Alberta Doctors' Digest July/August 2017 by Alberta Medical Association

Alberta Doctors'

DIGEST July-August 2017 | Volume 42 | Number 4

Special issue The future of e-health, technology and information management

Health information sharing

A foundation for our future health care system

AHS Clinical Information Systems

A revised information sharing approach

Patient portals and secure messaging

Do they improve patient engagement and physician workflow? Patients FirstÂŽ

CONTENTS DEPARTMENTS

Patients First® is a registered trademark of the Alberta Medical Association.

Alberta Doctors’ Digest is published six times annually by the Alberta Medical Association for its members. Editor: Dennis W. Jirsch, MD, PhD

4 7 10 24

Co-Editor: Alexander H.G. Paterson, MB ChB, MD, FRCP, FACP Editor-in-Chief: Marvin Polis President: Padraic E. Carr, BMedSc, MD, FRCPC, DABPN President-Elect: Neil D.J. Cooper, MD, FRCPC, Dip. Sport Med. Immediate Past President: Carl W. Nohr, MDCM, PhD, FRCSC, FACS

From the Editor Letters Health Law Update PFSP Perspectives

27 Dr. Gadget 34 In a Different Vein 37 Classified Advertisements

FEATURES

6 Special issue

The future of e-health, technology and information management

8 Health information sharing

A foundation for our future health care system

13 AHS Clinical Information Systems

A revised information sharing approach

Alberta Medical Association 12230 106 Ave NW Edmonton AB T5N 3Z1 T 780.482.2626 TF 1.800.272.9680 F 780.482.5445 amamail@albertadoctors.org www.albertadoctors.org

14 Should study of the history of medicine be a requirement for medical trainees?

September-October issue deadline: August 14

18 AMA Youth Run Club teams up with ParticipACTION 150 Play List

The opinions expressed in Alberta Doctors’ Digest are those of the authors and do not necessarily reflect the opinions or positions of the Alberta Medical Association or its Board of Directors. The association reserves the right to edit all letters to the editor.

The Alberta Medical Association assumes no responsibility or liability for damages arising from any error or omission or from the use of any information or advice contained in Alberta Doctors’ Digest. Advertisements included in Alberta Doctors’ Digest are not necessarily endorsed by the Alberta Medical Association.

16 Patient portals and secure messaging

Do they improve patient engagement and physician workflow?

Celebrating physical activity with Fort McMurray students

20 Members tell the AMA these are uncertain times

April AMA tracker survey reflects complex issues and varied opinions

28 Community Information Integration

Providing better access to primary care and community health information

30 How do patients feel about accessing their health information through an online portal?

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AMA MISSION STATEMENT The AMA stands as an advocate for its physician members, providing leadership and support for their role in the provision of quality health care.

An early report on real-life experience

32 Many Hands™ on the front lines

Calgary surgeon travels to Iraq to care for people living amidst the horrors of war

To request article references, contact:

daphne.andrychuk@albertadoctors.org COVER PHOTO:

Dr. Heidi E. Fell JULY – AUGUST 2017

FROM THE EDITOR

Anger and beyond Dennis W. Jirsch, MD, PhD | EDITOR

he world’s in trouble: terrorism and other violence, climate change, hunger, homelessness, massive debt, the prospect of another financial bubble. Old rules don’t apply. Everything is topsy-turvy and we seem on the edge of anarchy. I’ve become sensitized to the anxiety and anger which threaten our lives. I seem to find it everywhere. Anger’s there in our personal relationships. Not for nothing is homecoming called the “suicide hour,” at the end of the day, when parents and children are tired, hungry and in need of attention. Add in an ever-moredemanding workplace and the need to do more with less, even as job security becomes ever more evanescent. “Going postal” comes to us from a mass shooting in Oklahoma where Patrick Henry Sherrill, enraged at losing his job as a postal worker, killed 14 employees and injured six others.1 “Road rage” is endemic and ranges from raised fists and extended long fingers amid a cacophony of car horns, all the way to the recently aggrieved driver who followed a woman home and beat her with a tire iron, breaking multiple bones.

I’ve become sensitized to the

anxiety and anger which threaten our lives. I seem to find it everywhere.

Even when anger’s unbridled force is acknowledged, it is still considered a strong emotion, somehow linked to self-respect. To react to provocation without ire is to risk being called cowardly or spineless. And nowhere are our strange attitudes to anger and violence more apparent than in contact sports. Here we expect young, most often testosterone-charged males to slam each other per the

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dictates of each sport, but woe betide players inaccurate enough to slam or tackle beyond the sanctioned zone, especially if they produce real injury. Violence brings in the crowds, just as it did in Roman amphitheatres or the town-square hangings and tortures of centuries past. As Martha Nussbaum points out, anger is a dumb way to organize one’s life.2,3 Nussbaum reminds us that Hippocrates felt there were four base substances in the human body which are in balance in health. The four humors include black bile, yellow bile, phlegm and blood. An excess of yellow bile was thought to be associated with anger, hence bilious or angry. Hippocrates near-contemporary, Aristotle, was closer to the mark. He defined anger as a response to damage or trespass, physical or otherwise, inflicted on someone or something one cares about. Aristotle also brought up the notion of payback or retribution. Research has added further details, but I think Aristotle captured the gist of things (though, truth-to-tell, Hippocrates has a certain lingering appeal). Has much changed? Well there are more of us – 7.5 billion at last count – chasing fewer resources and we communicate incessantly. Our technologies are laced with anger and violence which need not be restrained, perhaps part of their allure. Our electronic games generally depend on digital destruction of opponents and challenge us to wreak destruction ever faster and with more pizazz. Our social media have become pernicious activities; with near anonymity, we can respond as we wish, often with bitter name-calling and vitriol. Our need for retribution is ancient, a holdover from the Code of Hammurabi that conflates our need for law and order with our appetite for vengeance. In our courts we commonly hear aggrieved impact statements before sentencing. Though the death penalty has been denounced in most civilized countries, numerous states continue electrocution, lethal injection, hanging … even death by firing squad. Recall Martin Luther King: “The old law of an eye for an eye leaves everyone blind.”4 >

> A childhood experience with anger and the need for vengeance embarrasses me. Perhaps I was four, and my sister a year younger, riding in the back of our father’s car. When we stopped, I got out but clumsily closed the door on my thumb and began to howl unceremoniously. When asked, “Who did it?” to my eternal shame, I pointed to my sister. She, as you might expect, got a spanking even though she was innocent. Once guilt had wormed its way through me, I told the truth – my turn for a spanking – and, as I recall, sis got a treat at the candy store as amends. Some people seem angry all the time. We call them irascible. I’ve read of the 18th century surgeon and anatomist Dr. John Hunter.5 Hunter, an early advocate of experimentation and observation, is perhaps best known for inoculating himself with both syphilis and gonorrhea, but he suffered from angina. “My life,” he lamented, “is at the mercy of any scoundrel who chooses to put me in a passion.”

Even when anger’s unbridled

force is acknowledged, it is still considered a strong emotion, somehow linked to self-respect.

His words were prophetic. Hunter got into an argument with fellow board members at St. George’s Hospital in London. He walked out, but dropped dead in an adjacent room. I saw the link between anger and emotion for myself half a century ago as an intern charged with assisting a senior surgeon. The veteran started off smoothly enough, but even with straightforward cases – an appendix, say, or even a gall bladder – would seemingly lose track of where we were in the course of things and it was downhill thereafter. I tried to attend to the surgeon’s suture tails with my scissors, but heard only “too long” or “too short.” I couldn’t find a Goldilocks situation that was “just right.” As things became increasingly tense, the surgeon yelled and threw successive instruments to the floor. His wrath included the scrub nurse who, evidently, handed him every instrument but the right one. At a point in this misery, he would pull gloved hands to his chest and repair to a stool in a corner of the room for some minutes, after which his precordial pain would improve sufficiently for us to resume. Nowadays health care folk may comport themselves better and I’m prepared to admit that boorish behavior

has become less acceptable. Yet there’s still ample opportunity for anger and angst with our endless battle for resources in an environment of perpetual reorganization. This environment is often unresponsive to the needs of both patients and their caregivers. In a remarkable work, The Better Angels of Our Nature, Canadian-born psychologist Dr. Steven Pinker has argued that violence (and presumably antecedent anger) has been in decline on a century-over-century basis.6 Pinker’s critics complain that the scope of the work is myopic and Eurocentric, with singular focus on battle deaths and not enough concern for the fate of non-combatants caught up in wars. Though Pinker may be right, it doesn’t feel right, and that’s the takeaway: the world feels angrier all the time. Anger management has become big business, fostered no doubt through attempts by social workers and the courts to prevent further family violence. There is no way to be accurate regarding the effectiveness of these courses, which implement a variety of approaches including prevention strategies as well as reframing and relaxation techniques. We’re a world in search of quick fixes and I note several agencies that advertise court-approved courses that can be taken in just one day. In a world suffused and pervaded with anger, there are certainly heroes who have responded without anger to situations usually producing it. Nelson Mandela, we recall, spent 27 years imprisoned in South Africa. Initially he promoted violence and payback, but over the years of incarceration he mellowed and persuaded the African National Congress to forego retaliation in the interests of progress toward nationhood. But we are not Nelson Mandela. Most times if we examine our anger, it will not be because we have been imprisoned or dealt an ethical affront that we can constructively work to repair. What’s the old saw? Anger, it’s never just about what it’s about. It’s true enough. We tend to localize the source of our anger poorly. Most often if we stop to examine the context of our anger, we will find a minor puncture in our emotional integument. Something small and often accidental has tapped into the insecurity and anxiety of our lives. Certainly, from time to time, we may be able to move forward with our anger, like Mandela, attempting to repair our lives. But most times we won’t and know that indulging our anger will lead us astray, tangled and worse off than ever. Most times we’re best to heed Mark Twain: “When angry, count (to) four; when very angry, swear.”7 It’s hard to improve on this. As a doc, I might make it into an Rx, adding, “Repeat prn,” or “ad libitum.” It could stand us in good stead. References available upon request.

JULY – AUGUST 2017

FEATURE

Special issue The future of e-health, technology and information management Marvin Polis | EDITOR-IN-CHIEF

elcome to another themed edition of Alberta Doctors’ Digest. As you may recall, our last themed issue was about daring ideas for health care. In this issue, we’re going to explore the future of e-health and technology. Is this a daring idea in and of itself? In some ways, it may be. But with the right mixture of gumption and wisdom, the benefits to patients and the health care system can be tremendous. So what do we have in store for you? Some of your colleagues have contributed as guest-authors with stories about important issues like information sharing policy, community information integration, patient portals, secure messaging and much more. You’ll also learn how patients feel about emerging e-health technologies. And of course, some of our regular columnists chimed-in on the subject of e-health as well, so we’d like to thank everyone who has generously volunteered their time and effort to helping us put together this special issue. As the saying goes, “many hands make light work.” Marvin Polis Editor-in-Chief Alberta Doctors’ Digest

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LETTERS

thoroughly enjoyed Dr. Paterson’s column entitled “Genies in bottles and my daring idea for Alberta” in the March-April 2017 issue of Alberta Doctors’ Digest. Seldom do I read articles so well thought out by someone who is like a soulmate with myself. Often I talk to my friends who American-bash while we are golfing in Palm Springs.

am an internist in Calgary. Overall I am very happy with the efforts of the Alberta Medical Association. I leaf through Alberta Doctors’ Digest when it arrives at my door. When something catches my eye, I will read it. I enjoyed the March-April 2017 issue with the theme: “Daring ideas for health care in Alberta.” I certainly recognize we need to have new ideas to keep this sinking ship afloat a little longer and maybe even right the ship.

I do not, however, appreciate the editorial staff of Alberta Doctors' Digest allowing Dr. Paterson to voice his opinions on a) our current prime minister, b) the CBC and c) climate change. For the record, other than Calgary’s Mayor Naheed Nenshi, I am not a supporter of any politician in Canada, I don’t really have the time to listen or watch the CBC and if one thinks that the actions of humans isn’t currently or isn’t in the future going to affect the ecosystem of the earth, then they are either naive or ignorant.

It is then that I wish there was a genie to instantly transport them from Palm Springs at temperature 30 Celsius, to Bassano (not bashing the town per se) at temperature minus 20 Celsius. Perhaps if the Cascadia fault extends a little into Alberta, we can have that southward tectonic shift that Dr. Paterson alluded to.

Anyways, I had a smile while reading your article. Keep it up and keep those pro-Trudeau, climate fear monger anti-Americans on their toes.

With respect to the environment, Dr. Paterson is correct. There are no absolutes in science. This fact is certainly germane to medical practice. I was recently taught the adage “never say never and never say always in medicine” by one of my trainees. But if one has cancer, I would hope they would seek the opinion of the most knowledgeable people (i.e., an oncologist and not a naturopath or a celebrity). When one has a question about climate change, they should probably ask climatologists, not physicians, executives of oil companies or car manufacturers, presidents of world powers, etc. I digress.

If in the future, I would appreciate it if the editorial staff of Alberta Doctors’ Digest would stick to “your business” which is medicine and continue to publish articles that are relevant to physicians. There are plenty of other venues in our society through which Dr. Paterson can voice his political and ecological opinions.

