoming older and
they have a number of disorders, particularly those relating to
the heart. These patients need closer medical supervision.
Providing them with renal replacement care without a nephrologist being on site can present problems. One possible solution
lies in the technological advances that make remote supervision a viable solution.
At the CHUQ - L'Hôtel-Dieu de Québec, “Dialys”, a mobile
hemodialysis unit, provides the answer to both these difficulties.
For Baie-Saint-Paul and Portneuf, the number of patients was
not sufficiently large to justify setting up a renal replacement
therapy unit. A bus, containing several units, enables hemodialysis treatment to be provided three days a week to each town,
on an alternating basis. The bus leaves Quebec City each day
with the nursing personnel required to provide therapy. A satellite
videoconference link allows the personnel to contact the nephrologist responsible for supervising hemodialysis treatments at the
CHUQ - L'Hôtel-Dieu de Québec. The physician can also ask
patients questions directly. The camera’s resolution is sufficiently
good to allow a brief examination of a patient’s arteriovenous
fistula, for example. An electronic stethoscope can also be used.
At the Centre hospitalier de Trois-Rivières, the nephrology team
administers renal replacement therapy to two satellite units
located at Drummondville and Hôtel-Dieu d’Arthabaska.
and retention of certain medical specialists and general practitioners is of concern to the regions; changes in the
organization of services, such as home care, in order to be
able to react rapidly to the first signs of cardiac or respiratory decompensation, thus reducing visits to the ER,
hospitalizations; etc.
All these considerations imply the existence of excellent
management teams. These should be balanced in terms of
clinical, administrative and technical expertise, with a
common vision of telehealth as well as a good knowledge of
the characteristics and operating conditions of the clinical
and management processes to be modified. The teams must
be experienced in managing the numerous interfaces and
relationships that telehealth requires between clinicians, care
teams, establishments, general and specialized services,
regions, RUIS and the control centre. The teams must have
field experience. They must to know how to develop,
innovate, adapt and make the numerous changes required.
It then becomes important to identify and support the innovative environments. We must take advantage of their role
as pioneers of telehealth and learn from their strategies.
Indeed, we have excellent research and evaluation expertise
that is under-utilized. Quebec is fortunate to have teams in
its university and local health establishments that the MSSS,
Agencies and RUIS can build on.
Governance must be based on an overall strategy, yet be
decentralized and support a network organization.
Management must be at the site of the action. Too much
centralization leads to excessive bureaucracy and to solutions
that, as a general rule, are harder to adapt to circumstances
in the field, slowing down decision-making. In such situations,
some local leaders wonder, at times, whether it would not be
useful to remember Sérieyx’ declaration that the greatest innovations are, in fact, instances of successful disobedience7.
SOME LOCAL LEADERS WONDER, AT TIMES,
WHETHER IT WOULD NOT BE USEFUL TO
REMEMBER SÉRIEYX’ DECLARATION THAT
THE GREATEST INNOVATIONS ARE, IN FACT,
INSTANCES OF SUCCESSFUL DISOBEDIENCE
A remote medical videoconference link permits patient supervision and also communication with the nursing staff in both
units. It also allows a brief examination of patients. The nephrologist in charge can also use remote equipment to consult
patients’ medical and radiology records.
In a context where the number of patients with chronic renal
failure is constantly growing and the demand for hemodialysis
care in regions far from main urban centres is becoming increasingly imperative, the remote supervision of renal replacement
therapy appears to hold the promise of major developments.
But the MSSS is also essential. Telehealth cannot really
develop without known strategic policies, the optimal functioning of major infrastructures like the RTSSS, norms and
standards to ensure system compatibility, adequate and
appropriate financing that takes into account both the costs
and gains related to the use of telehealth, and appropriate
remuneration agreements. The MSSS must also clarify its
policies with regard to public-private partnerships. In view
of the above, it is important that other provincial organizations (corporations, federations, unions) help to ensure
optimal conditions of practice and organization suited to
telehealth.
A study of the roles and functions of the different levels of
intervention (local, regional and central) makes it clear that
a great deal more effort is needed to promote synergy levels,
as opposed to pursuing the great debate polarizing centralization and decentralization!
25
TELEMEDICINE
IS QUEBEC READY?
How Quebec can regain its leadership position
Quebec must regain its leadership in the field of telehealth.
Besides the strong network, challenges must be faced. It is
important to:
• Better inform clinicians, managers, decision-makers, the population and elected officials of the added values of telehealth,
the best practices and optimal conditions of use;
• Recognize that telehealth is first of all a clinical challenge, but
also encompasses management, organization and technology;
• Rely on clear, known strategic policies that reflect a comprehensive vision of care, services and ITTs;
• Develop client programs and action plans that incorporate
telehealth;
• Ensure balanced governance, locally and regionally where
needed, (clinical, administrative and organizational) and teams
dedicated to telehealth;
• Respond to the needs defined by those requesting services;
• Pay more attention to local first-line needs;
• Invest in areas known for their ability to innovate and capitalize
on clinical, organizational, research and evaluation expertise,
along with field experience;
• Adopt a financial and budget strategy that encourages the
dissemination and sustainability of telehealth.
These conditions can be met through the mobilization of people
who believe in telehealth.
Mobilization, Networking and Managing
Knowledge
The principal actors on which the development and adoption
of telehealth depend must become involved and mobilized.
Physicians along with other professionals are at the heart of
the health system and their involvement is essential if telehealth is to develop in Quebec. A certain number have already
been leaders in the field since the inception of telehealth and
confirm their interest in using it further. But many others need
to be better informed. The professional federations and associations, and physicians themselves, must consider telehealth
as a priority to improving the accessibility, continuity and quality
of services while ensuring optimal conditions of practice in large
urban centres and the regions. Scientific meetings, conferences, continuing professional development programs, the
Réseau québécois de télésanté (RQT) symposium are all opportunities to integrate telehealth into current practice. Once
physicians are better informed as to the added value and
operating conditions of telehealth, they will become ambassadors and, in their turn, will influence decision-makers, potential
partners, the population and elected officials in Quebec.
22
The Réseau québécois de télésanté (RQT) organizes a
symposium for the purpose of making telehealth, its projects
and actors better known. It encourages the sharing of
knowledge, experience and expertise, while establishing and
consolidating links and cooperative networks. It also promotes
dialogue with industry representatives. The RQT has created
close links, alliances and partnerships with firms having identical
or similar goals in Quebec itself or elsewhere in Canada or other
countries. Joint projects are undertaken with the Société québécoise d’informatique biomédicale et de la santé (SoQibs), the
Canadian Society of Telehealth, and the Club des acteurs en
télésanté (CATEL) in France. A French-language telehealth web
portal has been created, in association with the International
Society for Telemedicine & eHealth (ISfTeH). With its vision, goals
and activities, plus knowledge and
expertise, the mobilization of a
wide range of interested individTELEHEALTH IS ONE
uals and its flexible operation,
many consider the RQT as a major OF THE MAJOR
component of the project to
COMPONENTS THAT
integrate ITTs into clinical practice
as well as the organization of care WILL INFLUENCE THE
and services. Some even suggest FUTURE OF OUR
that it be included in a possible
strategy for telehealth change HEALTH SYSTEM
management.
Telehealth is one of the major components that will influence the
future of our health system. Its development must be coordinated. To achieve this, physicians must be part of the solution.
Let us give ourselves the means to succeed together in facing
this collective challenge. We will all win, as physicians, health care
actors or managers – and, above all, as Quebecers.
S
L
Bibliography
1
Fortin JP. Le Québec perd du terrain, beaucoup de terrain… Le Point
en administration de la santé et des services sociaux, 2008 ;4(1):44-6.
2
Venne M. Pour en finir avec Les Années Molles.
Le Devoir, 7 avril 2009, A-7.
3
Toffler A. La richesse révolutionnaire. Paris : Plon, 2007.
4
Société canadienne de télésanté. Télésanté: ce que l'avenir nous
réserve. Kingston : SCT, 2007.
5
Telehealth Change Management Repository,
http://www.cst-sct.org/cm/
6
Lamothe L, Fortin JP. Gestion du changement et L’intégration des
technologies dans le continuum de soins : rapports finaux.
Ottawa : Santé Canada, Programme des partenariats pour
l’infostructure canadienne de la santé (PPICS), 2007.
7
Sérieyx A. Mettez du réseau dans vos pyramides : penser,
organiser, vivre la structure en réseau. Paris : Village Mondial, 1996.
Maître Sylvain Bellavance
Director, Legal Affairs
Telemedicine and Remuneration
A discussion of the legal aspects of telemedicine can be done from various points of view.
For instance, there is the definition itself of telemedicine activities, the applicable ethical
standards, the civil and professional responsibility of caregivers, patients’ rights, etc.
Although all these factors deserve consideration, this article
dwells more on remuneration for telemedicine activities, and any
related legal and negotiation problems.
Is it an insured service?
It is important to specify here that, since the start of the Quebec
health insurance plan, it has been set out in the regulation that
any consultation provided by telecommunication or correspondence should be considered to be an uninsured service and,
therefore, not payable by the Régie de l’assurance maladie du
Québec. At that time, Quebec legislators were either a long way
from foreseeing the expansion telemedicine would experience
over the years or they did not consider the full impact of that
provision. The intention was no doubt to exclude payment of
doctor/patient telephone consultation, but the reality is that the
formulation of the text opens the way to far greater consequences.
SINCE THE START OF THE QUEBEC HEALTH
INSURANCE PLAN, IT HAS BEEN SET OUT IN THE
REGULATION THAT ANY CONSULTATION
PROVIDED BY TELECOMMUNICATION OR
CORRESPONDENCE SHOULD BE CONSIDERED TO
BE AN UNINSURED SERVICE AND, THEREFORE,
NOT PAYABLE BY THE RÉGIE DE L’ASSURANCE
MALADIE DU QUÉBEC
For years, it has been difficult to discuss remuneration for
telemedicine procedures with MSSS representatives without
coming up against that provision in the regulation. It must also
be acknowledged that the budget restrictions of the 1990’s
delayed many telemedicine projects in Quebec, which did not
help exert the pressure necessary to deal with the question of
remuneration. Although many aspects of telemedicine were being
worked on, the question of payment was suspended in the
meantime. Some specific payment measures were introduced
on an individual basis by certain associations, but the fact is that
many telemedicine activities are not covered by specific
measures. The physicians involved have often had to resign
themselves to only billing the fees already provided for in the
Agreement, as if the service had been provided in a hospital and
not at a distance. Although this is not the ideal way to be paid
for such activities, physicians had to compensate for the lack of
specific measures and make sure that they received at least a
basic payment.
Work begins
During the current decade, we have however witnessed the
evolution of telemedicine to some degree. Instead of simply
talking about it, we have seen the implementation of various
projects. This change is, in particular, the result of greater provincial and federal investment in connection with the
computerization of the health system. Investments have therefore
been made in a number of hospitals to promote remote- monitoring consultation and image interpretation.
This development has also been felt during negotiations, although
it is still very rudimentary. In March 2002, as part of its renewal
proposal with regard to the Master Agreement, the Federation
emphasized the importance of developing telemedicine and
agreeing on the methods of remuneration necessary in order to
benefit from new technologies. The Federation asked for the
adoption of a remuneration protocol with regard to the following
activities:
1. Video consultation;
2. Interpretation of tests or images;
3. Experimental activities being developed;
4. Remote duty or treatment.
An embryonic start, against a background of strife with the
Minister, François Legault, which resulted in agreement on various
points but not on the introduction of measures specific to
telemedicine. Under Letter of Agreement No. 145, signed on
April 1, 2003, the FMSQ and MSSS did however agree to
continue with the work undertaken during the previous months
on the question of the remuneration of telemedicine activities.
The Federation then took action to again make MSSS representatives aware of the need to amend the text of the regulation
and ensure that telemedicine activities are considered as insured
services. However, over the next few years another major dispute
arose with the MSSS – this time, the Minister was Mr. Couillard
– and communication was limited, to say the least.
23
TELEMEDICINE
IS QUEBEC READY?
It was during this period that the government amended the legislation to encompass what was to be known as “telehealth
services” from that time on. It stated that a health facility could
not provide telehealth services to another establishment, organization or person, or obtain such services from one of them,
unless a formal agreement had been reached to that effect.
“Telehealth services” were defined as including any service
performed at a distance for purposes of diagnosis and/or
treatment, etc., but telephone consultation was excluded.
Along with these amendments, the government subsequently
amended section 22(d) of the regulation in order to provide that,
in future, “any service provided by correspondence or telecommunication, except the telehealth services referred to in section
108.1 of the Act … for which payment is otherwise provided for
under the Act” should be considered to be uninsured. In this
way, although a door was opened to the payment of telehealth
services, these were restricted to those provided under a service
agreement that had to be reached with an establishment.
A BUDGET OF $240 M WAS FORTHCOMING FOR THE
INTRODUCTION OF TWENTY-FOUR (24) “BUSINESS
RELATIONS” MEASURES. AMONG THESE, TELEMEDICINE WAS AGAIN TARGETED IN THE FOLLOWING
THREE AREAS: TELECONSULTATION, TELEIMAGING
AND TELEPHONE CONSULTATION.
How do matters stand today?
Telemedicine activities were again discussed when dealing with
the agreements signed with the MSSS during 2007 and 2008.
First of all, an envelope of $144.5 M was granted to pay various
targeted measures, including medical services delivered using
a means of telemedicine or its technology. However, this envelope
was finally allocated to financing other targeted measures such
as duty and university remuneration. A further budget of $240
M was forthcoming for the introduction of twenty-four (24)
“business relations” measures. Among these, telemedicine was
again targeted in the following three areas: teleconsultation,
teleimaging and telephone consultation. The new telemedicine
payment measures will be financed by this latter budget.
Telemedicine activities have thus been the subject of specific
negotiation for only a short time. The Federation emphasizes
the importance of introducing incentive payments for certain
telemedicine procedures in order to take into account the additional effort expended by physicians when services are provided
by this means.
24
A first project to see the light of day recently has
concerned the Attikamekw community of Manawan. A
joint telehealth project between the Nord de Lanaudière
CSSS and the Attikamekw community of Manawan has
been set up in order to provide obstetrics-gynecology
and otorhinolaryngology remote-monitoring health
services to the members of this community. To ensure
payment of the medical specialists concerned, Letter of
Agreement No. 162 has been reached between the
Federation and the MSSS. This Letter provides that
medical specialists who deliver remote-monitoring technology services introduced as part of this project will
retain the payment method now applicable to them at the
Centre hospitalier régional de Lanaudière. In addition, all
medical services delivered to a patient under this
Agreement will be paid at the outpatient billing rate plus
25% to take into account the additional time required to
provide services using telecommunication, among other
things. Furthermore, the rule restricting billing to one
main outpatient visit every four months does not apply.
In addition to this Agreement, which has been in effect since
July 1, 2008, talks are now under way to permit the development of other telehealth projects in Quebec. Discussions have
already begun on a telepsychiatry remuneration project. The
telepathology project of the Université Laval RUIS has also been
discussed; this aims at making certain services available to
regional hospitals where there are no pathologists or which need
a second diagnostic opinion.
Telehealth projects will undoubtedly develop over the coming
months. This is definitely good news, since we know that Quebec
lags behind in this area compared with other Canadian provinces
which have already introduced specific telemedicine remuneration measures. As was the case in these provinces, it is important
to introduce incentives not only for the purpose of recognizing
the complex elements of such activities and the resulting responsibility for the physician, but also to encourage their development.
If you have any telehealth projects in your particular setting,
please let the Federation know.
S
L
Bernard Têtu M.D.
Medical Director,
Telepathology Project, RUIS-Laval
The RUIS-Laval Telepathology Project
T
he field of pathology is currently facing a serious
shortfall in human resources, yet pathologists have
never before been so frequently called upon to help
improve both the delivery and quality of care. For
example, the introduction of more specifically targeted
and personalized therapies in oncology has required
that pathology departments’ reporting methods become more
structured and also more complicated to apply. Cancer programs
throughout Canada are in the process of having all pathologists
adopt these standardized reports. All this is taking place at a time
when the specialty is having difficulty gaining new practitioners.
For many reasons, including lack of exposure at the preclinical
level, the recruitment of new residents has become difficult in
recent years. Pathology is often perceived as a specialty requiring
little technology, its main tool still being the microscope.
Government’s increased interest in pathology in recent years is
due to the central role of histopathological diagnosis in clinical
practice. Recent incidents involving our specialty in
Newfoundland and New Brunswick are the most eloquent illustration of the major role pathologists play in therapeutic decisions.
Surgeons and administrators in hospitals with no pathologists
or pathology laboratories are well aware of the limits imposed
by this deficiency. Some surgeons hesitate to operate on cancer
patients since access to the extemporaneous tests that would
allow them to adjust their surgical procedure is impossible. In
other areas, where pathologists are only present a few days per
month, the list of surgeries must be adjusted accordingly, which
further complicates an already complex process. In still other
cases, the list of surgeries must take the pathologist's vacations
into account. This results in little flexibility for the system and
prevents it from responding to unforeseen situations.
Moreover, given the growing complexity of histopathological
diagnoses, pathologists in university hospitals regularly consult
one another in order to take advantage of the experience of
colleagues more familiar with certain types of illnesses.
Pathologists in solo practice often need to consult university
colleagues regarding certain difficult cases where the precise
diagnosis can radically change the therapeutic approach. For
example, pathologists at the CHUQ are often consulted by
colleagues throughout eastern Quebec and even elsewhere. In
these cases, slides have to be delivered to the consultant by mail
or messenger service, which delays both the final report and the
start of treatment.
Telepathology therefore appears to be an innovative approach
which would not replace the pathologist, but would help
surgeons, pathologists and managers to deliver more effective
histopathological diagnostic services.
RUIS-Laval currently has 48 pathologists in 14 institutions. The
great majority of these can be found in university hospitals, while
most regional hospitals are served by 1 or 2 pathologists; some
only have access to replacement pathologists. This makes organizing clinical care difficult, results in service interruptions and
fosters professional isolation.
The RUIS-Laval telepathology project
therefore proposes to:
1. Provide extemporaneous services to establishments
where there is no pathologist;
2. Provide rapid consultation with pathology colleagues for
a second diagnostic opinion;
3. Provide duty sharing in hospitals with insufficient
medical staff;
4. Provide the results of immunohistochemical tests
(performed only in university hospitals) to the regions
more speedily, thus allowing regional hospital pathologists to finalize reports with less delay.
It is interesting to note that the reports of the two commissions
of enquiry on the problems experienced in both Newfoundland
and New Brunswick specifically recommend that pathologists
in their respective territories be given access to telepathology
services, so that they can consult one another more easily and
thus improve the quality of patient care.
The equipment required for telepathology includes three specific
components: a macroscopic platform, a slide digitizer and a
graphics display system. The macroscopic system allows for
remote and real-time viewing of a specimen to be examined
during a surgical procedure. This allows the pathologist to talk
with the remote surgeon in order to select the type of specimen
to be taken during the procedure. A histological section is
prepared and scanned. The scanned image is then transmitted
by the RTSS to the hospital where the duty pathologist is located.
The image viewing system includes the hardware and software
required for the distribution and viewing of the scanned slides
(virtual slides), thus allowing the remote pathologist to establish
a diagnosis.
25
TELEMEDICINE
IS QUEBEC READY?
TELEPATHOLOGY WILL REDUCE
PATHOLOGISTS’ TRAVEL AND, IN TURN,
DELAYS AND ADDITIONAL COSTS.
It is planned that extemporaneous duty for certain hospitals
without pathologists will be performed in some cases by pathologists in the same region or, in others, by a team of pathologists
from the various university hospitals in Quebec City. A number
of pathologists will act as consultants to their regional pathologist colleagues. This will allow all hospitals lacking this service
to have access to emergency pathology services, and will make
it possible for pathologists in solo practice to consult colleagues
in real time. Pathologists will also be able to better manage
extemporaneous services which will eventually be performed at
home or by replacement colleagues during vacation leave or
illness. In other words, telepathology will reduce pathologists’
travel and, in turn, delays and additional costs. We are confident
that this network will promote the retention of regional pathologists and surgeons and will facilitate their recruitment.
Telepathology will also help university hospitals by allowing the
improved management of absences in satellite laboratories and
by making the practice more attractive.
clinical aspect of the project. In January 2007, the project was
approved by the Telehealth Program Director of Canada Health
Infoway. In December 2007, a meeting was organized between
RUIS-Laval pathologists, the Collège des médecins du Québec,
the Association des pathologistes du Québec and the Agence
d'évaluation des technologies et des modes d'intervention en
santé (AETMIS) to discuss the medicolegal aspects of
telepathology and the importance of performing an evaluative
prospective research study when the new technology enters
clinical practice. In January 2008, the telepathology project's
organization manual was officially approved by the MSSS, with
a budget of $6 million. In February 2009, a call for tenders was
issued to choose the technology and in April 2009, we
proceeded, with the members of the expert committee, to
evaluate the clinical and technical aspects of the various types
of equipment and make a final technological choice. We expect
the technology to be introduced in June 2009 and will undertake
its prospective evaluation to confirm its reliability within our clinical
network. At the same time, we implemented a process to
manage change and train staff.
A Dream of Doctors Without Borders
The Day Will Come …
This endeavor began in the early years of this decade with Dr.
Réal Lagacé, a retired pathologist from the CHUQ, helping to
develop a telepathology system with the assistance of a Quebec
company. The final product unfortunately never saw the light of
day, but the experience allowed several pathologists from the
CHUQ to become more familiar with this technology. In 2004,
the RUIS became the organizational structure for health network
services. At the same time, Canada Health Infoway announced
major investments in the computerization of health services
throughout the country, $150M of which was specifically tagged
for telehealth. Committees were then formed in each RUIS to put
forward promising telehealth projects in Quebec. RUIS-Laval,
with its previous experience in telepathology, was chosen by the
MSSS to develop an ambitious project and equip several
hospitals within its territory with telepathology equipment. Lastly,
an expert committee composed of 18 pathologists from university and non-university facilities holds regular videoconference
meetings to follow up on the project, ensure its relevance and
take part in drawing up a clinical procedures guide. Members of
the entire telehealth team have been in constant contact and
working closely together since the very start of the project.
In June 2005, Phase 0 of the project was initiated. In April 2006,
the Prime Minister announced a plan to computerize the health
and social services sector, including telehealth service applications. In November 2006, the Minister of Health approved the
26
Photo : Kris Torgeson
A brief history...
Last September, a young 23-year-old
man in Congo had his left arm and
shoulder amputated because of
gangrene. However the British vascular
surgeon performing the amputation,
who was working on a voluntary basis
for the humanitarian organization
Doctors Without Borders (DWB) – or
Médecins sans frontières – had never
carried out such a procedure before
and knew that it was very risky. He
Dr. Joanne Liu
therefore sent a text message asking
a colleague to help him and give him
tips on how to perform this delicate medical procedure. A few
hours later, the colleague sent a long message setting out the
steps to follow, point by point, the difficulties he might
encounter and medical advice.
The operation was a success and the story circled the world.
From the depths of Africa, a doctor had just demonstrated a
non-conventional application of telemedicine via a cell phone!
The current President of DWB-Canada, Dr. Johane Liu, has
made this vision of mutual assistance transcending national
boundaries her own particular challenge and objective. “We
have all the tools we need to achieve this goal, today. We can
organize a network that crosses borders. We have a powerful,
innate, collegial link that appeals to physicians”.
We expect all the equipment to become available in the 6 regions
of RUIS-Laval over a period of 18 months, incorporating the
prospective evaluation of the technology and its acceptance by
the medical teams.
We believe this project will improve the quality of care throughout
the territory covered by RUIS-Laval. It will have a positive impact
on the visibility of our specialty, improve our recruitment of new
pathology residents and make it easier to attract pathologists
to Quebec university hospitals and regions. This project will give
our specialty a more modern, technological aspect. Lastly, the
easy transmission of relevant images and information will facilitate continuing education in the regions and teaching in
university centers.
Making this project a reality also requires the adoption of
adequate remuneration measures for specialists taking part in
it. Negotiations have begun between the Federation and the
MSSS in order to reach a rapid agreement in this respect.
S
L
To Learn More
Many documents, articles, studies and Internet sites are devoted
to telemedicine and its issues. Following are some references of
interest concerning the ethical and legal stakes, as well as medical
responsibility.
Ethical Stakes
Medical practice may differ from one country to another. In
Canada, ethical aspects differ from one province to another.
When borders become virtual, new methods of organizing care
have to be established.
In May 2000, the Collège des médecins du Québec (CMQ) was
one of the first professional orders to state its position on the
practice of telemedicine. The Collège considers its primary
responsibility is to physicians, the general population and the
delivery of medical care in Quebec.
You can consult the CMQ's position paper at:
http://www.cmq.org/en/MedecinsMembres/Profil/Commun/APro
posOrdre/Publications/~/media/624CD6B46CC94CA2B0B374790
B888209.ashx?sc_lang=en&60922.
Professional Responsibility
During her term of office, which will soon be ending, Dr. Liu
has laid the foundations for the organization of a mutual help
network in which every voluntary doctor would be twinned with
other colleagues. If necessary, they would be able to call upon
these confrères or consoeurs to validate diagnoses, find
medical data or obtain advice. It would also allow doctors who
are unable to participate in an actual mission for professional
or personal reasons, to do so.
Dr. Liu has been able to talk to specialists in this area. The
Swinfen Charitable Trust, created in 1999, is particularly interested in linking physicians in the developing world with those
in industrialized countries. The Trust has funded a research
project on the use of e-mail telemedicine between doctors in
the Middle East and those elsewhere. The Swinfen Trust
considers telemedicine a mandatory tool in supporting medical
workers who are unable to be in regular contact with their peers.
The health benefits for populations who do not have modern
hospital facilities are also a major focus for the Trust, because
it allows better use of the on-site resources available.
Dr. Liu’s project has not yet reached fruition. She says there is
still a great deal to be done on various aspects, such as medical
responsibility, field organization, setting up work teams, duty
hours, etc. “I am convinced however that this telemedicine
project will come into being”.
1
J Med Internet Res 2007, vol. 9 no. 4 e30 p.1-9
Who is really responsible? The physician, thousands of kilometres
from the patient, who makes a diagnosis and suggests a mode of
treatment, or the one who is at the patient’s bedside and administers the treatment? What if the attending physician is in another
country and is called to consult for his or her own patient?
The Canadian Medical Protective Association (CMPA) states at
the outset that physicians must still be prudent because of a lack
of regulations, standards, directives and jurisprudence in the
area of telemedicine. The CMPA has published some articles
illustrating problems that have arisen and the assistance it can
offer its members.
Two articles are of particular interest:
Medico-legal problems generated by the use of new technologies in healthcare. https://www.cmpa-acpm.ca/cmpapd04/docs
/resource_files/infosheets/2007/pdf/com_is0777-e.pdf.
The CMPA can help in the case of law suits resulting from the
practice of telehealth: the technology reduces the importance of
the physician's location http://www.cmpa-acpm.ca/cmpapd04/
docs/member_assistance/com_is0661-e.cfm.
Legal Stakes
The Quebec Bar has published a short article on the legal and
ethical stakes posed by telemedicine. The purpose of the study
by Maître Frédéric Pérodeau was to identify major issues created
by this new form of medical practice. The author quotes and
analyzes legal texts, official positions (for example, that of the
CMQ) and available jurisprudence.
Telemedicine: Legal and Ethical Stakes
http://www.medicine.mcgill.ca/Ruis/Docs/telesante/T%C3%A9l
%C3%A9m%C3%A9decine_enjeux%20juridiques%20et%20d%
C3%A9ontologiques.pdf (in French).
27
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GREAT NAMES IN QUEBEC MEDICINE
Patricia Kéroack
CONSEILLÈRE EN COMMUNICATION
Dr. Denis Marleau,
On the starting line of hepatology
n 1963, Professor T.E. Starzl of Denver, Colorado, attempted
the very first liver transplant, in a 3-year-old child.
Unfortunately, the outcome was not successful, but it
opened the door to a new medical discipline which, a few
years later, did succeed and gave a completely new meaning
to liver transplants.
I
“The liver is a delicate organ that has its own complete identity
within the body. When the liver is upset, all systems in the human
body are upset. When that happens, repercussions can be felt
on the neurological system, the kidneys, heart, lungs, etc. The
liver can also cause many infectious diseases. In other words, a
sick liver can have multisystem repercussions”. These remarks
were made by Dr. Denis Marleau. Understanding the liver a little
helps us understand who Dr. Marleau is: a complete physician
who, without saying so officially, has one purpose and has
invested his whole life in it.
Why hepatology?
Hepatology was recognized in the late 1950’s. There were few
hepatologists in the world at that time, but those at the beginning
ensured the rapid advancement of this science and gave it its
letters patent. This was particularly true of Dr. André Viallet who
worked in the United States and Europe. “Dr. Viallet arrived in
Quebec in the mid-1960’s with plans to set up a hepatology
department; he was looking for people to support him. I was an
intern at the time. He was an excellent salesman! My greatest wish
was to go into internal medicine and he showed me that hepatology is, in fact, internal medicine. That’s how everything began”.
There are 10 or so hepatologists in Quebec at the most.
Hepatology is a sub-specialty of gastroenterology or internal
medicine, because both specialties are concerned with the liver,
its function and the many pathologies associated with it.
Determined to become a specialist in liver disorders (the term
“hepatology” was not yet widely used), Dr. Marleau did a first
Fellowship in liver hemodynamics with Professor Viallet, followed
by another in Paris with Dr. Benhamou. He then practiced at
Hôpital Saint-Luc and at Montreal General Hospital where, under
its director, Dr. Carl Gorecki, he did a third Fellowship, this time
in hepatic microcirculation.
Dr. Marleau had one very clear idea in his mind: he, too, wanted
to transplant livers successfully. After the failures of the early
1960’s, a number of attempts had been made and some work
gave rise to the belief that actual transplants would soon be
possible. The use of cyclosporin in 1979 (although it would not
be authorized by the U.S. Surgeon General until 1983) was
already showing remarkable results in transplant patients. Wanting
to prepare himself properly, Dr. Marleau took a oneyear sabbatical to study clinical epidemiology under
Professor Feinstein, whom he cannot praise
enough. Then, before returning to Montreal, he took
the opportunity of visiting American liver transplant
centers and seeing the successful results with his
own eyes.
Dr. Denis Marleau
Upon his return to Hôpital Saint-Luc, Dr. Marleau received the
authority to carry out preparatory research work in his laboratory.
The administration only authorized him to work on small animals,
as the laboratory was not suited to larger species. “The laboratory was on the 3rd floor of the Research Centre. It was difficult
to get to. We had to take the animals in through places where
there were patients. But we managed to carry out tests on larger
animals, unknown to the director. Outside normal hours, we took
a dog in (well covered up) on a stretcher so no one would notice!”
It was only after having simulated transplantations on animals
(over a long period of time), and carrying out a complete simulation with full operating room personnel, that Dr. Marleau
performed a human transplant.
With the years, and above all with Dr. Marleau’s contribution,
Quebec has carved itself a fine reputation in hepatology research.
Today, Quebec leads Canada in liver transplants, with a quarter
of them (100) being performed in the province each year.
A hepatologist, but …
As soon as Dr. Marleau obtained his certifications in internal
medicine and gastroenterology, his qualifications made him an
ideal candidate to pass on his knowledge to future practitioners. He began teaching in 1972 and is still teaching third
year residents.
As a member of the Université de Montréal Jury, he must also
review and evaluate the theses presented for subsequent
approval. “It’s great: I discover things or researchers I never
expected. There are people there who are known internationally
because of their research work. I really feel at the heart of the
University. It’s a lot of work, and I spend all my weekends from
January to April on it. I receive around 25 files per week during
that period”.
On behalf of all those who have benefited from the work of this
distinguished hepatologist throughout his career, we want to
express our warmest thanks to Dr. Denis Marleau, our great name
in Quebec medicine.
