Book review

Computerization and Going Paperless in Canadian Primary Care. By Nicola T. Shaw. Oxford: Radcliffe Publishing, 2004. ISBN 1-85775-623-1. Paperback, 288 pages. $53.50.

Dr Nicola Shaw is a research scientist at the Centre for Healthcare Innovation and Improvement at the University of British Columbia. This book is based on a similar publication that was published in the UK in 2001 and has been adapted with significant research for the Canadian primary care setting.

In the fast-changing world of information technology and electronic medical record (EMR) software, any print-based publication faces the risk of becoming outdated before it even reaches publication. Dr Shaw has limited the redundancy of this guide by focusing on the decision-making steps that physicians should consider when selecting a primary care clinical system (EMR). Each chapter is prefaced by an algorithm that progressively builds based on the stage at which clinicians may find themselves depending on the decision-making process. Herein lies the strength of the book. Even though there are frequent references to resources that are specific to the UK health system, such as PRIMIS (Primary Care Information Services), the references are well thought out and reflect the significant experience that has already been achieved in primary care computing in countries such as the UK.

Selecting and implementing an EMR system in a primary care practice is a complex process that requires an understanding of the systems that could be relevant choices in any given practice. As a result, the selection process requires a rigorous and disciplined approach if the right system is to be chosen. Frequently however, technical books tend to be quite dry and don’t usually lend themselves to easy reading. Computerization and Going Paperless in Canadian Primary Care is an exception.

Dr Shaw follows Dr Jones and colleagues as they navigate through a number of clinically relevant scenarios. Each chapter describes who would benefit most from reading that specific section. This allows the reader to quickly find the sections that are pertinent to a given situation. Once a system has been chosen, the focus of the book shifts to issues related to the management of information. This is where EMR systems begin to demonstrate their true value. Chapters 10, 11, and 12 deal with data recording, quality, and reporting. These chapters will be useful to all physicians who have selected and implemented an EMR system.

A number of useful appendices include “A buyer’s checklist,” “Questions to ask your staff,” and “An overview of Canadian EMR systems.” Many of the product descriptions are likely to be outdated and readers are encouraged to contact vendors of EMR systems for updated product descriptions.

Dr Shaw has done a commendable job in the compilation of this book. She does not provide answers to every possible scenario, but any physician reading this book would be well prepared for the difficult task of selecting an EMR system or improving on the use of an existing system. I highly recommend this book for both beginner and advanced users.


Medical clinics—don’t forget about business liability!

Why do I need this coverage?

If you are involved either as a director or an owner in the business aspects of a medical clinic where you have no medical relationship with patients, you are well advised to have separate liability insurance to ensure that the clinic will protect you financially for any claims arising from that business relationship.

With new laws and court decisions more broadly defining the responsibilities of corporate directors and officers, the number of personal liability suits—and the value of the settlements of these suits—is escalating every year. As well, legal costs are escalating along with the settlements. Every director and officer of a company (public, private, or family-owned) is a potential target for significant financial loss.

Directors and officers are being watched more closely than ever by shareholders, customers, government, suppliers, and creditors. Wise management must protect its directors and officers against personal liability with effective insurance coverage when they act in the name of their company.

Doesn’t my commercial general liability insurance policy cover this?

A typical commercial general liability policy insures directors and officers against liability for bodily injury, property damage, personal injury, and advertising injury, but not against liability for all other types of injury or damage. For example, everyday decisions affecting shareholders, unions, customers, consumer groups, competitors, creditors, and suppliers may result in lawsuits alleging misrepresentation, misleading statements, neglect, breach of duty, or violation of a statute, which would not be covered under a commercial general liability policy. Directors’ and officers’ liability insurance provides coverage for errors and omissions in a broad range of management decisions that could conceivably result in a lawsuit against directors and officers.

What are my duties as a director and officer?

Directors and officers of private corporations are required by law to act diligently and with due care, and to both personally and corporately comply with the numerous federal and provincial statutes regulating management and corporate conduct.

Failing to act properly can leave you liable to shareholders, employees, customers, creditors, regulators, and competitors. Shareholders’ claims can be particularly significant, especially when new shareholders with different expectations and loyalties appear as a result of death, divorce, bankruptcy, or other extraordinary occurrence. In Canada, directors can also be held liable for unpaid employee wages, vacation pay, and taxes. This liability is imposed without fault, on a strict liability basis, and can include liability for amounts that become outstanding even after the director has resigned.

What does directors’ and officers’ liability insurance cover?

A directors’ and officers’ liability insurance policy covers a company’s directors and officers for defence costs, settlements, and judgments on account of claims made by shareholders, creditors, customers, regulators, and other third parties for a broad range of allegations such as unpaid wages, vacation pay and taxes, negligent misrepresentation, mismanagement, negligence, antitrust, unfair trade practices, consumer protection violations, and copyright, patent, and trademark infringements.

Coverage responds to many types of claims, not just lawsuits, such as a written demand for monetary damages, a civil lawsuit commenced by the service of a complaint, a criminal proceeding commenced by the return of an indictment, a formal administrative or regulatory proceeding commenced by the filing of a notice of charges, formal investigative order, or similar document.