Cheers, Tom Y. Woo, MD, FRCPC Calgary AB

Sincerely, J. Paul Davis, MD, PhD, FRCPC Calgary AB

But to the point of this email, this is a magazine for physicians, paid for by physicians, that is supposed to talk about health care and physician related issues. Dr. Paterson states what the United States does with its immigration policy is “their business” and he is correct in that assertion.

JULY – AUGUST 2017

COVER FEATURE

Health information sharing

A foundation for our future health care system Heidi E. Fell, MD, CCFP, FCFP

any of us have thought about health information sharing in terms of the referral/ consultation pathway or in terms of our obligations to protect information under the Health Information Act, but have you thought about it as a core value of a high-functioning health care system? What if every health care provider in the province had exactly the right information, exactly when it was needed? What if patients had the relevant information at their fingertips to share with their providers, in a format that was easy for everyone to digest and that patients could help update? What if patients could refer to it as needed to remind themselves of their role in their care, just as providers refer to past information to remember the details? How many lives could be saved? How many dollars? How much time?

What if every health care provider

in the province had exactly the right information, exactly when it was needed?

The potential promise of information sharing is huge, and other areas of the world are beginning to leverage this environment to improve their health care systems, but although we in Alberta lead in areas such as Netcare, large gaps still exist in our information sharing abilities. These gaps leave patients at risk and consume large amounts of resources in terms of time and dollars due to delays, missing information and repetition of tests and information. For example, primary care physicians in several areas of the province still receive no notification that their patient was seen in an urgent care center or emergency room.

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Starting late last year, I had the opportunity to participate in a working group that created a discussion paper Health Information Exchange: Engaging Providers in Health Care Innovation. Although initially leery of yet another committee, once we got going, it turned into a robust discussion among several stakeholders including the Alberta Medical Association (AMA), Alberta Health, College of Physicians & Surgeons of Alberta, Alberta Health Services, Alberta College of Pharmacists and University of Calgary. The discussion centered on the state of information exchange in Alberta and the need for an integrated health record for each patient. This does not mean a single software program, but a secure central place for information accessible to all who need access to it, including the patient.

Physicians want to share data,

but it needs to be clinically valuable and done with the full understanding and input of our patients

Through this paper and an accompanying symposium in February, many topics were explored, including the substantial literature supporting an integrated health record and its benefits, potential challenges and mitigating strategies, and an action framework to move things along. As your AMA representative, my key messages were these: • Physicians want to share data, but it needs to be clinically valuable and done with the full understanding and input of our patients. • The AMA wants/needs to be a key partner in these activities, as evidenced by the Amending Agreement and subsequent board and Representative Forum attention. >

> • The challenging clinical environment must be recognized in that any tools must not impede the relationship with the patient (workflow); the wide variety of clinical and non-clinical competing priorities must be acknowledged and streamlined; and significant attention must be paid to change management, including financial cost to the provider.

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For further information, please contact: I understand there are many remaining challenges and concerns about privacy, workload, information overload, EMR burnout, patient expectations and professional autonomy – to name but a few. At the end of the day, though, I felt for the first time that these challenges were acknowledged as real barriers that could be overcome with appropriate attention and that this attention would come over time.

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While we are waiting for some of this background and technical work to be done, we can resolve some issues among ourselves by collegially working together to ensure we all have appropriate information to care for our patients. Here are some of my thoughts to get things started: • Copy the family doctor on a report to a fellow specialist, even though the family doctor wasn’t the referral source. • Take an extra minute to check that your referral or consult has all the necessary information (but not every lab result since the dawn of time). • Give the patient a copy of their cumulative profile so they have a list of their problems, meds, allergies and past medical history in case they ever need to go to emergency or obtain care while traveling. I look forward to hearing more ideas about how we can shape the integrated health record together. Contact information: Dr. Heidi Fell heidi1234@me.com

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JULY – AUGUST 2017

HEALTH LAW UPDATE

Some pitfalls when using electronic medical records Jonathan P. Rossall, QC, LLM | PARTNER,

iven the theme of this edition of Alberta Doctors’ Digest (and the fact that this is a medical/legal column), I thought it might be helpful to reflect on some of the risk factors associated with electronic medical records (EMRs). I recently participated in a panel of doctors and lawyers speaking to physicians on a variety of risk management issues, including EMRs. At the outset it should be made clear that, used properly, an EMR is a valuable tool that is very effective in improving patient care. The discussion, though, was focused on pitfalls. It was very animated and helpful, and I took away six specific aspects of EMRs that could, if not used properly, give rise to potential liability or at a minimum, investigation by the Office of the Information and Privacy Commissioner. The information outlined in this article, however, is intended as a high level overview of these issues; other resources should be accessed for a more in-depth review.1

Use of templates/check boxes EMRs are designed by their vendors to make life easier on record keepers. Many, if not most, will feature templates for various medical conditions with associated check boxes reflecting identified symptoms, risk factors, imaging and other options. Again, used properly, these can create efficiencies in record keeping. The problem with moving in this direction is the potential to create “cookie-cutter” charts and the possibility of the physician becoming so dedicated to ticking off the boxes that the ability to look outside the boxes is lost. The use of free text options, where appropriate, should be encouraged to ensure that the record continues to be unique to individual patients. Also, users should be cautious with regard to default settings and the dreaded auto-fill function, which may inadvertently add information that was not actually obtained from the patient.

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MCLENNAN ROSS LLP

A February 2015 article in the Ontario Medical Review made a few suggestions that make common sense: • Delete fields that are not applicable such as prostate exam results for female patients. • Delete fields or contents that do not reflect what you have actually done. • Avoid unrealistic, overly detailed templates that are not typical of your practice. Sound advice.

Copy/paste function It is tempting to copy entries from previous visits and paste them into an EMR narrative, rather than take the time to type an entirely new entry. Or, on occasions there are descriptions of clinical examinations or techniques available in electronic versions of publications that can be copied and pasted into an EMR, again to make life easier. Great caution should be used with such an approach, as the overt similarity of the entries from visit to visit will erode the impression that a unique and individual assessment occurred. This is especially so if the cut and pasted paragraph contains details that were not common to the two visits. And, most assuredly, a chart review by the college which reveals identical entries on different dates may raise suspicions as to how much time was actually spent with the patient and what was actually done.

Audit trails Most computer users have heard the term “metadata.” This is the background information which confirms when, by whom and for what purpose data entries were made. It is essentially an electronic log of all data entry. Reverting to metadata, an investigator can confirm exactly when a chart note was made, by whom, using what password and whether changes/alterations have occurred. All of which should serve as a caution when considering corrections or alterations to an EMR. >

> Alerts Most EMRs will have a system of pop-up alerts which vary from notifications of incoming messages, to advice regarding office issues (patients waiting) to more serious issues such as significantly deviant test results. These can be distracting and some might be tempted to delete alerts, forgetting that some can be more serious or clinically relevant than others. Physicians should avoid that habit, because the system assumption is usually “dismissal equals acknowledgement.” They should either carefully read each alert, modify their EMR so that only serious and clinically relevant alerts come through, or check if there is an “Are you sure?” feature that prompts second thoughts about deletion.

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Drop-down menus Who hasn’t inadvertently sent an email to the wrong person from their drop-down menu of email contacts? This might result in embarrassment to the author or potentially a privacy breach. However, drop-down menus on EMRs raise a host of other potential issues, including the inadvertent identification of the wrong patient, misfiling of results or inadvertent signing off of results. Drop-down menus are useful tools, but caution should be exercised by physicians and staff in using them.

Privacy Finally, overall caution should be exercised in using and storing electronic data. The newspapers are replete with stories of stolen or lost laptops or media storage tools such as memory sticks. The lessons learned are typically not to take such devices from the office or, if removal from the office is necessary, ensuring that they are encrypted and password protected. However, in larger practices or hospitals, risks are also associated with sharing laptops or computers or failing to properly log off when use is completed. Inadvertently allowing another user to access information can lead to consequences.

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Overall, EMRs have made communication between physicians and other health care providers easier and quicker, quite aside from the fact that entries are more legible! However, caution must still be exercised with these systems and their hardware to avoid medical misadventures and to protect the privacy and the integrity of the information stored on the EMR.

Thank you My thanks to the Canadian Medical Protective Association (CMPA) for allowing the use of material generated by the CMPA for their ongoing CME/Risk Management purposes. For more information, access the following link: https://www.cmpa-acpm.ca/static-assets/pdf/advice-andpublications/risk-management-toolbox/ com_electronic_records_poster_11x17-e.pdf References available upon request.

JULY – AUGUST 2017

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FEATURE

AHS Clinical Information Systems A revised information sharing approach Robert Hayward, MD, MPH, FRCPC | CHIEF

MEDICAL INFORMATION OFFICER, ALBERTA HEALTH SERVICES

revised approach to information sharing among users of the Alberta Health Services (AHS) Clinical Information Systems (CIS) will take effect January 1, 2018, pending approval from a number of key stakeholders. Stakeholders include AHS, Alberta Medical Association (AMA), College of Physicians & Surgeons of Alberta (CPSA), University of Alberta (U of A) and University of Calgary (U of C). This development of a revised approach has been facilitated by Alberta Health (AH). Under the new approach, AHS will be the sole custodian of health information, with clinicians acting as “affiliates” for the purposes of information sharing within AHS CISs. This will mean a change in assumptions about how some physicians relate to AHS CISs. A prior “Information Sharing Framework” contemplated ambulatory care physician “co-custodians” for some uses of the eCLINICIAN CIS in the Edmonton Zone and the Sunrise Clinical Manager CIS in the Calgary Zone. Key timeline milestones include: • June 30, 2017 – consensus reached among stakeholders regarding information sharing approach for AHS CISs. • Summer 2017 – begin socializing new approach with physicians. • January 2018 – begin implementation process. Communications activities throughout this process will need to ensure that physicians within and outside of AHS: • Are aware the change is underway. • Understand why it’s important. • Understand how it will impact information sharing assumptions in their ambulatory care practice. • Understand the benefits of the new approach for current CISs and for the AHS Provincial CIS.

• Have access to relevant documentation or have high level understanding of the changes. • Have opportunity and means to get their questions answered. With these considerations in mind, a comprehensive communications plan is being developed to help with the transition, ensuring alignment with key stakeholders when it comes to messaging, interventions and timelines. Physicians can look to the following for communications and engagement: • Development of informational page on AHS external website (ahs.ca/medicalstaff) as a central location to direct clinicians. • Links and/or integration with existing zone CIS web pages and the AHS Provincial CIS web pages, both internal and external. • Integration with existing clinician-to-clinician handbooks. • Integration with CIS dashboards, resource links and other within-CIS information and help services. • Memoranda via AHS Medical Affairs and AMA. • Physician publications, including Strategic Clinical Networks Newsletters, Vital Signs, Alberta Doctors’ Digest, U of C Continuing Medical Education Newsletter, U of A Medicine News, MD Scope, Section News, CPSA Messenger and PCN Newsletters. • In-person engagement opportunities, including ZMAC meetings in all five AHS Zones and PPEC meetings. • In-person engagement opportunities including AHS north sector and south sector telehealth sessions featuring AHS CMIO, provincial physician liaison forum, regional medical staff associations, faculty/academic departments. • Social media via AHS social media channels.

JULY – AUGUST 2017

FEATURE

Should study of the history of medicine be a requirement for medical trainees? Dawna M. Gilchrist, MD, FRCPC, FCCMG, DHMSA | PROFESSOR EMERITA, FACULTY OF MEDICINE AND DENTISTRY, UNIVERSITY OF ALBERTA AND SECRETARY TREASURER, ALBERTA MEDICAL FOUNDATION

s yet, the history of medicine is neither mandated for medical student accreditation, nor included in specialty or generalist competencies, but powerful arguments are being made to relevant committees and through academic publishing. I am one of many physicians and historians who posit that an appreciation for the history of medicine would be of significant value to medical trainees.

By virtue of its interdisciplinary nature,

the study of medical history provides essential commentary on the social, economic and political context of the medical profession: not only the “how” of where medicine is today but the “why.”

Our suggestion is that studying medical history should not be just a recitation of who, what and when. Rather than a simple compendium of names, dates and past events, the history of medicine provides important perspectives and insights into current medical education, research and clinical practice. It is a comprehensive collection of observations on the evolution of medical philosophy, technology and knowledge that allows us to understand evolving concepts of disease, therapeutics and medical organization. Further, by virtue of its interdisciplinary nature, the study of medical history

AMA - ALBERTA DOCTORS’ DIGEST

provides essential commentary on the social, economic and political context of the medical profession: not only the “how” of where medicine is today but the “why.” The skills derived from exploring the historical aspects of medicine encourage investigation, strengthen judgment and enhance critical thinking. Such study can provide pragmatic knowledge and the enhancement of professional behaviors. The history of medicine captures the attention, fires the imagination and engages the intellect. According to Jones, Greene, Duffin and Warner in Making the Case for History in Medical Education, key historical themes that could be incorporated into medical trainee education include: “the changing burden of disease, the social determinants of health, the contingency of medical knowledge and practice, and the complex meanings of therapeutic efficacy.” How can you promote an interest in the history of medicine, especially for medical trainees? You can attend and encourage attendance at events in the history of medicine. You can promote and advocate for more formal activities in the history of medicine throughout the health sciences and in other faculties, either singly or in collaboration. You can contribute your opinions by letter, publication, print or social media. If you plan seminars, rounds, or conferences in medicine, please consider adding history content. For those who supervise medical trainees, encourage reading and even formal history research projects. An understanding of our history empowers us in the present and for the future. Let us work together to expand our horizons! Editor’s note: This opinion piece has previously appeared in modified form in “The Quad” – an e-blog at the University of Alberta

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FEATURE

Patient portals and secure messaging Do they improve patient engagement and physician workflow?