S
L
29
CONTINUING PROFESSIONAL EDUCATION
Dr Gilles Hudon
DIRECTEUR,
OFFICE DE DÉVELOPPEMENT PROFESSIONNEL
The Importance of Continuing Professional
Development for Affiliated Associations –
and the Person Responsible for It.
n March, the Études médicales Department of the Collège
des médecins du Québec (CMQ) sent us the revised
standards for the Continuing Professional Education
Accreditation Committee (CPE-AC) (Comité d’agrément
de l’éducation médicale continue – CAÉMC). As you will
recall, the CPE-AC falls under the umbrella of the
Association of Faculties of Medicine of Canada, a partnership
formed of the Canadian Medical Association, College of Family
Physicians of Canada, College of Physicians and Surgeons of
Canada (RCPSC), Federation of Medical Regulatory Authorities
of Canada and the Collège des médecins du Québec. This is
the committee that sets the accreditation standards used by
Canadian universities and the FMSQ with regard to continuing
medical education (CME) units and continuing professional
education (CPE). For the Professional Development Office (PDO),
it signals that the time has come to prepare the next accreditation visit of the Federation’s 36 continuing professional
development (CPD) units (the Department itself, the 34 affiliated
associations and the Société des experts en évaluation médicolégale du Québec). The PDO has set up a four-part program for
those responsible for CPD in the affiliated associations, each part
covering a specific aspect:
I
• Management of CPD human resources and knowledge
• Analysis of the needs of members and society itself
The importance of affiliated associations’
CPD units
The CPD unit is the central link in the chain of responsibilities
imposed on us by the CMQ with regard to professional development. As you know, the ultimate objective of this is the
consistent improvement of the quality of patient care.
Accreditation standards devote one of the four chapters to the
standards and criteria with which the CME/CPD units of the
learner organizations must comply, as follows: the CME/CPD
unit has an organization and decision-making structure designed
to fulfill its mission, goals and objectives. It ensures that its
governance, operations and activities meet accepted professional, ethical and legal norms. It possesses and manages
financial resources sufficient to carry out its mission, goals and
objectives. This includes and requires the support of the
Organization (in our case, this means the association involved).
The CME/CPD unit possesses and manages human and administrative resources. It possesses or has access to sufficient
resources with regard to facilities to meet its mission, goals and
objectives. It has an efficient system for storing and using files
on its decision-making processes, general operations and
learner participation. The unit provides participants with documentation if necessary or on demand. The CAÉMC therefore
expects all organizations involved with the continuing professional development of its members to make available human,
material and financial resources for the purpose.
• Development, adjustment and assessment of a strategic plan
• Facilitation of self-managed learning process.
Each of these themes must form the subject of an interactive
presentation at a meeting of the FMSQ’s Professional
Development Council. These six-monthly (April and October)
meetings – previously information meetings – were changed
three years ago into accredited educational activities under
Section I of the RCPSC Maintenance of Certification program.
The last three themes listed will be discussed in the fall of 2010.
The first one – Management of CPD human resources and
knowledge – was presented on April 21, 2009 at the 104th
meeting of the Professional Development Council held in the
offices of the FMSQ: 33 of the 35 association representatives
attended, as well as 20 directors and administrative assistants.
30
Ten years ago, some associations barely had a file drawer to
store documents. Great progress has been made since then and
all associations have now developed an acceptable structure,
to some degree or other. One of the major difficulties for the
Office in its relationship with association CPD units is the fact
that incumbents change too frequently. Continuity is fundamental to the pursuit of any objective. In most cases, those
responsible for CPD units remain in their positions for shorter
periods of time than associations’ administrative assistants and
directors. Many years ago, the Office took the step of giving CPD
training to directors and administrative assistants so that, with
the agreement of the physicians responsible, they could be
invited to attend education meetings of the Professional
Development Council. A great number of them have been doing
this for three years now. Their diligence represents a major factor
in providing continuity with regard to both the transfer of
documents and understanding of the responsibilities involved.
The turnover rate of those responsible for CPD units is still too
high, at least for many associations. The following question was
asked at the last meeting: How many of you were present for
the last accreditation visit in 2006? Only a few hands were
raised. And, as a corollary, how many of you will be at the next
CMQ accreditation visit in 2011? Once again, only a few
(sometimes hesitant) hands were raised. Does that mean that
being responsible for an association’s CPD is a punishment? Or,
on the contrary, can we make the task pleasant and educational – the position everyone wants? The experience acquired
can be useful elsewhere in a hospital/academic setting and
pave the way to university promotion …
Part of the solution: plan for the next
generation
Planning for those who will follow means developing a plan and
process to cope with the changes that will occur when people
holding key positions leave, thus enabling the organization to
continue to function in accordance with the mission and
present/future objectives. If there is no such plan, the person
responsible for the CPD unit will often be a designated volunteer,
who has little information about their role and/or responsibilities,
and little knowledge of the field of CPD and the resources
available. Without some form of preparation, they will have to
learn on the job and take on an unexpected workload, considering their new duties to be an obligation or penalty. If, in addition,
no recognition is received from their peers, the new person will
rapidly become disenchanted and inclined to let matters drop
without further ado. For the association, a high turnover in this
area results in difficulty in recruiting committee members, a loss
of expertise, the loss of a cooperative partnership network,
culminating in little educational innovation and a loss of credibility. On the other hand, planning for replacements will bring
stability and viability to the organization, and the continuity of
member services. It will prevent re-creating systems and
processes, while preserving partnerships: the organization will
really learn and innovate. The literature shows that some of the
elements that make recruitment easier by raising the appeal of
the position are recognition of its value by the incumbent’s peers,
making it stimulating work that forms part of career planning and
progress, with the added advantage of further education. A
CPD unit is a committee composed of several members who
share the work guided by an experienced chairperson, a
committee into which newcomers are gradually incorporated
and acquire the necessary knowledge, with the gradual transfer
of responsibility.
What can the FMSQ PDO do?
To welcome those newly responsible for associations’ CPD
activities, the PDO has prepared a description of the duties and
responsibilities of both committee and association members
(http://www.fmsq.org/pdf/medecins/f/description_taches.pdf in French). The Office has already prepared an introductory kit
that contains various documents, including relevant articles,
sample forms and a copy of the Vade-mecum en éducation
médicale continue published by the Conseil de l’éducation
médicale continue du Québec. The Office invites everyone
assuming these responsibilities to meet with it on an individual
basis, so that they can become aware of their new duties and
the availability of ongoing support. The Office asks each new
incumbent to attend a one-day training course for educators
(F-201, les quatre phases du cycle des apprentissages) which
is provided free of charge twice yearly by the FMSQ PDO to
everyone interested in CPD (in your association, hospital or
university department).
What can an association do to support the
person responsible for its own CPD unit?
A description of the duties and responsibilities of the members
of a CPD unit is accompanied by a description of the responsibilities of the association itself, to be used as a guide in selecting
members of its CPD unit/committee and the chair or person
responsible. Needless to say, the chairperson or incumbent will
be the main resource person. It is vital that they be assisted in
their duties by a committee composed of members selected to
ensure the best possible representation of all association
members (academic/non-academic, urban/intermediate/
outlying regions). The number of members can vary based on
the size of the association. The latter should choose the person
responsible for its CPD very carefully. It is a position that should
be announced and receive a commitment of support from the
association. It is interesting to note that, based on a survey we
carried out in February 2006, 30% of associations answered they
had at least one member with expertise in adult education/CPD/
FMSQ. Strangely, these physicians were not always asked to
be members of the CPD committee.
CMQ accreditation criteria stipulate that all affiliated associations must provide the resources and administrative structure
that would allow the CPD unit to carry out its objectives and
goals successfully. But that is not all. Peer recognition is the
best reward and encouragement members of CPD units can
receive.
Continuity and recognition are essential if the mission of associations’ CPD units is to succeed.
S
L
31
IN THE WORLD OF MEDICINE
Louis Bessette, M.D., FRCPC, M Sc.*
CaMos Study
Jacques Brown, M.D., FRCPC**
SPECIAL COLLABORATION
(Canadian Multicentre Osteoporosis Study)
Osteoporosis is a disease of the skeletal system, characterized by a loss in bone resistance
and a consequent predisposition to fractures. One woman in 4 and at least 1 man in 8 will
suffer an osteoporosis-related fracture after age 50. There is clear evidence that minimal
trauma fractures have a direct impact on quality of life and are also associated with a
reduction in life expectancy. The CaMos study will allow us to learn more about this very
frequent bone condition.