A directors’ and officers’ liability coverage package has been designed exclusively for BCMA members by Chubb Insurance Company of Canada. For more information or an application form, please contact MGI at 604 877-7762

—Sandie Braid, CEBS
Assistant Director, BCMA Benefits

Protecting the blood supply from West Nile virus—BC update, 2005

Blood donor WNV testing and surveillance

Canadian Blood Services (CBS) screens all blood donations for West Nile virus (WNV) by nucleic acid testing, using minipools of six specimens. No case of transfusion-transmitted (TT) WNV has been reported in Canada since donor WNV testing was implemented in July 2003. In 2003, 14 asymptomatic, viremic donations were detected by CBS WNV testing, all from Saskatchewan, which experienced the highest level of WNV activity in North America in that year. By contrast, in 2004 no presumptive positive WNV blood donors were detected in Canada, although almost 200 viremic donations were detected through WNV donor screening in the United States.

WNV remains a threat to the blood supply, despite donor WNV screening.[1,2] Six cases of TT-WNV were reported in the United States in 2004 involving WNV-tested donations. Cases of TT-WNV have almost exclusively been attributed to blood collected in the early window period of WNV infection (1 to 2 days after being bitten by an infected mosquito), and were associated with low (but infectious) levels of WNV in blood.

Single unit WNV donor testing: CBS plans for 2005

WNV testing sensitivity can be improved by employing single-unit testing instead of minipool testing. CBS has laboratory capacity for performing WNV single-unit testing on about 15% of its national collections (i.e., about 3000 units per week). Single-unit testing is assigned to collections from clinics in regions of higher WNV risk, determined by an ongoing weekly risk assessment process that includes analysis of donor as well as public health WNV surveillance data from Canadian and US sources. Preset start and stop dates for WNV single-unit testing were used by CBS in 2004. This year, to ensure more efficient use of available resources, CBS will be using threshold triggers, similar to other North American blood suppliers. For 2005, single-unit testing will be initiated in a health region when a positive blood donor is detected using minipool testing or if the incidence of WNV human cases in the preceding 2 weeks exceeds 1/2500 in urban areas or 1/1000 in rural areas. Single-unit testing will cease if these criteria are not met over a 2-week period.

In the event of widespread, high levels of WNV activity in Canada this year, the triggers for implementing or discontinuing single-unit testing may have to be modified. In some instances, if laboratory capacity for single-unit testing is exceeded, additional measures may be considered, such as suspending collections from areas of intense human WNV activity while augmenting collections in areas of little or no activity. In addition, there has been no stockpiling of frozen plasma products for 2005 since previous years’ experience demonstrated limited benefit of this strategy.

BC WNV Blood Action/Readiness Plan

In BC, the Ministry of Health Services, Provincial Blood Coordinating Office, transfusion medicine and blood banking specialists, CBS, and the BC Centre for Disease Control (BCCDC) are cooperating closely to monitor and communicate timely information about WNV risk to the blood supply for patients throughout our province. A Provincial WNV Blood Action/Readiness Plan is in place to plan, prepare, and respond effectively to all levels of WNV threat. This plan, along with other WNV blood-related information and links to other WNV-related resources, can be accessed at the Provincial Blood Coordinating Office’s Transfusion Quality Management Program web site (address below).

Public health reports suspect WNV cases to CBS

In BC, suspect WNV cases are reported by BCCDC to CBS to enable the fastest possible inventory withdrawal of potentially infectious blood products that may have been collected recently from an infected donor, and so that potentially infected donors can be deferred from donating blood for a 56-day period. The value of this data linkage was demonstrated last year when 25 BC donors (including two who either donated or tried to donate blood within 56 days of being tested for WNV) were identified among 555 suspect WNV cases reported by BCCDC.

BC is also the pilot site of an anonymized data linkage project between BCCDC and CBS. WNV is being used as an indicator blood-borne pathogen to evaluate an anonymized data linkage process aiming to achieve virtual real-time linkage of infectious disease data relevant to blood safety, while addressing statutory and agency requirements for privacy and confidentiality of information.

Physicians’ roles in protecting patients from TT-WNV

Physicians are reminded of the need to ensure that their patients are aware of the risk of WNV transmission through transfusion. During the WNV season, this should be part of the informed consent for transfusion. Transfusion recipients who present with signs and symptoms of WNV infection in the summer and fall should be investigated for the possibility of TT-WNV and reported to CBS by phone at 604 876-7219 or by fax at 604 879-6669. Suspected transfusion-transmitted infections are also reportable to the local medical health officer. Physicians should routinely question patients who may have WNV infection about recent blood donation, and patients who have donated in the previous 8 weeks should be reported to CBS so that in-date components can be withdrawn.

For more information

For questions about WNV-related transfusion practice, please visit the Transfusion Quality Management Program web site at www.traqprogram.ca/wnv-contingencies.asp.