B. Wayne Chang, MD, CCFP, FCFP | REPRESENTATIVE

ver the last decade or so, the advent of computer technology has ushered in a new age of health care in Alberta. From the transition to electronic medical records in community medical offices to the implementation of large-scale electronic health records and clinical information systems, the medical profession in Alberta is now at the crux of integrating the flow of digital health information across the health continuum.

Electronic medical records are now moving beyond electronic “paper charts” and have evolved to the point where practitioners are ready to use them as clinical tools.

Physicians in Alberta were amongst the first adopters of computer-based clinical systems. Electronic medical records are now moving beyond electronic “paper charts” and have evolved to the point where practitioners are ready to use them as clinical tools. Using the analytical power of a computer, physicians now know the size of their practice, the age distribution and the types of patients they help. They can also examine trends in their patients’ health. Coupled with the growth of the medical home model that is emerging in many parts of the province, the knowledge gained from these electronic clinical tools will become an important component of the primary care environment and may be a critical driver for future health initiatives or programs. The inclusion of technology in the medical landscape will hopefully provide more efficient and safer health care.

AMA - ALBERTA DOCTORS’ DIGEST

FORUM DELEGATE, CALGARY ZONE

Along with the adoption of electronic clinical tools, the way care is delivered, leveraged by these computer tools, is taking health care in a new direction. In Alberta, patient portals are available via the electronic medical records that are used primarily by community-based physicians. Even a provincial patient portal is on the verge of providing access to a patient’s own health information. Above and beyond these portals, secure messaging is a feature available from dr2dr for electronic communication between providers, as well as communication between providers and patients. Giving patients online access to their health information and, more recently, asynchronous electronic messaging, will hopefully enhance the physician-patient relationship. Some of the advantages touted by patient portals and secure messaging are the added convenience for patients, increased engagement in health care, increased health literacy, health savings and, hopefully, improved patient health. Patient portals provide patients direct online access to their own health information. In most jurisdictions, this will include access to their problem list, allergies, immunizations (if applicable), medications, investigations and blood work. Some patient portals allow access to clinical notes. Many patient portals, including the one sponsored by Alberta Health (MyHealth.Alberta.ca), provide online health clinical information and health facility information.

The impact on physician workflow is

equivocal. Some studies suggest that workflow is improved, while others say the opposite.

With the advent of this novel direction in health care, a few concerns have been raised. A key concern is the privacy of health data. How can this risk be mitigated >

> given that the most secure system is never 100% secure? Another area of concern is whether electronic medical/health records really do enhance the health of the population. Workflow issues/concerns are also commonly brought up by physicians. With these caveats in mind, electronic access to one’s health records and more recently, secure messaging, is seeing steady adoption. This adoption is more prevalent in the USA under their Meaningful Use Initiatives. After a quick scan of the literature on patient portals and, more so, secure messaging, a couple of key themes are emerging. First, patients like the option of secure messaging. The added convenience and access to their health care provider are widely appreciated by patients. Second, the impact on physician workflow is equivocal. Some studies suggest that workflow is improved, while others say the opposite. The data are clear that secure messaging is a change to one’s workflow and volume. It really depends on the individual physician’s point of view if they feel secure messaging with patients and having patients with access to their information is worthwhile. These are interesting technological times for health care in Alberta. The hope for technology is that it helps us in our journey with our patients. Good luck to us all.

Need confidential advice dealing with patient advocacy or intimidation in the workplace? Call the Zone Medical Staff Association. ZMSA operated.

PRACTITIONER ADVOCACY ASSISTANCE LINE (PAAL)

1.866.225.7112



The PAAL is a 24-hour confidential service you can call to share the issue and obtain advice from your ZMSA. All calls are answered by Confidence Line, an independent provider of confidential reporting lines.

The PAAL service has been transferred out of Alberta Health Services and is now operated at arm’s length by ZMSAs.

For more information visit albertadoctors.org/paal

Because so much depends on you. You work hard to protect the people you love, the patients you serve, and the practice you’ve built. But who will protect them if you can’t?

Your Alberta Medical Association (AMA) membership gives you exclusive access to AMA’s non-profit group insurance plans tailored for physicians and their families. Rates are competitive, but made even better

because excess premiums are returned to participating members through the AMA Premium Credit. For 13 years, this has meant an average of 18% off published rates for disability, life and professional overhead expense insurance plans. With ADIUM Insurance Services* you deal only with AMA’s salaried insurance advisors and administrative staff. T 780.482.0692 TF 1.800.272.9680 ext 692 adium@albertadoctors.org *ADIUM Insurance Services Inc. is a wholly owned subsidiary of the Alberta Medical Association and has been providing competitive insurance services since 1950.

JULY – AUGUST 2017

FEATURE AMA Youth Run Club teams up with ParticipACTION 150 Play List Celebrating physical activity with Fort McMurray students Vanda Killeen, BA, Dip Ad/PR | SENIOR

COMMUNICATIONS CONSULTANT, AMA PUBLIC AFFAIRS

ort McMurray’s MacDonald Island Park buzzed with activity in May as over 300 students, teachers and families celebrated physical activity and Canada’s 150th birthday with the Alberta Medical Association (AMA) Youth Run Club's (YRC's) Fun Run and the ParticipACTION 150 Play List national tour. The end-of-school-year Fun Run was identified as a Tour Stop & Event on the ParticipACTION 150 Play List. The Play List “features 150 activities that define our land and people” in celebration of Canada’s 150th birthday. The YRC event was accompanied by a showcase sampling of ParticipACTION 150 Play List activities, including kayak and surfboard simulators, field hockey, stick pull and Tae Kwon Do. “We’re very excited to bring the AMA Youth Run Club to Fort McMurray to run with members of our four local Youth Run Clubs and so many other students and teachers from Fort McMurray schools,” Dr. Padraic Carr, AMA President commented to the crowd. “And we couldn’t think of a community or a group of students more deserving of a Fun Run.”

L to R: Kerri Murray, EAS; Janet Boyer, AMA; Dylan Fougere, Some Other Solutions; Hayley Degaust, EAS; Dr. Padraic Carr, AMA; Brian Torrance, EAS; Michael Brown, Northern Elite Football

About the AMA Youth Run Club Through the AMA Youth Run Club, a partnership of the AMA and Ever Active Schools (EAS), AMA member physicians, medical students and residents can meet with the children, teachers and families of their communities to encourage physical activity and healthful living.

About our sponsors The AMA Youth Run Club has been steadily growing in numbers and scope since its quiet beginnings with 4,000 kids and 77 schools in 2013. The impressive growth of this school-based children’s health and physical activity initiative would not be possible without the support of program sponsors: gold-level sponsor Alberta Blue Cross and bronze-level sponsor MD Financial Management. The AMA Youth Run Club is grateful for the increased capacity and enhanced program offerings resulting from these sponsors’ generosity and commitment to Alberta youth.

Over 300 Fort McMurray students joined the AMA Youth Run Club’s end-of-school-year Fun Run May 25 at MacDonald Island Park

Makes me feel

(Comments from YRC members, Mee-Yah-Noh School, Edmonton)

… “healthier and happier.” (grade 4) … “more less stressed.” (grade 6) … “welcome and needed.” (grade 6)

Favorite thing

(Comments from YRC members, Mee-Yah-Noh School, Edmonton)

“I feel that running club is my family.” (grade 6) My favorite part of run club is “running with my friends.” (grade 6) My least favorite part is “that it’s only once a week.” (grade 6)

Survey says … healthy students are better learners AMA Youth Run Club supports physician health advocacy in schools Evidence shows that active children are physically, mentally and socially healthier and happier, and they’re also better learners.

ImPRovINg CommuNITY hEAlTh ThRough PhYSICIAN lEAdERShIP ANd AdvoCACY (394 schools and 23,000 students)

The AMA is proud to partner with Ever Active Schools on the AMA Youth Run Club, a school-based program that through organized activities (running, walking, hiking, snowshoeing and more) and School Health Advocacy Talks helps children and youth develop lifelong, healthy habits. How can you get involved with the AMA Youth Run Club? Be an AMA YRC CHAMPion! Run with or help coach a club, help school staff set up and manage a YRC, or give a School Health Advocacy Talk (talking points for seven suggested topics are available on albertadoctors.org/YRC). For more information, contact: Vanda Killeen, AMA Public Affairs vanda.killeen@albertadoctors.org / 780.482.0675

YRC PARTNERS

YRC SPoNSoRS

amayouthrunclub.com

FEATURE Members tell the AMA these are uncertain times April AMA tracker survey reflects complex issues and varied opinions

or 18 years, the Alberta Medical Association (AMA) has commissioned regular polling of members to guide planning, benchmark member satisfaction and assess the response to changes. The ability to hear from members is vital for the leadership of the AMA in planning to meet member needs. For years, members have shared the need for the AMA to lead ongoing discussion in many areas from funding mechanisms, to health care delivery models or, more recently, items related to our Amending Agreement. This includes matters such as Schedule of Medical Benefits Savings Initiative, peer review, physician resource planning, integrated care and more. Outside of the Amending Agreement, the Representative Forum (RF) has discussed and directed the AMA to proceed toward income equity in the next five years. Compensation and income naturally draw a great deal of strong opinion from members. Over the years, some members have expressed feelings that their compensation reflects that they are undervalued. Others have experienced inequities from evolving practices and technology. Compensation connects with many members’ core values around the impacts of payment methods on patient care and how their contributions are valued. Over the years, members have continued to express a common desire for the AMA to advocate on the issue of compensation, but opinion among members on the solution to achieving fairness and providing an incentive to deliver quality care has not been commonly shared. The AMA and members are now well into the implementation of the Amending Agreement and beginning the move toward income equity as directed by the RF. The latest tracker survey demonstrates the impact of those discussions on members. Some members are feeling more heard and understood, while others are not sure if the discussion captures their needs and circumstances. The AMA conducted its first tracking survey of 2017 with a random sample of 3,750 members. The survey opened on April 4 and closed on April 11. Responses were received from 470 members for a response rate of 12.5%. The data is valid 19 times out of 20 within a margin of error of +/- 4.44%. AMA - ALBERTA DOCTORS’ DIGEST

Some are less sure than in the past Leadership and stewardship have been embraced by the medical profession as core responsibilities. The tension created as leaders set new directions can create either an opportunity for a better future or a retrenchment of the past. The last two tracker surveys have indicated trends suggesting more members are not sure about the evolution of compensation and the extent to which they are being represented in that process. Approximately one-third of members participating in the survey are “neutral” about the AMA’s making progress in fair allocation of compensation based on relative value and the fairness of the Physician Compensation Committee (PCC) process for defining and administering physician compensation. While tensions can be healthy, the AMA hopes to increase member confidence through robust consultation, transparent processes and clear two-way communication through which members know they are heard. A majority of members still agree that the AMA is effective in supporting the Patients First® vision (64%) and that the AMA is an effective advocate for physician members in providing leadership and support (63%). While these results are positive, the number of “strongly disagree” has increased as the number of “strongly agree” has decreased. Some physician groups have felt more strongly about recent shifts. For instance, in the historically more positive Zone 4 – Edmonton, agreement levels with the benchmark questions have dropped significantly, as they have with the collective of “specialists” (secondary and tertiary care). Given the nature of changes to compensation, declines in agreement are expected while members and the AMA work through the process. Periods prior to the introduction of change require both reaction and empathy. Members who feel unheard or underrepresented will need an opportunity to provide input into the review process and feel informed by it. The continued tracking of member opinion is one method of understanding the impacts of change on members, but there are other methods, such as members contacting the AMA directly, their RF delegates or those leading the various consultation processes on compensation and other significant initiatives in progress. >

> Peer review

The data

The Amending Agreement provides for the development and implementation of a new AMA/Alberta Health (AH) peer review process to encourage appropriate billing practices and complement AH’s audit and compliance activities. To carry out this work, an AMA/AH Peer Review Committee has been established. Accordingly, we added a number of questions about help for billing practices to the April survey. Overall, the sense was that most physicians do a reasonable job of billing accurately and appropriately, and that it is not the norm to do otherwise, but that further education would be welcome. Members also suggested what kind of information they would like to receive as well as how they would like to receive it.

Word frequency count: top items

Who responded? • • • • • • • •

Male (56%), female (35%), no response (9%) Family physician/GP (24%) Specialist: Family medicine (25%) Specialist: Other (51%) Urban (80%) Primary care network members (40%) Community-based practice (41%) Community or hospital-based appointment from AHS (71%) • Between 11 and 25 years in practice (42%) • 26 or more years in practice (29%)

Fee Family System Care AHS Need Support Process Patients Compensation Time Government Billing Work Overall averages: benchmark questions 63%

Feb 2014

64%

65%

60%

64%

67%

Jun 2014 Sept 2014 Apr 2015 Sept 2015 Dec 2015 Feb 2016 Jun 2016

Summary of findings: benchmark questions ranked Questions

Disagree

Mean 0

4.45

2. An integrated provincial electronic medical record (EMR) strategy that includes seeking value from existing infrastructure is essential for improvement of the health care system.