Based on a randomized sample representative of the Canadian
population and recognized internationally for its quality and
validity, the CaMos study provides a long-term projection of
the disease, with a retention rate of nearly 70% after a 10-year
follow-up. The first analyses and publications of this study
provide a clearer understanding of the importance and impact
of osteoporosis in Canada's population.
Some of the results from the CaMos study confirm that, in
women, menopause is a critical period during which BMD
diminishes in all the bones studied.1 In particular, we observed
an average BMD reduction in the hip of 6.8% over 5 years. A
significant reduction was also observed after age 70, particularly in the hip bone. In men, mineral bone density starts to
decrease earlier (around 40 years of age), but is more gradual.
While the rapid reduction of BMD after menopause is a known
phenomenon, it had never been quantified, whereas the
decrease occurring after age 70 is a completely new finding.
n extensive questionnaire was administered at
enrollment; participants' bone mineral density
(BMD) was evaluated via a bone scan and ultrasound; height and weight were measured.
Subjects over 50 years of age also had an X-ray
of their thoracolumbar spine to establish the prevalence of vertebral deformity. Study participants have continued
to take part in CaMos, filling out a short questionnaire every year
or a more complete one 3, 5 and 10 years after their enrollment.
One of the goals of the follow-up questionnaires was to provide
information on the occurrence of fractures. A fracture diagnosis
reported by patients is confirmed by a review of their medical
records. After 5 and 10 years of participation, bone mineral
density was verified via a bone scan and ultrasound, height
and weight was measured and thoracolumbar X-rays were
taken in participants aged 50 and over.
A
32
Another important observation of this study is the high prevalence of vertebral deformity in women and in men after age
502 (figure 1). Between 50 and 54, vertebral fractures evaluated
by a spinal X ray were observed in more than 16% of male
participants and 14% of females in the study. This proportion
increases gradually with age, attaining a prevalence of more than
50% after age 80. One interesting finding was that the prevalence of vertebral fractures is similar for both genders, while the
literature suggests that osteoporotic fractures are more
common in women.
CaMos study investigators also evaluated the treatment of
osteoporosis in Canada – i.e. the diagnostic and therapeutic
care gap.3 When the study started, 28% of women and less
than 1% of men after age 50 with a history of minimal trauma
fractures were receiving therapy for osteoporosis (figure 2).
After a 5-year study follow-up, this proportion increased to 51%
for women and 10% for men, an increase of 23% and 9%
respectively. Despite an improvement in treatment rates during
the first five years of the study, the care gap remains very high
Figure 1. Prevalence of vertebral deformities
in men and women after age 50
So far, the results of the CaMos study have helped provide
information to public health authorities and have improved the
prevention, diagnosis and treatment of osteoporosis in Canada.
Participant follow-up now exceeds 10 years. Many other studies
are now under way and will provide a clearer definition of osteoporosis risk factors, the course of the disease and the long-term
consequences of fractures.
Men
S
Women
Jackson et al. Osteoporos Int 2000;11:680-687
even if physicians have access to effective therapy to reduce
the recurrence of fractures. These results indicate that the
management of fracture-causing osteoporosis is suboptimal
des
sous
thérapie*
in Canada,%
and
thatparticipants
the care gap is even
higher
in men.
L
* Louis Bessette, M.D., FRCPC, M Sc.
Clinical Professor, Faculty of Medicine, Université Laval
Rheumatologist, Centre hospitalier de l'Université Laval
Co-Director, Centre de Québec, Étude CaMos
** Jacques Brown, M.D., FRCPC
Clinical Professor, Faculty of Medicine, Université Laval
Head of Rheumatology, Centre hospitalier universitaire de
Québec
Director, Centre de Québec, Étude CaMos
Figure
2. Proportion
of participants
treated for
% des
soussous
thérapie*
%participants
des participants
thérapie*
osteoporosis during the first 5 years of the study
References
Men
Women
*HRT, bisphosphonate, raloxifene, calcitonine ou fluore
*HRT, bisphosphonate, raloxifene or calcitonin/fluoride
The CaMos study also assessed the impact of fracture-causing
osteoporosis on the quality of life of patients with this condition.
Using scales such as the SF-36 and the HUI (Health Utility
Index), the investigators showed that the quality of life of
patients who suffered a minimal trauma fracture was significantly less than that of a person with no such fracture. The
impact of the fracture was mainly related to pain and reduced
function.4 The decrease in patients' quality of life is comparable to that experienced with arthritis and greater than with
other conditions such as heart disease and chronic obstructive pulmonary disease5.
1. Berger C, Langsetmo L , Joseph L, Hanley DA, Davison SK,
Josse R, Kreiger N, Goltzman D, Tenenhouse A, CaMos
Research Group. Bone mineral change as a function of age in
women and men and association with the use of antiresorptive
agents. CMAJ 2008 ;178(13):1660-8.
2. Jackson SA, Tenenhouse AM, Robertson L, CaMos Study
Group Vertebral fracture definition from population-based data:
preliminary results from the Canadian Multicentre Osteoporosis
Study (CaMos). Osteoporos Int 2000 ;11(8):680-7.
3. Papaioannou A, Ioannidis G, Tenenhouse A, Gao Y, Berger C et
al. Diagnostic and therapeutic care gap in both women and
men who have been told they have osteoporosis: the Canadian
Multicentre Osteoporosis Study (CaMos). International
Osteoporosis Foundation World Congress on Osteoporosis,
Toronto, Canada, June 2-6, 2006.
4. Adachi JD, Ioannidis G, Berger C, Joseph L, Papaioannou A, et
al. The influence of osteoporotic fractures on health related
quality of life in community dwelling men and women across
Canada. Osteoporos Int 2001 ;12(11):903-8.
5. Sawka AM, Thabane L, Papaioannou A, Gafni A, Ioannidis G, et
al. Health-related quality of life measurements in elderly
Canadians with osteoporosis compared to other chronic
medical conditions: a population-based study from the
Canadian Multicentre Osteoporosis Study (CaMos). Osteoporos
Int Dec 2005 ;16(12):1836-40. [Epub 2005 Aug18]
33
SOGEMEC ASSURANCES
Am I Properly insured with Sogemec?
Dr. Diane Francœur, chef du département d’obstétrique-gynécologie, CHU Sainte-Justine
Misfortune temporarily entered my life on November 4, 2006 when, traveling to Kuala
Lumpur, I learnt that my house was on fire.
house was in total chaos and it was raining inside. We were going
to be talking about “heavy claims” with the adjuster, Mr. J., a very
nice person who right away reassured us that we were well
covered and told us what steps we would have to take – i.e, sell
everything or rebuild. We decided to rebuild, because it was our
family home and we couldn’t abandon it that way. Then we had
to cope with a whole parade of swindlers who appeared on our
doorstep, leaving their cards and telling us to beware of insurance
claims companies, etc. Mr. J. had warned us in advance, but we
said yes to all these companies who guaranteed full recovery of
this or that…
he person calling me, my baby-sitter’s mother, told me
she had 15 minutes to get in and asked what she
should bring out of the house. My answer was surgical:
the jewellery in the safe, no problem; the pictures in
the living room and the silver beside the fridge. She
said, “Is the fridge normally on the right or left when
you enter? It’s now in the pile in the middle of the floor”. We had
a feeling that things were not good at all …
T
She had already taken matters in hand and, in
particular, had called our insurance. The claims
team was on the job and was waiting for the flames
to burn out. It was Saturday and we needed to
return to Canada as quickly as possible, but there
was no plane out until Monday! We followed the
drama on our cell phone – and waited.
A siren in the middle of the night …
In the middle of the night Montreal time, we had
another call: the fire had started up again and the
firefighters were back! To avoid having to repeat
the exercise, they demolished everything in the
way this time. It was a code 10-13, a full alert
because of the adjoining houses.
Our return
After three interminable days of planes and transfers, we finally
arrived in Montreal during the night. The meeting with The
Personal Group adjuster was scheduled for the morning. It’s a
strange feeling to go to your home and have to wait until someone
unlocks the padlock barricading the door. When we went in, the
34
We moved into a reasonable hotel, as a family, while looking for
an apartment. The following Monday, I found myself in the midst
of a media windstorm caused by the announcement of my
colleagues in the Obstetrics Department of Sainte-Justine’s
University Hospital that they did intend to renew their professional liability insurance.
Luckily, my husband took over the family’s survival (find an
apartment, buy school books, clothes, uniforms, etc.). Mr. J.
placed no restrictions on us, and he even authorized us going
over budget to find a fully-furnished apartment large enough for
our needs. We moved in for four to five months, in theory (not
knowing that it would
actually be far longer) and
began to look for subcontractors. Our file was very
complicated. We agonized
over the value of its
contents – in other words,
the complete reconstruction
of our home. We had to
prepare our file carefully, find
old photos and bills to
“present” our house. After a
brief feeling of desperation
and a long conversation
with the President of
Sogemec, Dr. Gilles Robert,
and his team, we presented our final demands to the insurance
company. As the FMSQ reached a memorandum of agreement,
we were finalizing the contract for the rebuilding of our home. After
the Christmas duty periods and leave, we began a rather
miserable period, making lists of what we needed and shopping
for it. We had to start from virtually scratch.
Photos : www.coderouge.com. Alexandre Sigouin
Do you want to save
thousands of dollars?
Take photos of everything you own
and keep them safely at the
hospital, a relative’s or in a bank
safety deposit box. We spent an
incredible amount of time trying to
remember everything we had in
each room and validate the price.
And you collect piles of stuff after
22 years together! We made the rounds of all the stores and
spent our weekends drawing up this list. We had to be very sure
what we were doing, because substantial amounts of money
were involved. We also had to negotiate with the insurance
company about the contents (what we owned). Once again, Dr.
Robert was of considerable help.
As misfortunes never come singly, thousands of dollars slipped
through our fingers. The reconstruction work obviously
progressed at a snail’s pace; nothing would be ready for May (the
date planned) and our anxiety increased. The contractor and
subcontractors did not keep to their schedules; the vacations we
were to use so we could move would be wasted; nothing was
ready. Household appliances were delivered without any
insurance or supervision … we were in agony. We weren’t going
to make it; we would separate, kill each other or someone else.
Costs mounted with lightning speed, and we still weren’t done.
POUR TOUS VOS
BESOINS D’ASSURANCES
The final negotiations
After our forced removal at the end of August (the painting was
not finished and the insurance refused to pay for the fact the
contractor was so slow), we negotiated the final list and reached
the sad conclusion that our insured capital was not enough. Of
the final amount, some $200,000 had disappeared into thin air
in the company managing and cleaning our property. In addition,
half our things had to be thrown out!
The final equation
We used up all our insured capital and The Personal Group paid
in full. Our coverage, which had seemed very generous to us, was
not enough. Watch your small hidden outlays …
We got through it, but I don’t know how. We now have the most
beautiful house on Carré Saint-Louis, with a super-kitchen worthy
of the finest operating rooms, but I would willingly go back in
time if I could recoup those two lost years and wipe out the
nightmare we experienced.
In conclusion, I honestly believe that our insurance with Sogemec
is very good. We have to realize the weight brought to bear by
7,999 friends who hold the same insurance plan. Dr. Robert was
there whenever needed: he reassured us and handled our file efficiently. Once again, I was able to benefit from the solidarity and
power of the FMSQ!
Thank you, Sogemec ! Thank you, Dr Robert! Thank you, The
Personal Group!
Grâce au
SERVICE PRÉFÉRENCE
SOGEMEC ASSURANCES
ÉVOLUE AVEC VOUS
Avec le SERVICE PRÉFÉRENCE de
Sogemec Assurances, toutes vos
assurances sont pensées en fonction
de votre style de vie et de vos besoins.
POUR EN SAVOIR PLUS :
1 800 361-5303 / 514 350-5070 / 418 658-4244
Par courriel ou Internet :
[email protected] / www.sogemec.qc.ca
L E S P É C I A SOGEMEC
L I S T E · V OASSURANCES
L . 1 1 no. 2 · J u n e 2 0 0 9
filiale de la
35
GROUPE FONDS DES PROFESSIONNELS
Alain Doucet, a.s.a., acs, Pl. Fin.
DIRECTEUR - PLANIFICATION FINANCIÈRE
The Simple Truth about Incorporation
great deal of ink has flowed on the subject of incorporation since this option has been available to
physicians. Some believe that incorporation is not
for them, while others think the contrary.
Unfortunately, we still find doctors puzzled by incorporation, so we will attempt to clarify its advantages
and disadvantages below.
A
The main advantages
There are a number of advantages to becoming incorporated.
The main ones are:
1) Income splitting with your spouse and/or adult age children
with little or no earnings.
You can pay your spouse and/or your adult children, if they
have no income, up to around $38,000 per person in
dividends from your company. On this basis, they would only
pay around $2,000 in provincial tax and no federal tax at all.
2) Capital gains exemption on the sale of shares up to $750,000.
If you can sell your shares you would benefit from a capital
gains exemption that applies to the sale of shares of a small
business. The maximum allowable is $750,000, less any
deductions previously taken on such shares.
If you already have savings other than RRSPs, incorporation
allows tax to be deferred on income earned and saved in the
company versus personal income, as the corporate tax rate is
lower than the personal rate (see the following table):
Federal
Corporate
income, up to
$500,000 ceiling
Corporate
income of
$500,000 and up
Interest and
rental income
11.00%
19.00%
34.67%
8.00%
11.90%
11.90%
Total
19.00%
30.90%
46.57%
Personal tax
48.22%*
48.22%*
48.22%*
Tax deferred
29.22%
(48.22%-19%)
Provincial
(Québec)
17.32%
(48.22%-30.9%)
1.65%
(48.22%-46.57%)
* Assuming the maximum marginal tax rate – taxable income over
$126,264
36
However, you must understand that for this situation to be truly
worthwhile, you must really take advantage of tax deferral, leaving
savings in the company. These must be relatively large and/or
of long-standing for this option to be worthwhile in relation to
corporate maintenance costs.
The first two advantages are relatively easy to quantify compared
with the last one. If you do not qualify for the first two, deciding
to incorporate based on the third advantage may be difficult.
It would be better to consult an expert rather than make a
wrong decision.
The main disadvantages
3) Tax deferral.
Corporate tax
You will note from the table above that there are two advantages
to incorporation with regard to tax deferral when your corporate
income is less than $500,000 once expenses have been
deducted. The first one is that more money can be used for
investments when taxed at 19% rather than 48.22% (i.e. 29.22%
more). The second advantage is that income from investment
in the company would be taxed at a lower rate than personal
earnings, if the marginal tax rate is 48.22%. For example, interest
income is taxed at 46.57% in the company versus 48.22%
personally (1.65% less). Subsequently, when dividends are paid
by the company to cash in the money accumulated in it, this
income will be taxed up to a maximum rate of 36.35% –hence
the principle of tax deferral.
1) The additional administration created by incorporation can
prove to be a burden for some.
2) Incorporation and maintenance costs can be high, depending
on how your company is structured. Generally, costs range
from $5,000 to $10,000 for incorporation, and maintenance
costs are $1,000 to $3,000.We have designed a small questionnaire at Groupe Fonds des professionnels, which will guide
your decision about whether to incorporate or not. You can
consult the questionnaire on our Internet site at
www.groupefdp.com by clicking on Service Offering – Financial
Planning – Mandate.
Since every situation is unique, the general principles above may
not apply to you. Your Groupe Fonds des professionnels Member
Advisor can help you with your choice by suggesting an incorporation study at little cost. He/she will be happy to give you all
the information you need regarding incorporation.
MOT DU PRÉSIDENT
DR GAÉTAN BARRETTE
Le projet de loi no 34… il faut corriger le tir !
u moment d’aller sous presse, nous préparons notre
intervention devant la Commission des affaires
sociales sur le projet de loi no 34 : Loi modifiant
diverses dispositions législatives concernant les
centres médicaux spécialisés et les laboratoires
d’imagerie médicale générale. Nous sommes plus
que jamais préoccupés des conséquences qu’aura ce nouveau
projet de loi sur la pratique médicale et l’accessibilité aux soins de
santé spécialisés et surspécialisés, de concert avec les dispositions
se trouvant dans la Loi sur la santé et les services sociaux.