—Mark Bigham, MD, FRCPC
Canadian Blood Services
BC & Yukon Centre, Vancouver

See an update on WNV from the BC Centre for Disease Control.

Docs on the Run

On the eve of the 2005 Sun Run, the first annual CME evening for the Docs on the Run Sun Run team took place. Organized by the BCMA Athletics and Recreation Committee, preparation for the Sun Run began 4 months prior with the online training program through SportMed BC. Ms Lynn Kanuka, the director of the training clinics for the Sun Run, gave weekly tips for doctors around BC who signed up to follow the Sun Run training programs to learn to walk 10 km, run 10 km, or run 10 km faster. About 25 doctors signed on to the training program. Some of the program participants, along with some others who didn’t do the training program, formed a team (called Docs on the Run) for the Sun Run. A total of 25 participated on the team, which came 11th in the Clubs and Associations division. Congrats to all those who completed the run on a drizzly Vancouver day on April 17.

What is sure to become an annual event was the dinner and CME meeting held at the Coast Plaza Hotel near Stanley Park. After a good carbo-loading meal the crowd was treated to a stimulating presentation by Dr Darren Warburton, professor in the School of Human Kinetics at UBC. Dr Warburton stated that the benefits of physical activity have been well documented by research and what was necessary now was to get on with the work of promotion. He showed some of the work soon to be published that will help doctors provide appropriate information to patients. The evening was concluded with stirring encouragement from Ms Kanuka, who motivated everyone to stay active and work at motivating patients to be active to gain the benefits as described by Dr Warburton. Ms Kanuka, a bronze medalist in the 1984 Olympics in the 1500 metres, capped off her leadership of the online training sessions by encouraging everyone to exercise for fun and for good health. The crowd who attended was small, but even Terry Fox got off to a small start, and then the momentum of his accomplishment grew and grew into the great success it is today. Likewise, a small start this year should grow into an annual event that will encourage doctors and their patients to become more physically active.

—Ron Wilson, MD, Chair, Athletics and Recreation Committee, 
Council on Health Promotion

2005 Health Promotion Award recipients

The Excellence in Health Promotion Award, sponsored by the BCMA Council on Health Promotion, was presented to three candidates at the BCMA awards ceremony on 11 June 2005.

Mr Lloyd Craig, president and CEO of Coast Capital Savings, was awarded with the Individual Category Award for his work promoting awareness of depression and other mental health conditions. After losing his son to a depression-related illness, Mr Craig made a personal commitment to increase education and understanding of mental illnesses. His efforts have resulted in the creation of a Chair in Depression Research at UBC, workshops for employers on mental health as it affects the workplace, and a provincial business and economic roundtable on mental health.

Two awards were given in the Corporate/Community category; both the Healthy Heart Society of British Columbia for its hearts@work program and the Geriatric Dentistry Program operated by Providence Health’s Centre for Aging and Health were deemed to have outstanding programs worth of recognition.

The hearts@work program is a heart health campaign that uses innovative means to increase awareness of cardiovascular risk factors, encourage patient self management, improve access to community-based health care resources, and increase practitioner chronic disease case management.

The Geriatric Dentistry Program provides dental care to 1000 seniors living in residential care across the city of Vancouver. The program seeks to meet the dental needs of a population for which dental care is often neglected. The program also addresses dental health prevention and education of staff at residential care facilities, and includes research on geriatric dentistry.

Sandie Braid, CEBS, Mark Bigham, MD, Ron Wilson, MD, CCFP, Alan Brookstone, MD. Pulsimeter. BCMJ, Vol. 47, No. 6, July, August, 2005, Page(s) 317-320 - News.

Above is the information needed to cite this article in your paper or presentation. The International Committee of Medical Journal Editors (ICMJE) recommends the following citation style, which is the now nearly universally accepted citation style for scientific papers:
Halpern SD, Ubel PA, Caplan AL, Marion DW, Palmer AM, Schiding JK, et al. Solid-organ transplantation in HIV-infected patients. N Engl J Med. 2002;347:284-7.

About the ICMJE and citation styles

The ICMJE is small group of editors of general medical journals who first met informally in Vancouver, British Columbia, in 1978 to establish guidelines for the format of manuscripts submitted to their journals. The group became known as the Vancouver Group. Its requirements for manuscripts, including formats for bibliographic references developed by the U.S. National Library of Medicine (NLM), were first published in 1979. The Vancouver Group expanded and evolved into the International Committee of Medical Journal Editors (ICMJE), which meets annually. The ICMJE created the Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals to help authors and editors create and distribute accurate, clear, easily accessible reports of biomedical studies.

An alternate version of ICMJE style is to additionally list the month an issue number, but since most journals use continuous pagination, the shorter form provides sufficient information to locate the reference. The NLM now lists all authors.

BCMJ standard citation style is a slight modification of the ICMJE/NLM style, as follows:

  • Only the first three authors are listed, followed by "et al."
  • There is no period after the journal name.
  • Page numbers are not abbreviated.

For more information on the ICMJE Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals, visit www.icmje.org

BCMJ Guidelines for Authors

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