4.05

3. I am satisfied with the benefits and services provided by the AMA, e.g., insurance, continuing medical education (CME), Physician and Family Support Program (PFSP), etc.

Nov 2016 Apr 2017

Neutral

100

79.1% 0

3.87

3.75

Agree

93.3%

77.2% 0

4. I feel well informed about the activities and news from the AMA.

57%

Category percentages

(scale: 1 – 5)

1. Patient-physician confidentiality and safeguarding of that private information remains a requirement for effective patient care.

60%

75.5%

JULY – AUGUST 2017

Disagree

22 >

Questions

Mean 0

3.71

6. The AMA is effectively supporting the Patients First® vision where physicians positively influence a health system built around patients and families.

3.59

7. Primary care network (PCN) evolution toward the medical home model will improve access, quality and continuity of care.

3.50

8. The AMA is an effective advocate for physician members by providing leadership and support for their role in the provision of quality health care.

3.49

9. The AMA is creating and sustaining opportunities for physicians to play active leadership roles within their communities e.g., leadership development, Many Hands™, Youth Run Club, etc.

3.44

10. Physicians are shifting their practices to support partnering with patients in the delivery of care.

3.43

11. I am able to effectively share my opinion with the AMA when an issue or change will impact me.

3.42

12. The AMA is effectively contributing to efforts to promote system-wide efficiencies and savings.

3.38

13. I feel well informed about the news and initiatives within the Alberta health care system.

3.27

14. I feel the Representative Forum is able to understand and receive feedback from physicians to support their governance role.

3.27

15. The AMA is effectively building and managing the partnership with Alberta Health and Alberta Health Services.

3.27

16. The Physician Compensation Committee process for defining and administering physician compensation is fair.

2.90

17. The AMA is making progress in supporting fair allocation of compensation based on relative value.

2.90

18. In our system, incentives and financial/compensation supports for physicians are aligned with the system objectives of timely access for patients to quality care.

2.65

Overall averages

3.46

100

68.7% 0

100

63.6% 0

51.7% 0

100

62.5% 0

49.4% 0

100

51.0% 0

100

57.4% 0

100

55.4% 0

100

49.9% 0

100

48.3% 0

100

48.8% 0

100

31.3% 0

100

34.1% 0

100

23.1% 0

AMA - ALBERTA DOCTORS’ DIGEST

Agree

Category percentages

(scale: 1 – 5)

5. Physicians are being supported by the AMA in maintaining their own health and that of their families.

Neutral

56.7%

100

JULY â&#x20AC;&#x201C; AUGUST 2017

PFSP PERSPECTIVES

e-health literacy: Creating our best selves Vincent M. Hanlon, MD | ASSESSMENT

PHYSICIAN, PFSP

continue to think about Dr. Gadget’s (AKA: Dr. Wesley Jackson’s) provocative question at the end of his column in the March-April 2017 issue of Alberta Doctors’ Digest: “If you were going to invest now in your future best self, where would you put your time and your energy?” Dr. Jackson was quoting Dr. Robert Waldinger in his 2015 TED Talk about the Harvard Study of Adult Development.

The CPSO document references the College of Physicians & Surgeons of Alberta’s 2012 e-health Vision Statement.

Our best self is intimately dependent on the quality and strength of our relationships. Dr. Gadget gave some examples of how digital connectivity has the power to enhance or harm those relationships. His two-year-old grandson was able to call and surprise his grandma using touchscreen technology on his mom’s smartphone. On the other hand, a physician deeply immersed in the electronic medical record during an office visit may leave a patient feeling unseen and unheard.

His lines of inquiry include tele-health to engage rural practitioners, patient safety, and public engagement in information and communication technologies (social media, multimedia, the Internet and bio-sensors). Dr. Ho uses the word “mHealth” to refer specifically to the use of mobile phones in accessing and deploying these technologies. Smartphone health apps are one mammoth subset of e-health literacy. How mammoth? The European Commission published The myhealthapps directory 2015-2016. It features a few hundred health apps from over 100,000 available.

Earlier this year I was a companion

and informal medical guide for my brother and his wife during their too brief encounter with Tim’s non-small cell lung cancer. As the “medical person” in my family of origin, I also volunteered to send out periodic progress reports to our seven siblings.

What are we talking about here when we discuss e-health literacy? The College of Physicians and Surgeons of Ontario (CPSO), in their 2013 e-health Statement, gives us this definition: “The awareness of and ability to use relevant e-health tools, processes and resources that facilitate best practice and the provision of quality care.”

AMA - ALBERTA DOCTORS’ DIGEST

Vancouver emergency physician Dr. Kendal Ho comes to mind when I think about e-health tools, processes and resources, AKA: TEKT (technology-enabled knowledge translation). Dr. Ho was the founding director of the Univeristy of British Columbia Faculty of Medicine’s e-health Strategy Office. After leading that initiative for several years, he now focuses his e-health research energies within the department of emergency medicine, and renamed the initiative digital emergency medicine.

Dr. Ho has also read the demographic writing on the wall about older Canadians and their health care needs and wants. He encourages seniors to participate in the digital health revolution. To address that agenda item, Dr. Ho connects with small groups at seniors’ centers in Vancouver where he does presentations such as “An app a day keeps the doctor away.” Dr. Ho’s e-health work is helping to cultivate what Dr. Eric Topol optimistically envisions as digitally empowered, connected, data-driven, participatory consumers of all ages building and living within a healthy culture (The Creative Destruction of Medicine, 2012). It won’t be long before Dr. Gadget’s wife will be looking to her grandson for some new health app recommendations. We are talking primarily about information and communication: tons of information and dozens of ways to communicate. From the perspective of physician health, how does our degree of e-health literacy contribute to our well-being? >

> Earlier this year I was a companion and informal medical guide for my brother and his wife during their too brief encounter with Tim’s non-small cell lung cancer. As the “medical person” in my family of origin, I also volunteered to send out periodic progress reports to our seven siblings.

What digital devices and apps did I find helpful in fulfilling these roles? What communication tools did we use as a family to help us find a path with heart through this distressing time? Things started with a voice call from Tim in November. He told me how short of breath he’d become when trying to run the bases playing slow pitch with his snowbird team in Surprise, Arizona. His wife, Nicki, and I also had our cell phones in hand at the time of his death. On a weekend in March, Tim deteriorated abruptly and somewhat unexpectedly. Nicki tried to call me. Inadvertently she FaceTimed me instead – the video image that appeared on the phone when I answered her call was Tim lying dead on their living room floor.

An indelible memory for me is accompanying my brother on the first day of winter to a follow-up visit with my specialist colleague.

What digital devices and apps did

I find helpful in fulfilling these roles? What communication tools did we use as a family to help us find a path with heart through this distressing time?

In between the beginning and the end, there was a lot information to access, decipher, store and share. I relied mostly on UpToDate for “the evidence.” In contrast, my “non-medical” brother and his wife visited numerous websites, especially in the first few weeks of the illness. They enlisted me to check out possible options, including a Mexican clinic and other sites promoting alternative therapies. I had to consciously restrict the amount of time I spent online each day. I also had to reconcile that what I might do if I were in Tim’s predicament was not what he and Nicki needed to hear or wanted to do. For communicating with each other, we used texts, emails and a family sharing group on Telegram. We shared words of encouragement, our questions, uncertainties and sadness. We exchanged family photos but also digital images, scans, lab results and pictures of medical devices including a wireless pulse oximeter and a tunnelled PleurX catheter drain. After Tim’s return to Alberta from Arizona, our electronic calendars filled with appointments. Our lists of medical and nursing phone contacts grew and grew.

Strength is not only about structures of steel and concrete. Our best self is intimately dependent on the quality and strength of our relationships.

I used voice calls selectively. To share the initial shocking news of our brother’s diagnosis, I phoned rather than texted my siblings. As his illness progressed, Tim made and received fewer and fewer voice calls. He lacked the breath and emotional reserve for such calls. He depended on Nicki to make the essential ones. Tim observed that over the years it had been hard enough staying healthy; it was so much harder being sick. On his better days, he texted. He upgraded to the latest iPad two weeks before his death. Sharper pictures, he said. >

JULY – AUGUST 2017

> I knew that Tim enjoyed listening to music; he was a teenager in the 60s. I started sending him a Song of the Day. He replied with his suggestions for me. Technology facilitated easy access to our selections. The music helped us express our fondness for each other when we weren’t able to use words. Every Breath You Take. Against the Wind. Just Breathe. Tomorrow is Another Day. The Waiting Game. Winter Has Me in its Grip. The music was our non-verbal conversation and a shared pleasure for the two of us. The music continues to be a source of consolation for me. Did technology help us meet our information and communication needs? Did it make for better care for my brother and strengthen our relationship? Yes and no. It certainly helped us access and exchange information quickly. It sometimes let us down when we needed to connect with each other or with a particular person on Tim’s care team.

It’s about e-health but it’s not all about e-health. An indelible memory for me is accompanying my brother on the first day of winter to a follow-up visit with my specialist colleague. After exchanging a few sentences of light-hearted sports banter with us, my colleague leaned towards my brother, placed his hand on Tim’s knee and quietly shared with him the bad news about the bronchoscopy biopsies. Then he paused.

Did technology help us meet our

information and communication needs? Did it make for better care for my brother and strengthen our relationship? Yes and no.

That physical gesture is a symbol of the human touch that is an indispensable part of the care we need and the care we need to provide. Given the unresolved technological tensions in our lives, how do we identify and sift digital necessities from digital distractions? What daily practices have we adopted to be able to show up repeatedly to each other in meaningful ways? In other words, how shall we continue to create our best selves – physicians, patients, colleagues, brothers, grandmothers and friends? Dr. Gadget – back to you.

Song of the Day: The music was our non-verbal conversation and a shared pleasure for the two of us. The music continues to be a source of consolation for me.

AMA - ALBERTA DOCTORS’ DIGEST

DR. GADGET

Point of care drug interaction checkers Wesley D. Jackson, MD, CCFP, FCFP

ne of the strengths of the electronic medical record (EMR) of today is the ability to supply clinical decision support in many areas of medicine, including pharmaceutical prescribing. Modern EMRs can warn clinicians of potential drug-drug, drug-allergy and sometimes drug-disease interactions at the point of care and allow for medication adjustment and harm reduction based on this information. Unfortunately, the amount and type of information provided by these tools may be inaccurate or insufficient to make reasonable clinical decisions in the relatively short time spent with our patients, resulting in increased risk and, depending on the EMR, significant time wasted responding to EMR-perceived interactions. Fortunately, several options are available to clinicians to quickly review potential interactions prior to entering them into the EMR or when the EMR is not readily available. After several years using these applications, I would like to share my favorites. Lexi-SELECT, my personal favorite, is a comprehensive evidence-based package covering core drug information, drug interactions analysis, medical calculators, IV compatibility, pregnancy and lactation information, natural products and more. The interaction analysis tool is extremely easy to use, comprehensive and gives rapid access to the type and severity of the interaction. This well organized, informative app is one of the few available at present that includes Canadian medications. Lexicomp online is available through Alberta Health Services (AHS) for those who work in an AHS facility, but it can be activated on personal mobile devices through the AHS Insite website if accessed from within an AHS facility. Once activated, the app is available wherever or whenever needed. The Lexicomp database is also included with any UpToDate subscription which is offered through many primary care networks. The cost for Lexi-SELECT is $215/year USD if no other options are available. Epocrates, a database similar in many ways to Lexicomp, is also available, with a login online and as an app. It is free of charge for basic functions with similar yearly upgrade costs ($174.99 USD) to Lexicomp for advanced features.

The drug information and the interactions analysis available in the free version, while well organized and very easy to use, do not provide the level of detail available in the Lexi package. Canadian medications and dosing are also not available in this app. However, if one is looking for a quick, free drug-drug interaction checker with minimal detail, this solution is a very reasonable alternative. Micromedex is also available for those who work in AHS facilities. It provides drug-drug interactions in a separate app with output detail somewhere between that of Epocrates and Lexicomp. Once again, Canadian medications are not included and general drug information is not available in this app, making it lower on my preferred list. The subscription cost is $3.99/year for interactions only, for those who do not have access to an AHS network.

Several options are available to clinicians

to quickly review potential interactions prior to entering them into the EMR or when the EMR is not readily available.

Drugs.com is a free website and app that supplies interaction checking to consumers. It is well organized and gives good patient level-information, but, once again, does not include Canadian medications. Web MD also includes a similar tool. Your patients may be using these websites or apps to check their own meds. RxTx is a Canadian drug reference app replacing the Compendium of Pharmaceuticals and Specialties, provided by the Canadian Medical Association and produced by the Canadian Pharmacists Association. Interestingly, it does NOT provide a drug interaction checker, making it less useful to the clinician. I hope that future iterations will include this essential tool. Clinicians and patients recognize the potentially avoidable harms associated with medication interactions. Hopefully, these and other modern electronic tools will help to reduce these risks. JULY â&#x20AC;&#x201C; AUGUST 2017

FEATURE Community Information Integration

Providing better access to primary care and community health information Michel G. Donoff, MD, CCFP, FCFP | PROFESSOR

AND ASSOCIATE CHAIR, DEPARTMENT OF FAMILY MEDICINE, UNIVERSITY OF ALBERTA

he Alberta Medical Association (AMA), Alberta Health (AH) and the College of Physicians & Surgeons of Alberta (CPSA) have collaborated to promote the Community Information Integration (CII) Initiative. The goal of this initiative is to improve the continuity of care for Albertans across the health system through better access to primary care and community health information. To achieve this goal, CII will: • Collect health data from all primary care and community clinics in Alberta.

