oma advantages - omr.dgtlpub.comomr.dgtlpub.com/2010/2010-09-30/pdf/omr_2010-09-30.pdf ·...

September 2010 Volume 77 Number 8

www.oma.org

Interpretive BulletinsSpecialist assessments and consultations; member queries regarding recent EPC Bulletin topics

EditorialOMA regional physician engagement strategy

Practice ManagementPoint-of-service terminal offers enhanced practice efficiency

Sport and Exercise MedicinePhysician role reflects specialized knowledge,diverse patient requirements

Electronic Medical RecordsSuccessful EMR adoption: optimizing workflow

Political Action UpdateDr. Eric Hoskins provides an inside look at life as a physician MPP

PM41

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Dedicated to Doctors. Committed to Patients.

OMA Advantages exclusive benefits and discounts for members

OMR Full 43 copy.pdf 1 11/25/2009 3:04:17 PM

Committee Chairs Agreement

(OMA-Ministry of Health and

Long-Term Care)

Agreement Board Co-ordinating Committee Dr. S. Wooder

Forms Committee Dr. A. Studniberg

Joint Committee on the Schedule of Benefits Dr. P. Conlon

Medical Audit Oversight Committee Dr. D. Hellyer

Medical Services Payment Committee Dr. D. Weir

Physician LHIN Tripartite Committee Dr. T. Nicholas

Physician Services Committee Dr. S. Wooder

Workplace Safety & Insurance Board Steering Committee Dr. J. Tracey

Governance

Governance Committee (Board Co-ordinating Committee) Dr. M. Toth

Annual Meeting Planning Committee Dr. S. Strasberg

Audit Committee Dr. R. Mann

Awards Committee Dr. D. Bach

Board Planning Committee Dr. M.S. Kennedy

Budget Committee Dr. S. Wooder

Committee on Committees Dr. R. Mann

Council Committee on Structure & Bylaws Dr. J. Willett

Nominations Committee Dr. S. Strasberg

Staffing Committee Dr. V. Walley

Health Policy

Health Policy (Board Co-ordinating Committee) Dr. S. Chris

Revalidation Committee Dr. A. Kapur

Member Services

Member Services (Board Co-ordinating Committee) Dr. V. Walley

Insurance Committee Dr. D. Zackon

Physician Health Program Advisory Committee Dr. D. Puddester

Quality Management Program-Laboratory Services Advisory Council Dr. V. Walley

Public & Political Advocacy

Communications Advisory Committee (Board Co-ordinating Committee) Dr. S. Wooder

Outreach to Women Physicians Committee Dr. R. Forman

Political Action Committee Dr. J. Tracey

(OMA Section Chairs, see page 6)

Executive, Board, Council, Committee Chairs

Executive Committee President

Dr. M. MacLeod, London

President Elect

Dr. M.S. Kennedy, Thunder Bay

Past President

Dr. S. Strasberg, Downsview

Chair of the Board

Dr. D. Weir, Toronto

Honorary Treasurer

Dr. S. Wooder, Stoney Creek

Secretary

Dr. V. Tandan, Hamilton

Board of DirectorsDistrict

1 Dr. D.J. Hellyer, Windsor

2 Dr. M. MacLeod, London

Dr. M. Toth, