Mandatory Gunshot Reporting in Ontario (2005) PDF

Shoot and Tell Mandatory Gunshot Reporting NOVEMBER 19, 2024 Shoot and Tell… “In September 2005, the Mandatory Gunshot Wounds Reporting Act was proclaimed in Ontario. It required public hospitals to report the name and location of anyone being treated for a gunshot wound. Representati...

Shoot and Tell Mandatory Gunshot Reporting NOVEMBER 19, 2024 Shoot and Tell… “In September 2005, the Mandatory Gunshot Wounds Reporting Act was proclaimed in Ontario. It required public hospitals to report the name and location of anyone being treated for a gunshot wound. Representatives of health professions expressed concern that this might damage their duty to patients, while others wondered whether similar reporting requirements should apply to other violent injuries. This case addresses several policy issues including: balancing societal needs for protection with patients’ right to privacy, the ethical basis of the physician- patient relationship, and framing of policy issues.” (Deber and Mah, 2014) Agenda Framing…again  Changing how we think about violent crime – i.e. Public Health Lens Mandatory Reporting Legislation in Ontario Ontario Mandatory Gunshot Wounds Reporting Act, 2005 and intersection with the Federal Firearms Act, PHIPA and the Regulated Health Professions Act Policy options to reduce Violent Crime Stakeholder analysis PHIPA fundamentals – PHI, Circle of Care, HICs and Agents Violence and Public Health Approaches – some successes Related/Support readings in Chapter 1 3.3 Policy Goals 3.4 Framing 3.6 Ethical Frameworks 5.2 Policy/Governing Instruments 6.3.1 Public Health 6.4 Professionalism Learning Objectives To identify how framing can affect how we choose to act on gun violence To summarize the different statutes in Ontario that are related to mandatory reporting and directly impact health care professionals To differentiate between pro-active and re-active policy choices To identify the various stakeholder views regarding the implementation of mandatory gunshot wound disclosure To understand the role of fiduciary duty in health care and how it relates to the current policy discussion To differentiate between HICs, agents and the Circle of Care To understand how violence can be treated as a public health policy issue Framing (Problem Identification) Unreported gunshot wounds are extremely rare – thus a small public health risk Likelihood of unreported shootings may be largest in rural areas – but most are accidental vs. intentional Disease prevention is facilitated when good data is collected, including information to help determine the root causes of episodes of ill health. Public health units and associations are, with increasing frequency, declaring violence to be an issue of concern to public health and an important determinant of health, especially in children. In 1997, the OPHA 1997 declared that violent crime was a public health issue Framing (Problem Identification) Fiduciary duty Individualism vs. collectivism Making communities safer vs. avoiding treatment Public Health Concern vs. Criminality Comprehensiveness? Every other province that has similar legislation also has a stab wound reporting element – statis in Ontario say violent crime is most likely to occur via shooting or stabbing (1/3 each) Prior to act being passed in 2005, it was up to HCP to use professional opinion re: when it should be reported to police Trade-offs (e.g. reporting accidental shots would be better handled with education and safety training) for HCP  A Public Health Issue? “Public health refers to all organized measures (whether public or private) to prevent disease, promote health, and prolong life among the population as a whole. Its activities aim to provide conditions in which people can be healthy and focus on entire populations, not on individual patients or diseases.” WHO 2016 “Violent crime can be seen as a public health issue whose impact is especially profound among youth and other vulnerable populations” Deber 2014, p.459 Should gunshot wounds be classified as a public health issue?  PROactive vs. RETROactive Prevention Treatment put money towards programs Put money towards treating and policy that help reduce gunshot wounds and police gunshot wound injuries resources Mandatory Communicable Disease Reporting The Health Protection and Promotion Act (HPPA) outlines the communicable diseases that are designated reportable in the province of Ontario. Under the authority of the HPPA, Ontario Regulations 559/91, these diseases or suspected occurrences of these diseases, must be reported to the local Health Unit by physicians, laboratories, administrators of hospitals, schools and institutions. The public health system depends upon these reports of communicable diseases to monitor the health of the community and to provide the basis for preventive action. Mandatory Reporting Legislation Gunshot wounds Child abuse or neglect Suspected elder abuse or death Health conditions that make it dangerous to drive, operate rail equipment Births, stillbirths and deaths Communicable disease or adverse reactions to immunizaiontion Fraud in health cards (OHIP) Sexual abuse  Mandatory Gunshot Wounds Reporting Act Mandatory Disclosure: “public hospitals to report the name and location of anyone being treated for gunshot wound” (p. 455 Deber, 2014) The Law says… “gunfire poses serious risks to public safety and that mandatory reporting of gunshot wounds will enable police to take immediate steps to prevent further violence, injury or death” Must be reported orally and as soon as