Data can also be aggregated and available for secondary use. Some CIHI data fields are already loaded onto Netcare, such as lab and diagnostic imaging results. These will not be duplicated onto Netcare. Text and narrative notes made by clinicians will not be uploaded from the EMR. One of the considerations with uploading CIHI data elements for clinical sharing, is to avoid overloading or cluttering Netcare and at the same time providing useful clinical reports. The Community Encounter Digest report will be a summary of the relevant information from community encounters for the prior 12 months. The format and content of community integration reports will evolve guided by clinical experience.

• Present this data in Alberta Netcare through clinically relevant reports. • Make this data available to appropriate stakeholders for secondary use (quality improvement, population health planning and research). The principles to guide this work include: • Keep it simple and move quickly. • Learn and evolve rather than wait for the perfect solution.

In the future, when resources and

supports are available, new functionalities of community integration may include better access to patient summaries and comprehensive patient-centered care plans.

• Collect data once and use it for all eligible purposes. • Minimize impact on clinics and providers. The selection of data to be extracted from community electronic medical records (EMRs) put priority on avoiding disruption of clinical workflows. The initial phase of CII will upload three kinds of data: 1. Canadian Institute for Healthcare Improvement (CIHI) Pan-Canadian EMR standard data fields. Seventy-eight data fields will be extracted from the community EMRs on a daily basis and go to a community data hub where some of the data will be formatted into reports for sharing on Netcare. Examples of CIHI data fields include patient identifier (PHN), birthdate, gender, provider name, role, expertise, clinic location, clinical observations (immunizations, allergies, blood pressure, height, weight and diagnostic assessment).

AMA - ALBERTA DOCTORS’ DIGEST

2. Canadian Primary Care Sentinel Survey Network (CPCSSN) data will be uploaded and integrated with the CII Initiative. Many Alberta family physicians have experience with CPCSSN data processes already, and are demonstrating minimal disruption to practice and producing high quality validated patient information. The expanded integration of CPCSSN promises to increase development of new case resources and improvement of timely access. Clinicians will obtain CPCSSN dashboards to assist identification of clinical needs within their patient panels. 3. Community-based specialist consultation letters. Community-based specialists will be able to upload a copy of a patient consult report to Netcare as a PDF document. >

> Surveys of Albertans show the majority (greater than 80%) support automatic sharing of their community health care data. However, most clinicians anticipate that sometimes information or encounters will be sensitive to some patients. The CII Initiative will allow clinicians to respect patient wishes for specific encounters or longer term preferences.

In the future, when resources and supports are available, new functionalities of community integration may include better access to patient summaries and comprehensive patient-centered care plans. Some of these activities might become part of the patientcentered medical home relationship with patients. However, the initial and careful limited scope of the CII Initiative is necessary to engage patients and providers with safe and efficient IT evolution. Successful evolution of community IT effectiveness will require ongoing patient and provider oversight and stewardship. To this objective, Alberta Health has implemented two new committees with significant provider and patient participation to review and advise on effective policies and operations for community information sharing. The Health Quality Council of Alberta will be conducting an independent evaluation of the CII Initiative. Alberta Health, AMA and CPSA will also be providing feedback to community physicians based on the results of the evaluation. Ongoing physician and public discussion about improving safety and quality of community information sharing is underway!

PHYSICIAN(S) REQUIRED FT/PT Also locums required

ALL-WELL PRIMARY CARE CENTRES MILLWOODS EDMONTON Phone: Clinic Manager (780) 953-6733 Dr. Paul Arnold (780) 970-2070

JULY â&#x20AC;&#x201C; AUGUST 2017

FEATURE How do patients feel about accessing their health information through an online portal? An early report on real-life experience Tim Graham, MD, MSc, CCFPEM, CPHIMS-CA | ASSOCIATE

CHIEF MEDICAL INFORMATION OFFICER, EDMONTON ZONE, ALBERTA HEALTH SERVICES CLINICAL PROFESSOR OF EMERGENCY MEDICINE, UNIVERSITY OF ALBERTA

cross the world, patients desire electronic access to their health information, and a trend is growing to facilitate this through web-based patient portals (PPs). Canada Health Infoway data show that approximately 80% of Canadians want access to their health records or other digital health solutions. In Alberta, public availability of self-serve health information is upon us and it will be a large change for many practitioners. For the last 18 months, seven clinics in the Edmonton Zone have piloted PP called eCLINICIAN MyChart (MyChart). About 1,600 patients across seven clinics in family practice, rheumatology, diabetes, gastroenterology, multiple sclerosis, addictions and mental health have been testing MyChart with highly encouraging results. In general, PPs can be categorized as those designed for, and bundled with, a particular electronic medical record (tethered PP) and those designed to collate information from many different sources (vendoragnostic or untethered PP). In Alberta, we already have both approaches. The greatest experience with tethered portals rests with American organizations such as Beth Israel Deaconess Medical Center, the Veterans Health Administration and Kaiser Permanente, although early pilots are happening in a number of Canadian jurisdictions, including the Children’s Hospital of Eastern Ontario in Ottawa. Examples of vendor-agnostic portals include the National Health Service in England and the Alberta Personal Health Portal (myhealth.alberta.ca). Tethered portals have inherent advantages. Most importantly, they seamlessly share data with whatever electronic medical record (EMR) they are tethered to, making deployment less complex and expensive relative to vendor-agnostic portals that need multiple interfaces.

AMA - ALBERTA DOCTORS’ DIGEST

Currently, in the Edmonton Zone of Alberta Health Services there are 650 physicians, 150 residents, 1,000 nurses and 4,000 other staff across more than 150,000 monthly appointments using a shared EMR called eCLINICIAN. It shares a single, patient-centric database among all users, and it is interfaced to most laboratory and diagnostic imaging (DI) centers in the Edmonton Zone. The data are now available to be shared with patients directly through the MyChart PP.

MyChart allows patients to access

all of their laboratory, DI and microbiology results dating back to 2006, as well as summary information about medications, allergies and medical problems.

After careful forethought, multi-stakeholder policy development, and privacy and confidentiality work, MyChart allows patients to access all of their laboratory, DI and microbiology results dating back to 2006, as well as summary information about medications, allergies and medical problems. During an office visit, patients can be offered MyChart, their email recorded in the EMR and the sign-up process completed at home. Once signed on, patients can do the following: • Create, modify, view and get reminders of appointments. • Exchange secure messages to health care providers or their staff. • Fill out pre-visit questionnaires. • Establish designated access for family members. >

> To implement MyChart, it was important to work closely with physicians. Physicians understandably expressed initial concerns: • How would patients react if they see critical results faster than physicians did? • Would patients be unnecessarily concerned about subtly abnormal results or abnormal results that are “normal” for them? • Would physicians be bombarded by trivial patient messages? • How will the doctor-patient relationship be affected?

we developed policy that enabled most lab tests to appear in MyChart in real time, with a small number of specific tests (e.g., hepatitis and HIV serology, radiology tests) released with a 10-day delay. To date, user assessment of MyChart has been extremely positive. The vast majority of patients are extremely satisfied (more than 90%) with MyChart and find it easy to use (more than 85%). As a result of using MyChart, patients feel generally closer to their care teams and more empowered over their health. In general, physicians also report feeling extremely positive, with one physician saying, “It is the single most positive practice change seen in the last 20 years.” The self-scheduling functions have led to some tangible effects:

As a result of using MyChart,

patients feel generally closer to their care teams and more empowered over their health.

• There has been a 40% relative reduction in missed appointments. • 50% of MyChart users say they avoided an in-person encounter. • 3% avoided an emergency or urgent care visit.

We established a highly clinically oriented working group and had many discussions surrounding these issues and how to deal with them. Most concerns were shared with clinicians from other jurisdictions and solutions were easily identified in the current literature regarding PPs. Each clinic had a physician champion and a document that guided the benefits evaluation plan. Ultimately,

These preliminary results are very strong and promising, and would represent important health system benefits if scalable. Currently, what is still unknown is the overall effect of making PPs more widely available in clinical practice in Alberta. Determining this is now a priority, as patients continue to demand electronic access to their health information and the provincial clinical information system will make a widespread PP a reality.

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JULY – AUGUST 2017

FEATURE

Many Hands™ on the front lines Calgary surgeon travels to Iraq to care for people living amidst the horrors of war

osul, a large city in northern Iraq, is caught in an ongoing, bloody battle between the Iraqi forces and Islamic State militants. The human toll has been devastating and has created a desperate need for medical and humanitarian aid. Dr. Jeffrey Way, a Calgary trauma surgeon, recently travelled to the area as part of a Samaritan’s Purse mission to help meet that need. “I’ve done previous missions with Samaritan’s Purse, including to Haiti to deal with a cholera outbreak,” explains Dr. Way. “They had acquired an emergency field hospital that they wanted to set up near Mosul to deal with the injured and they contacted me.” Although he was prepared to deal with the serious injuries you would expect in an active war zone, he was still stunned by the brutality of the injuries. “We were dealing with people who were mortally wounded. Landmines, drone attacks, rockets and sniper fire were common, and that resulted in a lot of severe head and neck trauma, open chest and abdominal wounds, and amputations. And many of those patients were children.”

Here we were, in this field hospital,

in the middle of nowhere, looking after trauma after trauma and it was amazing how well it worked.

The field hospital was the only facility in the active war zone. It was equipped with two operating rooms, but was without many of the resources Dr. Way would have at home. “One of the biggest issues is that we didn’t have narcotics, so pain management was difficult. But the patients were so happy to be alive and so grateful that we were there, they really didn’t complain.”

AMA - ALBERTA DOCTORS’ DIGEST

This field hospital was the only facility in an active war zone in lraq. lt was equipped with two operating rooms, but was without many of the resources Dr. Jeffrey Way would have at home.

Dr. Way’s daughter, Emily, an ICU nurse based in Red Deer, joined him on the three-week mission, which made the work additionally rewarding. Dr. Way and his daughter were grateful for the opportunity to help and both were surprised by how much they were able to do. “Here we were, in this field hospital, in the middle of nowhere, looking after trauma after trauma and it was amazing how well it worked.” >

> “We never felt that we were in danger while we were in the hospital because it was so heavily guarded. The only time we felt any fear was in transit to the airport.” Dr. Way and the other physicians on the mission spent time training locals so that they will be ready to take over the facility when the time comes. In the meantime, the organization welcomes donations and volunteers – medical and otherwise – who can help them continue their work.

“Most of the people there don’t want to be involved in the fighting,” says Dr. Way. “They just want to raise their families and live their lives. There’s a huge humanitarian crisis out there, and if we have the power to help, we need to do what we can.”

Share your story! We’re looking for stories from Alberta physicians who are volunteering their medical and/or other skills to make a difference. Whether it’s helping out in your community or traveling across the world to provide care to those in need, we’d like to feature your story as part of our Many HandsTM initiative! Send the details to Vanda Killeen at vanda.killeen@albertadoctors.org. The Alberta Medical Association established Many HandsTM to celebrate how simple actions can lead to big changes. Read the inspiring stories of your colleagues at www.albertadoctors.org/advocating/ many-hands.

AMA Physician Locum Services

Locums needed. Short-term & weekends. Family physicians & specialists. Dr. Jeffrey Way travelled to lraq as part of a Samaritan's Purse mission to help meet a critical need.

Experience: •

Flexibility – Practice to fit your lifestyle.

•

Variety – Experience different Alberta practice styles.

•

Provide relief – Support rural colleagues and rural Albertans.

•

Travel costs, honoraria, accommodation and income guarantee provided.

CONTACT: Barry Brayshaw, Director, AMA Physician Locum Services ®

barry.brayshaw@albertadoctors.org T 780.732.3366

TF 1.800.272.9680, ext. 3366

www.albertadoctors.org/pls

JULY – AUGUST 2017

IN A DIFFERENT VEIN

Interview with Captain Canada at 150 lt's been 50 years since your last performance review Alexander H.G. Paterson, MB ChB, MD, FRCP, FACP | CO-EDITOR

aterson: Sit down, Captain Canada. Fifty years, isn’t it, since our last review? Recently, problems have been cropping up with your assessments, work and reputation. There’ve been complaints. Shall we start?

Captain Canada: Fire away, dude. Don’t mind me sayin’ all of us national image guys have noticed you Alberta dudes getting crotchety lately. Paterson: Do you want the good news or the bad news first?

merchants in Montreal. And in school we knew about the Quebec Act which our history teacher said was a remarkably civilized act where the French were not lined up against a wall and shot, but were allowed to keep their language, religion and cultural practices.

Sit down, Captain Canada. Fifty years, isn’t

it, since our last review? Recently, problems have been cropping up with your assessments, work and reputation. There’ve been complaints.