A
Depuis plusieurs années, tant les médecins spécialistes que le
gouvernement se sont fixé des objectifs en vue d’une meilleure
efficience de notre système de santé. Après le jugement Chaoulli,
le gouvernement du Québec est allé plus loin en s’engageant à
ouvrir la porte à une dispensation plus grande de soins au privé et
en faveur d’une plus grande qualité des soins. De son côté, la
FMSQ, favorisant un système public fort, rappelait que les cabinets
de médecins pouvaient dispenser plusieurs services de manière
plus efficiente et que les centres hospitaliers devraient être
réservés de façon prioritaire pour la prestation de soins plus aigus
nécessitant une hospitalisation.
Nous pouvions alors espérer que des mesures seraient mises de
l’avant en faveur de l’atteinte de tous ces objectifs. Force est de
constater que, non seulement les mesures introduites par les
projets de loi n° 33 et n° 34 ne répondent pas à ces objectifs, mais
qu’elles ont au contraire pour effet d’y nuire.
La FMSQ a toujours été en faveur de mesures visant une médecine
en cabinet des plus sécuritaires. À cet égard, nous sommes donc
disposés à collaborer à la mise en place de mesures pouvant
favoriser cet objectif et sommes en accord avec les propositions
élaborées dans les projets de loi nº 33 et nº 34 qui favorisent une
pratique sécuritaire en cabinet.
Nous sommes toutefois en désaccord avec les mesures qui ne
contribuent aucunement à une meilleure qualité ou accessibilité
des soins et qui ont plutôt pour effet d’imposer des mesures
bureaucratiques inutiles, de miner la collaboration des médecins,
d’attaquer leurs droits et leur autonomie professionnelle, de donner
des pouvoirs discrétionnaires au ministre de la Santé et de réduire
l’accès de la population à nos soins médicaux.
Plusieurs des mesures prévues par les projets de loi nº 33 et nº 34
et les règlements afférents ne contribuent pas aux objectifs
recherchés ou nuisent à ceux-ci. Il est encore temps d’agir. Le
gouvernement doit retenir les orientations que nous avons
exprimées et apporter les modifications requises.
À cette fin et de façon plus spécifique, la FMSQ demande :
• de revoir la liste des traitements spécialisés à la lumière des critères
prévus par la loi et obtenir les intentions du ministre quant à l’accessibilité à ces services ;
• d’abroger toutes les mesures concernant l’émission de permis de
centre médical spécialisé (CMS) par le ministre de la Santé et des
Services sociaux. Sont ainsi visés les divers articles prévus à cet effet
dans la Loi sur les services de santé et les services sociaux ainsi que
les règlements concernant la délivrance de permis de CMS. (À défaut,
nous avons proposé des modifications) ;
• d’abroger l’interdiction pour les médecins participants et non-participants d’exercer dans un même centre et ainsi ne créer qu’un seul
type de CMS ;
• de retirer l’obligation pour les médecins non participants ou ceux qui
dispensent des services non assurés d’offrir à leurs patients tous les
services préopératoires, postopératoires, de réadaptation ou de
maintien à domicile et de leur donner plutôt l’obligation d’informer leurs
patients et abroger en conséquence l’article 78.1 de la Loi sur les
services de santé et les services sociaux ;
• d’abroger l’interdiction de dispenser en cabinet un traitement
spécialisé non prévu au règlement ;
• de mettre en place une rémunération adéquate pour les traitements
dispensés en CMS et en cabinet privé ;
• de mettre de côté l’adoption de mesures punitives contre les médecins ;
• de favoriser l’approche consensuelle et de revoir avec la Fédération,
par le biais d’ententes négociées, toutes les mesures concernant les
cliniques médicales associées.
En agissant ainsi, on évitera les processus inutiles et les résultats
attendus seront davantage en lien avec les objectifs recherchés. On
assurera aussi le respect des droits des médecins et l’accessibilité
des patients à leurs soins. À défaut, le gouvernement portera
l’odieux de remettre en question la collaboration des médecins
spécialistes lesquels n’auront d’autres choix que de s’opposer par
tous les moyens aux mesures contestées.
Finalement, il y a lieu de s’interroger sérieusement sur cette
propension récente du gouvernement de vouloir contrôler de façon
discrétionnaire la dispensation des soins en cabinet. En effet, la
Fédération s’inquiète ainsi des autres ambitions du ministre de la
Santé à cet égard, notamment en ce qui a trait au projet de loi
portant le numéro 26 – Loi sur les activités cliniques et de recherche
en matière de procréation assistée alors que le ministre entend à
nouveau se donner plusieurs pouvoirs discrétionnaires et imposer
encore une fois une multitude d’exigences aux centres de
procréation assistée !
Le mémoire de la FMSQ est publié sur le site Internet à l’adresse
suivante : http://www.fmsq.org/f/publications/memoires.html
S
L
37
C A P S U L E Facturation.net
•
par Suzanne Dorion
Directrice, division Québec
Service de facturation
de Solutions Cliniques
Le saviez-vous?
Les enquêtes de la RAMQ: comment vous en sortir?
Tel que vous le savez peut-être déjà, la RAMQ n’a pas seulement le mandat de payer votre salaire, mais également celui
de veiller à ce que votre rémunération soit conforme aux lois
et règlements, ainsi qu’aux ententes conclues entre les fédérations et le ministère. Pour ce faire, elle procède régulièrement
à des vérifications consistant à analyser votre facturation.
Ces vérifications peuvent concerner:
I un service non conforme;
I un service non requis;
I un service faussement décrit;
I un service non assuré;
I un service non fourni.
Lors de ses enquêtes, la RAMQ procède à des analyses
comparatives avec vos collègues et peut, si elle ne réussit pas à
expliquer votre écart ou encore, si elle suspecte que votre
service n’a pas réellement été donné ou est faussement décrit,
procéder à une visite d’inspection ou vous expédier une lettre
de réclamation.
Se sentant accusés plutôt qu’interrogés, la plupart des médecins
deviennent anxieux et inquiets à l’idée de ces vérifications. Mais
de quelle façon devez-vous réagir à ces enquêtes?
Dans un premier temps, souvenez-vous de ne jamais paniquer.
En effet, selon des informations recueillies à la RAMQ, sur les
16 850 médecins en pratique active au Québec, seulement
97 dossiers individuels et 14 dossiers de groupe ont été analysés
en 2008 par la RAMQ, parmi lesquels on compte seulement
29 enquêtes et 32 visites d’inspection. Ensuite, avant de répondre trop rapidement aux demandes de la RAMQ:
I
Obtenez rapidement de l’aide en vous référant à des gens
compétents et compréhensifs tel que votre agent de
facturation, l’ACPM, un avocat, un ami, etc.;
I
Préparez-vous adéquatement;
I
N’abandonnez pas. La plupart des médecins qui se défendent gagnent leur cause;
I
Évitez à tout prix de sous-facturer par crainte de faire l’objet
d’une enquête.
Solutions Cliniques – Facturation.net a mis sur pied une
conférence sur le sujet, offerte aux médecins et aux associations,
en collaboration avec un médecin qui a lui-même été victime
d’une enquête personnelle et d’une enquête de groupe qui
représentait tout près d’un million de dollars. Naturellement, il
a non seulement survécu à ce processus, mais a également
surmonté le jugement de ses pairs et amélioré la facturation de
sa discipline au Québec. N’hésitez surtout pas à nous contacter
pour obtenir de plus amples informations à ce sujet. Vous
prémunir contre les enquêtes, c’est habituellement payant!
Du nouveau !
Consultez notre site Web pour plus de renseignements
sur le sujet : www.solutionscliniques.ca/publication
Avec Facturation.net votre facturation médicale,
un véritable jeu d’enfant...
Facturation.net vous débarrasse des problèmes et des erreurs qui vous font perdre
temps et argent. Accessible de partout par Internet, il est le système de
facturation le plus simple et le plus efficace sur le marché.
Simplifiez-vous la vie !
Téléphonez-nous dès aujourd’hui.
1 866 3FACNET (332-2638)
www.facturation.net
Un produit de

Telemedicine Is Québec Ready?

Transcription

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