reasonably practicable… without interfering with the person’s treatment or disrupting regular activities of the facility Facility = defined by the Public Hospitals Act, but can also be any organization/institution/clinic that provides health care services Protection from liability Ontario Mandatory Gunshot Wounds Reporting Act, RSO 2005  Federal Firearms Act “requires individuals to obtain a license to purchase a firearms and/or ammunition” Deber 2014, p. 460 Mandatory training Stats Canada program when purchasing of firearms Tougher border control Personal Health Information Protection Act and Regulated Health Professions Act “ both acts required that all regulated health care providers in Ontario had a fiduciary duty to respect patient confidentiality unless the individual consented to disclosure or unless disclosure was permitted in limited circumstances established by law as being in public interest” Deber 2014, p. 458 Ontario vs. Saskatchewan Deber, 2014 Policy Options to Reduce Violent Crime 1. Mandatory reporting of all cases of criminal activity 2. Mandatory reporting of certain types of criminal activity 3. Voluntary reporting of criminal acts with or without the consent of the individual involved. 4. Increased educational support to address the connection between the social determinants of health and gunshot wound reporting 5. Increased support of healthcare provider confidentiality Shoot and Tell…A good thing? Two sets of arguments have been made in support of mandatory reporting of gunshot wounds: protection of the public violence prevention the more we know about the causes and the incidence of gunshot wounds, the more proactive we can be about prevention using a broad public health approach (see Chapter 1, section 6.3.1, Public Health) while also aiding the ability of the police to protect the public from the perpetrator Shoot and Tell…Some issues Fiduciary duty Highest standards of care at law – requires physicians to act in good faith (a la Virtue ethics) for the sole benefit and best interests of their patients Confidentiality Owe patients a physical, legal, ethical and professional duty to not disclose PHI except in limited circumstances In the context of doctor-patient relationships, confidentiality is a prima facie right Autonomy Patients have a right to make decisions about their care without influence of their physician – physician provides information, but must refrain from making decisions on patient’s behalf Like it? 2009, OMA Emergency Medicine section reaffirmed their support for current law – but they did not support mandatory reporting of other violent injuries Gunshot wounds were both more lethal, and could pose “a public health risk to people in the vicinity when the trigger is pulled”. The huge burden that knife wound reporting would place on health care workers and police is “extremely disproportionate to the minimal potential health benefit” Current legislation in Canada for gunshot trauma has steered clear of legislating penalties for those people that do not comply with reporting requirements; mandatory is better than voluntary as it does not open possibility of coercion Other Stakeholders? Canadian Association of Emergency Physicians – FOR Ontario Medical Association – FOR College of Nurses of Ontario – AGAINST Registered Nurses Association of Ontario - AGAINST Ontario Hospital Association – FOR Ontario Association of Chiefs of Police – FOR Family Violence Prevention Fund – AGAINST General public -? Ontario Minister of Health and Long-Term Care-? Mayor of Toronto -? Doctors-? https://www.cno.org/en/learn-about-standards-guidelines/educational-tools/ask-practice/ask-practice-mandatory-gunshot-wound-reporting/ Ethical Considerations: HCPs Already bound by fiduciary duty and duty to report for other situations More harm than good? Retaliation by the perpetrator and concern re: breached confidentiality; this can damage trust relationships between the victim and the HCP Compromise of trust deters victims from seeking help or returning; This, in turn, may jeopardize the safety of such potentially vulnerable individuals Law removes ability to exercise judgment and make decisions; disclosure should depend on professional assessment of not only the injury, but of the context in which it occurs What about Patient Confidentiality? Exceptions to duty of confidentiality include: Patient consent Duty to warn - patient poses a foreseeable risk to an identifiable 3rd party Public Safety exception – clear, serous and imminent threat of physical or psychological harm Fundamentals of PHIPA Establishes rules for the collection, use and disclosure of personal health information while at the same time facilitating the effective provision of health care; Provides individuals with the right to:  access their personal health information (PHI);  correct their PHI if it is incorrect;  place restrictions on their PHI – “consent directive”;  be notified if PHI stolen or lost;  challenge an organizations’ privacy practices;  request an independent review and resolution of privacy complaints (IPC). What is PHI? Any identifiable information about an individual, either living or deceased & includes information about their: physical or mental health of the individual any health service provided to the individual donation of any body part or any bodily substance of the individual results of testing or examination of a body part or bodily substance of the individual Includes information collected in the course of providing health services to the individual, e.g. demographics, health card number, identity of