Captain Canada: I’ll take the good news, buddy. Paterson: OK. The late Robin Williams said before he died, “You are a big country. You are the kindest country in the world. You are like a really nice apartment over a meth lab.” And Craig Ferguson, comedian and late show host said, “Canada is not the party. It’s the apartment above the party.” Captain Canada: That’s the good news? Paterson: Seems like these guys think there’re no drug problems here. Never mind. Listen. Remember my girlfriend and I came to look at you when you were 102 years young, in the long, hot summer of ’69? Montreal was glamorous and we watched the moon landing on television while in Saint-Bruno; we ate exotic food from paper plates at Expo '67 and rode the rollercoaster, gasping at that turn that steered you clear of a plunge into the St. Lawrence River. The bars were exciting, everyone smiling … except … on ordering a beer at a quiet bar on Rue de Montagne, a woman leaning on the bar smoking a cigarette snarled at me. “Et, toi, parle Francais, connard …” And earlier, to a boy at school in Edinburgh, Canada, was a vast wheat-filled granary, studied in daydreamy geography lessons through which canoe-paddling, laughing, singing French guys lugged furs to the Scots AMA - ALBERTA DOCTORS’ DIGEST

It was also a land that each Christmas was the source of ribbon-tied boxes, which you carefully unwrapped saving the precious paper: a tie from Eaton’s or a bar of soap with a Mountie stamped on it. But one year, one marvellous year, there was a View-Master, which you held up to the light and looked through like binoculars. You inserted a circular disc of tiny pictures, clicked a lever at the side and the tiny pictures sprang to threedimensional life. Canada now became a land of Niagara Falls and, best of all, a land of Banff’s Indian Days and the Rocky Mountains. Forgive my nostalgia. And in my father’s 1927 Chum’s Annual, a great tome of a book like a family Bible, were two great stories: “Cowboys of Alberta” by the Arizona Kid and “Nanook of the North.” Canada was the land of adventure. But where are the Mohawks and Nanook of the North now? You understand my nostalgia? And Canada at 150? I was puzzled when the Meech Lake Accord was being negotiated by the Mulroney government that there was no Indigenous representation and not surprised when Elijah Harper stood up in the Manitoba Legislature and closed the accord down. Don’t our politicians know their own history? If they’d a basic knowledge of the treaties signed, the handshakes and >

> pipes of peace, we might have had a noble story to tell. You’ve squandered that. Captain Canada: Ah! I can explain. We underestimated the French mood and the Indigenous guys back then. We’ve sorted it out. More Anglophone kids speak French now and the French run Canada. You know the little joke: "Canada had a great future – British administration, American know-how and French culture … but what we’ve got is French administration, British know-how and American culture.” Well, turned out the guy who said that was right, my friend. And the First Nations guys perform at all our opening ceremonies. Paterson: Oh, big deal. Canada was confident in the 1960s: wheat, oil, minerals, fish, cattle, a milk and honey land, a land where they liked children (even babies), the boyhood land of Mike Myers (alias Austin Powers). Mike now wants us to return to the time of his suburban Toronto childhood in the early 1970s, a golden era when John Lennon discussed with Pierre Trudeau how to change the world and even modest families had a cottage on Lake Simcoe. The future seemed Canada’s to mold – a comfortable, predictable land, envied by the world, the nasty parts half-hidden, waiting. Captain Canada: Mike Myers is a good friend of mine. And we’re working on it. Look, mistakes were made. The First Nations lobby is really powerful now. They can stop your leaky pipelines from being built. Paterson: And that’s an advance? There’s now a silly debate going on among the Ontario latte-rati about “cultural appropriation,” the idea being that unless you’re a member of a cultural group, you shouldn’t pirate others’ cultural trappings in your writings. The blabber got out of hand when a humor-lite CBC administrator, in a fit of hilarious wit, suggested there should be a prize for the best cultural appropriation piece of writing. Resignations, craven apologies and mea culpas. If there had been more real humor and less smugness, I’d be sympathetic. But no, I’m on the side of the pissed-off Indigenous artists who’ve had enough of the character stereotyping, the copying of totem poles and emblems of eagles, salmon and grizzlies, or the cloying reverence for their common-sense native philosophy from writers looking for a Canadian subject to write about other than losing their virginity at the lakeside cottage. The late, great, Margaret Laurence knew how to write Indigenous characters into her novels. Captain Canada: You’re right about the CBC, but this is getting boring. And I don’t like your tone. Are we done? Paterson: No. Sit down. So what has Canada come to in 2017? First, can we blow up a few Canadian identity canards? Canadians are not especially nice or polite. Californians, Spaniards, Texans and Western Samoans are just as polite.

Paterson: And the grunt “eh” is not a unique feature of Canadian speech and is uttered in at least 158 other countries in the world (sorry, planet). Captain Canada: Wrong, big guy. Listen to a couple of real Canadian dudes like Bob and Doug McKenzie, and I quote them: “Whoever said ‘Do the job right the first time and you’ll never have to do it again’ never shovelled snow off a Canadian driveway, eh?” That final “eh” is pure Canadian, man. And they’re right on the money with those wise words. Paterson: And Medicare is not a unique feature of Canadian life; at least 158 other countries have a form of Medicare. Captain Canada: You’re getting close to me dukin’ you on the snotlocker, my friend. Canadian Medicare is the fairest system in the world. It’s what glues our country together. Stops jerks like you shelling out to get to the front of the line.

Canada was confident in the 1960s:

wheat, oil, minerals, fish, cattle, a milk and honey land, a land where they liked children (even babies), the boyhood land of Mike Myers (alias Austin Powers).

Paterson: Oh come on, wise up. I can get to the front of the line just by going to the USA. And then there’s an opinion in central Canada and among younger adults that Canada’s traditional role in the world has always been as nice “peacekeepers.” While we can be proud of achievements in that field, the history is different. The Royal Canadian Air Force and Canadian regiments have been among the hardiest fighting outfits in recent military history, especially the achievements of the Air Force in the Second World War. Pilots and navigators were regularly seconded to the Royal Air Force and US Air Forces as trainers and leaders. And Vimy Ridge … enough said. On a sobering note, a major of the Argyle and Sutherland Highlanders, a Scottish regiment, told me that in the advance of the allies across France, the Argyle’s officers worried about sending the Canadian regiments ahead because of their reputation for taking no prisoners. Captain Canada: Never heard that and I don’t believe you, but you’re right on about the last war. Seen the movie Allied with Brad Pitt as the Ontario airman hankering after a ranch outside Medicine Hat? >

Captain Canada: Hey, take off, hoser; we’re politer than New Yorkers, Scots, Germans and Sicilians.

JULY – AUGUST 2017

> Paterson: Yeah, yeah, yeah ... OK it’s platitude time. This is a country of immigrants, so to be a Canadian is to live in a place where people wear coats of many colors; it’s not a salad, more like an oil painter’s palette with some colors mixing together more than others. And there’s still a tussling British and French politicoadministrative structure with English Common Law and French Napoleonic Law side-by-side. Captain Canada: Buddy, we still trust our politicians – not what they say, of course – but we trust that by and large they don’t have their snouts directly in the piggy bank, mainly because we keep vigilant close watch on them – except for the senate, of course. You can’t say that about most countries. Hey, this is getting boring, pal. Haven’t you any questions about real people … like Justin. Most of the world’s women have the hots for our prime minister and that’s what’s important for Canada.

Most of the world’s women

have the hots for our prime minister and that’s what’s important for Canada.

Paterson: Oh, grow up … the worry is about the direction of current Canadian politics toward vote-buying regional favoritism with disregard for the national interest – the smiling oblivion about the distress of Alberta unemployment with transfer payments still going east. Imagine the billions in relief funding that would have poured into Ontario, Quebec or the Atlantic provinces in the same position. And the proposed transfer of the National Energy Board from Calgary to Ottawa is a nice polite kick in the teeth. Where do you think the high standard of living in Canada comes from? Weed? Captain Canada: People love to lend us money but OK, OK, you have a point. Paterson: The clenched fist here is freedom of speech, but political correctness is on the rise, especially in universities. Captain Canada: Hey, take off, hosehead. If you want to say or write anything here you can do it without being beaten up or shot in the head. But then you also have to listen to or read the ravings of crackpots, fools and hucksters like you. And by the way it’s meant to be me doin’ the talkin’. Paterson: Tell me about class distinction in Canada. Captain Canada: Listen knobhead. That only applies to water closets on flights where they’re called “toilets” in first and biz, and lavatories for the rest. Class distinction

AMA - ALBERTA DOCTORS’ DIGEST

is money-based. There are two main classes: “the rich” and “the middle class.” There are also “the indigent,” “the poor,” the “street people” who may also be “middle class” or sometimes sons and daughters of “the rich.” These classes are not hereditary and you can move freely from one class to another in the space of a lifetime. Many Canadians are class unconscious, even ignorant and some would happily wear a baseball hat back to front while meeting the Queen in Buckingham Palace. Paterson: What about our top academics? Captain Canada: We have a beautiful disregard for the spoutings of academics in Canada, an amused, disrespect. Premier Notley, for example, herself a university-trained lawyer, dissected the current leader of the BC Green Party, the Cambridge-trained, career climate-alarmist and waffler, Andrew Weaver, by calling him “a tenured professor with no knowledge of the working man or woman.” Paterson: In Britain, you get called “prof” which has a modicum of respect; in Germany you can get called “Herr Doctor Professor,” which may be unctuous. Captain Canada: Here’s advice for you, toe-rag. In Canada, a red flag should go up if anyone says to you: “And what do you think, professor?” Paterson: Thanks. Why are Canadians so interested in tools? Captain Canada: OK, a real Canadian is fascinated by tools of any kind and will try to learn the function of each and every one. My friend, Joe, said: “Best moments in my life are when I find a tool I didn’t realize I could find a use for.” Canadians will seek a tool for everything: remotely warming the car in winter, scrambling an egg while still in its shell, adjusting the snow chute angle of a snowblower or lifting a golf ball out of the hole without bending down. Paterson: Tell me, then, what Canada at 150 is really about. Captain Canada: Duh … it’s the land: the Rocky Mountains; Muskoka lakes; the seas and rivers; the Arctic tundra; the vast carpets of firs; the deer, eagles, seals and salmon; the unique buildings (from the teepee to the Ukrainian barns to Fort Calgary to Chateau Frontenac); the political, legal and scientific heritage; the art, architecture and literature (Margaret Laurence, Robertson Davies, WO Mitchell, Group of Seven); our remarkable tolerance for difference (like putting up with people like you); famous Canadians (Dr. William Osler, Lucy Maud Montgomery, Terry Fox, Justin Bieber … hey, scratch that last one); the desire to be self-sufficient; the desire for peace but willingness to fight for it. That’s what Canada is, and what a Canadian is, at 150. Did I pass? Paterson: Barely. You’ve work to do. I think we should have another review next year. Make it annual.

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Our team works with other health care professionals and a pharmacy is on site to provide enhanced patient care. Flexible hours and competitive fee. Only qualified candidates will be contacted: Contact: Dr. Salim Hamid T 403.457.1953 psychiatry.consult@telus.net to submit your CV CALGARY AB Sante Medical, an established medical aesthetics centre in Calgary is looking for an experienced MD injector/dermatologist to join its practice and must be licensed with the College of Physicians & Surgeons of Alberta, fellow of the Royal College of Physicians and Surgeons of Canada, or eligible for fellowship with experience in dermatology/ cosmetic injectables. Our clinic offers flexible clinic hours, competitive compensation and benefits, and tremendous opportunities for growth. Contact: careers@santemedical.ca to send email inquiries/resume/CV CALGARY AB Med+Stop Medical Clinics Ltd. has immediate openings for part-time physicians in two of our Calgary locations. Our family practice medical centres offer pleasant working conditions in well-equipped modern facilities, high income potential, low overhead, no investment, no administrative burdens and quality of lifestyle that is not available in most medical practices. Contact: Marion Barrett Med+Stop Medical Clinics Ltd. 290-5255 Richmond Rd SW Calgary AB T3E 7C4 T 403.240.1752 F 403.249.3120 msmc@telusplanet.net

CALGARY AB Pristine Health is looking for family physicians and specialists to join our clinic. We offer Med Access electronic medical records, competitive overhead split (75/25) and opportunity for partnership. We have a branch each in north and south Calgary. We can help with transitioning from another clinic and provide relocation assistance. Contact: T 403.402.9593 pristinehealthclinic@gmail.com CALGARY AB Nuwest Medical Centre seeks family physicians and specialists. This is a newly built modern exciting location in Calgary. Physician owned and managed, well known for its high level of efficiency and great service. One block north of the Kirby C-station in the affluent west end neighborhood of Calgaryâ&#x20AC;&#x2122;s downtown, a busy residential and commercial location, making it an ideal location to build a busy practice. We are expanding our clinic hours in a few months and will need part- or full-time physicians with an interest in family practice or walk-in practice. Other specialties such as internal medicine and pediatrics will be considered as well. We provide Accuro electronic medical records and a well-managed practice. Competitive overhead split will be offered to help build and establish your practice. Contact: Dr. Nabil Elkabir T 403.993.6442 nabilelkabir@hotmail.com CALGARY AB Pain specialist Dr. Neville Reddy is looking to recruit physicians (general practitioners and specialists) to join his team of dedicated health care professionals. Innovations Health Clinic has two locations (southeast and southwest); favorable 25% expenses offered. >

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Contact: Neville Reddy, MB ChB, FRCPC (Anesthesia) T 403.240.4259 C 403.689.4259 nreddy@innovationshealth.ca www.innovationshealth.ca CALGARY AB An exciting opportunity is available for family physicians and specialists to join Revolution Medical Clinic. We are located in the bustling Signal Hill Shopping Centre. Come and join the most modern and innovative clinic in southern Alberta. We offer a very competitive fee split in exchange for a superior patient-focused approach. Part- or full-time, flexible hours to accommodate work/life balance, very competitive fee split. Possible partnership opportunity available to committed members of our team. Contact: Dr. Riyaan Hassen C 403.688.7867 rhpc@shaw.ca CALGARY AB Silver Springs Medical Centre is a brand-new family and walk-in clinic in northwest Calgary. A very exciting opportunity for family doctors looking to build a new practice as well as physicians with an existing panel. We offer a very competitive fee split, flexible hours, part- and full-time positions available. Ideal location with accessible diagnostic imaging clinics, pharmacy and Calgary Laboratory Services clinic nearby. Contact: Dr. Alvin Adriano T 403.612.3482 CALGARY AB Become part of the success of a new family practice/walk-in clinic in a sought-after Calgary location. Wellspring is seeking dedicated, enthusiastic, engaging, positive and eligible physicians to join this newly branded clinic opening this fall. The income split is very attractive, competitive and no hospital on-call. This is a fully computerized turn-key office. Contact: wellspringfamilyclinic@gmail.com to send your resume and cover letter

AMA - ALBERTA DOCTORSâ&#x20AC;&#x2122; DIGEST

CALGARY AND EDMONTON AB Retiring? Semi-retiring? Want someone to take over your panel? Imagine Health Centres (IHC) is growing and welcomes semi-retired and/or retired physicians who want to ensure continuity of care for their patients. Come work part- or full-time and allow us to introduce ourselves to your patients. Imagine Health Centres are multidisciplinary family medicine clinics with a focus on health prevention and wellness. IHC prides itself in providing the best support for family physicians and their families in and out of the clinic. Health benefit plans and full financial/tax/accounting advisory services are available to all IHC physicians. Do you want your patients to be cared by a team that collaborates with other health care professionals for enhanced patient care? If so, contact us. Contact: Dr. Jonathan Chan to submit your CV in confidence corporate@imaginehealthcentres.ca www.imaginehealthcentres.ca EDMONTON AB Flexible, full-time physician opportunities available. Queen Street Medical Management (QSMM) has exciting opportunities with four clinics to choose from throughout the greater Edmonton area. With over 40,000 patients, QSMM provides a platform to expand your goals. Friendly and experienced staff. Ownership opportunities. Created by physicians for physicians. Join QSMM today. Contact: MD Recruitment mdrecruitment@qsmmgroup.ca EDMONTON AB Belmead Medical Centre is a busy, well-established west Edmonton clinic seeking part- and full-time physicians. Fee-for-service with flexible terms and hours, and affiliated with Edmonton West Primary Care Network with in-house nurse. Experienced staff and great mix of patients. Contact: Dr. Peter Hum T 780.481.8812 jwcchiu@telus.net

EDMONTON AB Capstone Medical Clinic is a brand-new family medicine clinic in west Edmonton. It is in close proximity to an assisted-living facility, diagnostic imaging and multiple pharmacies. This is an ideal location for family doctors looking to build a new practice, as well as physicians with an existing panel. Both part- and full-time positions are available. Clinic hours are flexible and payment is fee-for-service. We use TELUS Health Solutions (Wolf) electronic medical records. We are part of the Edmonton West Primary Care Network (PCN) and have access to a PCN nurse on site. Interested physicians must be licensed with the College of Physicians & Surgeons of Alberta. Contact: Dr. Christopher Gee T 780.708.3012 info@capstonemedicalclinic.com EDMONTON AB MD Group Inc.â&#x20AC;&#x2122;s Lessard Medical Clinic and West Oliver Medical Clinic, each with eight examination rooms, are looking for full-time family physicians and specialists. West Oliver Medical Clinic, located in a great downtown area, 101-10538 124 Street and Lessard Medical Clinic in the west end at 6633 177 Street, Edmonton. Clinic hours are Monday to Friday 8:30 a.m. to 8:30 p.m., Saturday and Sunday from 10 a.m. to 5 p.m. The physician must be licensed with the College of Physicians & Surgeons of Alberta (CPSA). Qualifications must comply with the CPSA license requirements and guidelines. The physician income will be based on a fee-for-service arrangement with an average annual income of $300,000 to $450,000. MD Group can offer you competitive overhead splits for long term commitments. Essential medical support and specialists are employed within the company and are managed by an excellent team of professional physicians and supportive staff. We use Healthquest electronic medical records and maintain membership with the local primary care networks. >

Benefits and incentives to the employment within our group include the convenience of multiple locations around Edmonton to support your living arrangements, part- and full-time schedules available, staff familiarized with primary care programs and promotion, support staff including nurses for physicians' patients to provide one-on-one care, on-site diabetic management care and comprehensive medical follow up visits. Therapists within our clinic provide priority consults and on-site respiratory lab. Seminars and dinner workshops are well documented and monitored for CME credits. Flexible hours, vast patient populations at both locations, continuing care and learning opportunities for accredited physicians. Full-time chronic disease management nurse to care for co-morbidity patients, billing support staff and attached pharmacy are available. Work with friendly and dedicated staff, nurses available for doctor’s assistance and referrals as well as on-site mental health and psychology services. Contact: Stephanie Harris Operations Manager MD Group Inc. T 780.756.3090 F 780.756.3089 mdgroupclinic@gmail.com EDMONTON AB Two positions are immediately available at the West End Medical Clinic/M. Gaas Professional Corporation at unit M7, 9509 156 Street, Edmonton AB T5P 4J5. We are also looking for specialists, internist, pediatrician, gynecologist and orthopedic surgeon to join our busy clinic. Full-time family physician/general practitioner positions are available. The physician who will join us at this busy clinic will provide family practice care to a large population of patients in the west end and provide care to patients of different age groups including pediatric, geriatric, antenatal and prenatal care. Physician income will be based on fee-for-service payment and the overhead fees are negotiable. The physician must be licensed and eligible to apply for licensure with the College of Physicians & Surgeons of Alberta (CPSA); qualifications and experience must comply with the CPSA licensure requirements and guidelines.

We offer flexible work schedules, so the physician can adopt his/her work schedule. We also will pay up to $5,000 to the physician for moving and relocation costs. Contact: Dr. Gaas T 780.756.3300 C 780.893.5181 F 780.756.3301 westendmedicalclinic@gmail.com

EDMONTON AB To meet our growing needs, we have a practice opportunity for a pediatrician at the Parsons Medical Centre. The clinic is in south Edmonton and is a high patient volume clinic. You can enjoy working in a modern environment with full electronic medical records, friendly reliable staff for billing, referrals, etc., as well as an on-site manager. Parsons serves a large community and wide spectrum age group (birth to geriatric). The Parsons Medical Centre has a pharmacy on-site, ECG machine and offers a large array of specialist services. Parsons Medical is a member of the Edmonton Southside Primary Care Network which allows patients to have access to an on-site dietitian and mental health/psychiatry health services. Overhead is negotiable, flexible working hours and open seven days a week. Contact: Harjit Toor T 587.754.5600 manager@parsonsmedicalcentre.ca EDMONTON AB Windermere’s newest clinic is looking for physicians to start as soon as possible. Imagine Health Centres (IHC) newest clinic, Currents of Windermere is a top-notch, high-profile retail development within the proximity of Riverbend and McGrath. A multidisciplinary family medicine clinic with a focus on health prevention and wellness, IHC prides itself in providing the best support for family physicians and their families in and out of the clinic. Health benefit plans and full financial/tax/accounting advisory services are available to all IHC physicians.

We are looking for part- and full-time family physicians. Imagine Health Centres has an excellent opportunity to take over existing patient panels at our Edmonton locations. Do you want to be part of a team that collaborates with other health care professionals for enhanced patient care? Do you want to make a difference in your patients’ care and take a proactive instead of a reactive approach to health care? Compensation is fee-for-service and inquiries are kept strictly confidential. Only qualified candidates will be contacted. Contact: Dr. Jonathan Chan to submit your CV in confidence corporate@imaginehealthcentres.ca www.imaginehealthcentres.ca HIGH RIVER AB Pediatrician wanted for Charles Clark Health Clinic. High River is interested in adding a pediatric service within its LEED certified building that currently includes 13 family physicians. An additional nine family physicians and two obstetricians are also practicing in the community of 13,500 located 30 minutes south of Calgary. Leasehold improvements are included and there are opportunities to share the space. Contact: Dr. Ron Gorsche Charles Clark Health Clinic T 403.652.2929 rgorsche@telusplanet.net PINCHER CREEK AB Seeking a general practitioner surgeon to join the Associate Clinic in Pincher Creek. The Associate Clinic is seeking a full-time GP surgeon to join our dynamic family practice. Our current nine physician team includes two GP surgeons, two GP anesthetists and one endoscopist. Our entire physician team practices obstetrics and works together as a cohesive group both in clinic and hospital. The Associate Clinic in Pincher Creek is a rural primary care clinic that strives to provide excellence in primary care and urgent care for the community and enable patients to be partners in the management of their health care. Our clinic is co-located with the local hospital in rural southwestern Alberta. >

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We serve Pincher Creek and the surrounding communities, including many residents of the nearby Piikani Reserve, Cowley, Lundbreck and Waterton Park – approximately 10,000 patients. We also operate a satellite clinic on the Piikani Reserve and provide service to Vista Village (a Good Samaritan designated assisted living facility) and Crestview Lodge. Services are provided through the clinic by a team comprised of nine physicians, registered nurse, licensed practical nurses, medical office assistants, social worker, dietician, pharmacist, respiratory therapists, receptionists, resident physicians and medical students. Administrative supports include on-site billing, medical transcription, third-party billing and an IT database expert. Our physicians enjoy practicing in an environment that has low physician attrition and potential for high income in a clinic which has been secured through a favorable, long-term lease. The right person to join our team will be a family physician with enhanced surgical skills/GP surgery skills. Family physicians with the desire to complete enhanced surgical skills training may also be considered. Responsibilities will include performing Caesarean sections and other low-risk surgical procedures, assisting visiting orthopedic and general surgeons, as well as providing surgical and emergency on-call services for our rural community. Contact: Jeff Brockmann T 403.632.2100 jbrockmann@pinchermedical.ca

PHYSICIAN AND/OR LOCUM WANTED CALGARY AB Innovative multidisciplinary medical clinic is offering a rare opportunity for a family physician to take over a patient panel and practice in vibrant downtown Calgary. Imagine Health Centres (IHC) is currently looking for family physicians and specialists to come and join our dynamic team in part-time, full-time and locum positions in Calgary. Physicians will enjoy extremely efficient workflows allowing for very attractive remuneration, no hospital on-call, paperless electronic medical records, friendly staff and industryleading fee splits. AMA - ALBERTA DOCTORS’ DIGEST

Imagine Health Centres are multidisciplinary health clinics with a focus on preventative health and wellness. Come and be part of our team which includes family physicians, physiotherapists, psychologists, nutritionists, pharmacists and more. Imagine Health Centres prides itself in providing the very best support for family physicians and their families in and out of the clinic. Health benefit plans and full financial/tax/accounting advisory services are available to all IHC physicians. There are also limited time opportunities in our other locations in Calgary, Edmonton and Red Deer. As a family physician, Imagine Health offers an opportunity to build your practice in an environment that emphasizes physician happiness, well-being and work-life balance. To us, that means a few things such as exceptional spaces, unique and innovative technology, top-notch support staff, industry-leading staff-physician ratios, well-managed administration, work flow and billing optimization, attractive compensation package, medical business/ investment opportunities and flexible schedule. In summary, our people, technology and spaces are designed to let you focus on being an effective clinician first and foremost. Don’t miss the opportunity to join our talented and friendly team. The successful candidate must possess the following: effective interpersonal skills and the ability to work in a team environment; current license to practice medicine from the College of Physicians & Surgeons of Alberta or active license in any Canadian province. All applicants will be considered. We offer a competitive remuneration. If you are interested in this great opportunity with Imagine Health Centres, please send your resume along with any other credentials you may have and label the subject line: Physician/family doctor position. Contact: Dr. Jonathan Chan to submit your CV in confidence T 403.910.3990, ext. 213 corporate@imaginehealthcentres.ca www.imaginehealthcentres.ca

CALGARY, EDMONTON AND RED DEER AB Imagine Health Centres (IHC) is currently looking for family physicians and specialists to come and join our dynamic team in part-time, full-time and locum positions in Calgary, Edmonton and Red Deer. Physicians will enjoy extremely efficient workflows allowing for very attractive remuneration, no hospital on-call, paperless electronic medical records, friendly staff and industry-leading fee splits. Imagine Health Centres are multidisciplinary health clinics with a focus on preventative health and wellness. Come and be part of our team which includes family physicians, physiotherapists, psychologists, nutritionists, pharmacists and more. Imagine Health Centres prides itself in providing the very best support for family physicians and their families in and out of the clinic. Health benefit plans and full financial/tax/accounting advisory services are available to all IHC physicians. There is also an optional and limited time opportunity to participate in equity opportunities in IHC and related medical real estate. Enjoy attractive compensation with our unique model while being able to maintain an excellent work-life balance. We currently have three Edmonton clinics. The clinics are near South Common, west Edmonton and Currents of Windermere. We currently have two clinics in Calgary. The clinics are located downtown and south Calgary. We also have compelling opportunities available in Red Deer. All inquiries will be kept strictly confidential. Contact: Dr. Jonathan Chan to submit your CV in confidence corporate@imaginehealthcentres.ca www.imaginehealthcentres.ca EDMONTON AB To meet the growing needs, we have a practice opportunity for family physicians to start as a locum (with an option to join part- or full-time) at Parsons Medical Centre (PMC) and Millbourne Mall Medical Centre (MMMC). Both clinics are in south Edmonton. PMC and MMMC are high patient volume clinics with friendly reliable staff for billing, referrals, etc., >

> as well as an on-site manager. Enjoy working in a modern environment with full electronic medical records. PMC and MMMC serve a large community and wide spectrum age group (birth to geriatric). Both clinics have on-site pharmacy, ECG machine, lung function testing and offer a large array of specialist services including: ENT, endocrinologist, general surgeon, internist, orthopedic surgeon, pediatrician and respirologist. PMC and MMMC are members of the Edmonton Southside Primary Care Network which allows patients to have access to an on-site dietitian and mental health/psychology/ psychiatry health services. Overhead is negotiable, flexible working hours and both clinics are open seven days a week. Contact: Harjit Toor T 587.754.5600 manager@parsonsmedicalcentre.ca EDMONTON AB Exciting opportunity for family medicine physicians; become a member of our team of professionals. Newly renovated state-of-the-art facility, clinic member of the community for over 30 years and one of the largest members of the Edmonton West Primary Care Network (PCN). We offer permanent full-time, locum opportunities, daytime, evening and weekends. You choose your work hours. We are one of the busiest clinics in Edmonton and a highly motivated full-time physician can earn $500,000 to $700,000 or more annually. Plus we provide other great perks such as flexibility with your schedule, how you wish to organize your work days, no need to arrange locum coverage for your vacations as you are part of a large physician team. In addition to a busy booked schedule, we have a large walk-in patient population so you can see as many or as few walk-in patients as you want. Full-time physicians have their own dedicated medical office assistant, on-site PCN resources such as chronic disease management nurse, two licensed practical nurses, panel coordinator and offsite PCN resources such as a nurse/pharmacist that updates our patient medication profiles upon their discharge from hospital.

Required completion of appropriate university and degrees, licenses and certificates include College of Physicians & Surgeons of Alberta certification, licensure by provincial or territorial authorities. Two years of experience would be preferred, fluent in English, professional liability insurance and active licence with Med Access electronic medical records (we can help with this if needed). Skills and duties include examining patients, taking histories, ordering appropriate testing and diagnostic procedures. Prescribing and administering medications and treatments. Advising patients on health care and communicating health promotion, disease prevention and performing patient advocacy role. Consulting with other medical practitioners. To become part of our team, please contact. Contact: Nanci Stocks nanci_anne@hotmail.com or Amy Markovitz amy.ccmc@hotmail.com F 780.444.0476 to attention of Nanci or Amy SHERWOOD PARK AB Dr. Patti Farrell & Associates is a new, busy, modern family practice clinic with electronic medical records. We require locum coverage periods throughout 2017. Fee split is negotiable. Current clinic hours Monday to Friday 8 a.m. to 4 p.m. are negotiable. Dr. Farrell is a lone practitioner (efficient clinic design built for two doctors) looking for a permanent clinic associate. Contact: C 780.499.8388 terrypurich@me.com SHERWOOD PARK AB The Sherwood Park Primary Care Network is looking for several physicians to cover a variety of locum periods in a variety of Sherwood Park offices. Practice hours vary widely. Majority of practices run electronic medical records. Fee splits are negotiated with practice owners. Some practices are looking for permanent associates. Contact: Dave Ludwick T 780.410.8001 davel@sherwoodparkpcn.com

SHERWOOD PARK AB Well-established busy clinic with five family physicians seeks a locum or associate part- or full-time to replace a departing physician who has relocated to another city. We are located in a professional building with lab and X-ray on site, primary care network nurse support and excellent office staff. Clinic has been using Med Access electronic medical records for 10 years. Contact: Dr. Lorraine Hosford T 780.464.9661 hosford6@telus.net

SPACE AVAILABLE CALGARY AND EDMONTON AB Medical offices available for lease in Calgary and Edmonton. We own full-service, professionally managed medical office buildings. Competitive lease rates, attractive building amenities and turn-key construction management available. Contact: NorthWest Healthcare Properties Lindsay Hills Regional Leasing Manager T 403.282.9838, ext. 3301 lindsay.hills@nwhreit.com Michael Lobsinger Leasing Manager, Edmonton T 1.877.844.9760, ext. 3401 michael.lobsinger@nwhreit.com EDMONTON AB Space available for a specialist medical practice in the busy and vibrant south Edmonton community, close to South Edmonton Common. New, modern and easily accessible building with latest amenities for a medical practice at attractive rates and electronic medical records are available. Building houses multiple specialists and general practices. Contact: edmontonspecialists@gmail.com for further details >

JULY â&#x20AC;&#x201C; AUGUST 2017

CONFERENCE 15TH ANNUAL CME HEADACHE AND STROKE CONFERENCE JASPER PARK LODGE JASPER AB OCTOBER 7-8 This conference is designed for family/ general practice physicians, trainees and nurses seeking more expertise in stroke and headache. Hosted by the Division of Neurology, Department of Medicine, University of Alberta. Contact: Susan Tiller T 780.248.1884 or RaeAnne Barkhouse T 780.492.8787 neuroadmn@ualberta.ca https://www.ualberta.ca/ department-of-medicine/ vascular2017 for more information and to register

COURSES CME CRUISES WITH SEA COURSES CRUISES • Accredited for family physicians and specialists • Unbiased and pharma-free • Canada’s first choice in CMEatSEA® since 1995 • Companion cruises FREE WESTERN CARIBBEAN CME AWAY™ CRUISE August 13-20 (Featuring: Kids summer camp at sea) Focus: Family medicine, vaccines and geriatrics Ship: Celebrity Summit ALASKA CME AWAY™ CRUISE August 20-27 Focus: Infectious diseases and dermatology Ship: Celebrity Infinity RHINE AND DANUBE RIVER CME AWAY™ CRUISE September 1-15 (Sold out, wait list only) Focus: Cardiology, sport medicine and dermatology Ship: Avalon Illuminations ADRIATIC AND AMALFI COAST CME AWAY™ CRUISE September 6-16 Focus: Update on 2017 pain guidelines Ship: Azamara Quest

AMA - ALBERTA DOCTORS’ DIGEST

JAPANESE EXPLORER CME AWAY™ CRUISE September 24-October 5 (Limited space) Focus: Cardiology, internal medicine and endocrinology Ship: Celebrity Millennium TUAMOTUS AND SOCIETY ISLANDS TAHITI CME AWAY™ CRUISE October 18-28 (Bucket list destination) Focus: Cardiology and emergency medicine Ship: Paul Gauguin EXUMA, BAHAMAS RESORT CME AWAY™ November 5-12 (Limited space) Focus: Family medicine updates Resort: Sandals Emerald Bay Resort (adults only) THE GALAPAGOS ISLANDS CME AWAY™ CRUISE November 22-December 2 (Limited space) (Bucket list destination) Focus: Updates in gastroenterology, pain and rehabilitation medicine Ship: Silversea Silver Galapagos CHILE, PATAGONIA, CAPE HORN AND ARGENTINA CME AWAY™ CRUISE November 25-December 2 Focus: Neurology and infectious diseases Ship: MV Stella Australis LAS VEGAS RESORT CME AWAY™ November 26-30 Focus: Cardiology, diabetes and pain management Resort: The Cosmopolitan Resort of Las Vegas SINGAPORE TO HONG KONG CME AWAY™ CRUISE December 5-17 Focus: Rheumatology, pain management and emergency medicine Ship: Regent SS Voyager EASTERN CARIBBEAN CME AWAY™ CRUISE December 30-January 6, 2018 Focus: Male/female sexual health and endocrinology Ship: Royal Caribbean Harmony of the Seas

AUSTRALIA AND NEW ZEALAND CME AWAY™ CRUISE February 3-17, 2018 (Limited space) Focus: Pain management, chemical dependency, rheumatology and endocrinology Ship: Celebrity Solstice RIVIERA MAYA MEXICO RESORT CME AWAY™ February 4-11, 2018 Focus: Cardiology and family medicine updates Resort: UNICO Resort (all inclusive) CARIBBEAN RESORT CME AWAY™ March 10-17, 2018 Focus: CME details coming soon Resort: Hard Rock Resort, Punta Cana (all inclusive) WESTERN CARIBBEAN CME AWAY™ CRUISE March 11-18, 2018 Focus: CME details coming soon Ship: Royal Caribbean Allure of the Seas INDIA AND SRI LANKA CME AWAY™ CRUISE March 23-April 7, 2018 Focus: Endocrinology, neurology and dermatology Ship: Celebrity Constellation AUSTRALIA GREAT BARRIER REEF CME AWAY™ CRUISE March 30-April 11, 2018 Focus: Cardiology, obstetrics, pediatrics and cultural anthropology Ship: Celebrity Solstice MARQUESAS - TAHITI CME AWAY™ CRUISE April 14-28, 2018 Focus: CME details coming soon Ship: MS Paul Gauguin HAWAII RESORT CME AWAY™ May 5-13, 2018 Focus: Cardiology and more Resort: The Kahala Hotel & Resort, Honolulu ITALY AND CROATIA CME AWAY™ CRUISE May 28-June 7, 2018 Focus: CME details coming soon Ship: Celebrity Constellation >

> AMSTERDAM AND NORMANDY CME AWAY™ CRUISE June 7-17, 2018 Focus: Gynecology, psychology and dermatology Ship: Azamara Journey BORDEAUX RIVER CME AWAY™ CRUISE June 10-17, 2018 Focus: Neurology and infectious diseases Ship: Uniworld River Royale SCANDINAVIA AND RUSSIA CME AWAY™ CRUISE July 21-August 2, 2018 Focus: CME details coming soon Ship: Celebrity Silhouette NORTHERN ISLES CME AWAY™ CRUISE August 5-19, 2018 Focus: CME details coming soon Ship: Holland America Line MS Koningsdam ALASKA HUBBARD GLACIER CME AWAY™ CRUISE August 19-26, 2018 Focus: CME details coming soon Ship: Celebrity Infinity TUAMOTUS AND SOCIETY ISLANDS TAHITI CME AWAY™ CRUISE September 19-29, 2018 (Bucket list destination) Focus: Dermatology and emergency medicine Ship: Paul Gauguin JAPAN, KOREA AND CHINA AWAY™ CRUISE October 16-31, 2018 Focus: CME details coming soon Ship: Celebrity Millenium MEKONG RIVER CME AWAY™ CRUISE October 16-31, 2018 Focus: Neurology and endocrinology Ship: AmaWaterways ¬ AmaDara SANDALS BARBADOS RESORT CME AWAY™ November 3-10, 2018 Focus: Clinical pearls in family medicine Resort: Sandals Barbados (all inclusive)

EASTERN CARIBBEAN CME AWAY™ CRUISE December 30, 2018-January 6, 2019 Focus: CME details coming soon Ship: Celebrity Edge

For current promotions and pricing, contact: Sea Courses Cruises TF 1.888.647.7327 cruises@seacourses.com www.seacourses.com

SERVICES ACCOUNTING AND CONSULTING SERVICES Independent consultant, specializing in accounting and tax preparation services, including payroll and source deductions, using own computer and software. Pick up and drop off for Edmonton and areas, mail or courier options available for rest of Alberta. Contact: N. Ali Amiri, MBA Consultant Seek Value Inc. T 780.909.0900 aamiri.mba1999@ivey.ca aliamiri@telus.net DOCUDAVIT SOLUTIONS Retiring, moving or closing your practice? Physician’s estate? DOCUdavit Solutions provides free paper or electronic patient record storage with no hidden costs. We also provide great rates for closing specialists. DOCUdavit Solutions has achieved ISO 9001:2008 and ISO 27001:2013 certification validating our commitment to quality management, customer service and information security management. Contact: Sid Soil DOCUdavit Solutions TF 1.888.781.9083, ext. 105 ssoil@docudavit.com

DISPLAY OR CLASSIFIED ADS TO PLACE OR RENEW, CONTACT:

Daphne C. Andrychuk Communications Assistant, Public Affairs Alberta Medical Association T 780.482.2626, ext. 3116 TF 1.800.272.9680, ext. 3116 F 780.482.5445 daphne.andrychuk@ albertadoctors.org

JULY – AUGUST 2017

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On your first day, your match day, and the day you start your practice, we’re by your side. MD is giving away $45,000 in prizes to help new-in-practice physicians.* If you’re starting practice in 2017—or know someone who is—encourage them to share how they’re taking their #MDnextstep!

For more details visit md.cma.ca/nextstep2017 *Must be starting practice in 2017 and an active CMA member to be eligible. Promotion begins July 14, 2017. MD Financial Management provides financial products and services, the MD Family of Funds and investment counselling services through the MD Group of Companies. For a detailed list of these companies, visit md.cma.ca.