health care provider, name of substitute decision maker What is Identifiable Patient Information? Information is identifiable when it is unique to an individual. Examples include: name, medical record number (MRN), or health card number Information that, when used in conjunction with other information could re- identify an individual. Examples include: date of birth + surgical procedure + name of surgeon + date of surgery postal code + diagnosis/condition (unique/rare condition in a small population Circle of Care a person/group of persons providing care to the individual episode of care is an informal reference and is not defined under PHIPA but can include Who or What is a HIC? a person or organization who has custody and control of personal health information is legally responsible for personal health information (PHI) on all of its patients regardless of the purpose for which the PHI is used (e.g. health care, research, education, quality assurance), regardless of the format (e.g. hard copy, electronic, verbal) can include a hospital, an independent health facility, a physician in a private practice, a physician as part of a family health team Who or What is an Agent In relation to PHIPA, an agent is: …a person that, with the authorization of the custodian, acts for or on behalf of the custodian in respect of personal health information for the purposes of the custodian, and not for the agent’s own purposes.’ Can be employees, physicians, third party vendors, volunteers, students, etc. Use of PHI by the HIC - acceptable for the purpose it was collected (provide health care) obtaining payment for providing health care risk management/error management program planning/delivery education of agents to provide health care a proceeding where the custodian/agent or former agent of the custodian is expected to be a party or witness research conducted in accordance with PHIPA Acceptable Reasons for Disclosure within the “circle of care” chief Medical Officer prescribed entity (CIHI, CCO, etc.) significantly reduce the risk of harm (individual/group) SDM or acting Power of Attorney for Care the parent of a child …and other circumstances defined in the legislation Disconnect Between PHIPA and the Mandatory Gunshot Wound Reporting Act Provider – patient relationships Collection, use and disclosure of PHI The MGWRA becomes an ‘acceptable reason for disclosure’ and supersedes PHIPA Police do not have to abide by PHIPA Accidental incidents still must be reported  Violence and a Public Health Approach Aim: prevent the loss of 60,000 lives and countless traumas each year Violent behavior arises from contextual, biological, environmental, systemic, and social stressors A "trauma-informed" approach suggests that violence is not symptomatic of "bad people" – instead is a negative health outcome resulting from exposure to numerous risk factors The public health approach to violence focuses on prevention through addressing the known factors that increase or decrease the likelihood of violence. (American Public Health Association, 2018) https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2019/01/28/violence-is-a-public-health-issue  APHA 2018 – Basis for Public Health Beyond direct injury, exposure to violence increases the risk of: Asthma, hypertension, cancer and stroke contributes to psychiatric illness, including depression and post-traumatic stress disorder those who are exposed to violence are more likely to sleep poorly, to smoke, and to become socially isolated, all added risk factors for early death. Negative health outcomes are also seen in statistics related to HIV, maternal health, and adoption of unhealthy behaviors such as alcohol and substance abuse. APHA, 2018 https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2019/01/28/violence-is-a-public-health-issue  Positive Outcomes in the USA A Chicago program using public health methods to interrupt violence, reduce risk, and change neighborhood norms reduced homicides and shootings by up to 70% and retaliations by 100%.[Hemenway and Miller, 2013] In Baltimore, one historically violent neighborhood went more than 22 months without a homicide after implementation of the same model.[Skogan, 2019] In New York City, the John Jay College of Criminal Justice Research and Evaluation Center released an extensive independent evaluation of the local Cure Violence program that showed a 37% to 50% reduction in gun injuries in the two communities examined, a 14% reduction in attitudes supporting violence (with no change in the control groups), and increased confidence in and willingness to contact police.[Webster et. al., 2013] https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2019/01/28/violence-is-a-public-health-issue Trade-offs Who should report? Who should the report go to? As noted above, trade-offs may also include the fear that providers may be subjected to repercussions for their reports. Those fears, whether founded or not, may be different depending on who the report is sent to and how the report is handled (i.e., anonymous, mandatory report to public health vs. voluntary, full disclosure to police). police who are not currently bound by the Personal Health Information Protection Act.  Would you adopt a more comprehensive Act that includes other violent crimes? Is it worth the time and aggravation? How would you know if this Act is working? Is it better to leave this to the discretion of HCP? Related/Support readings in Chapter 1 3.3 Policy Goals 3.4 Framing 3.6 Ethical Frameworks 5.2 Policy/Governing Instruments 6.3.1 Public Health 6.4 Professionalism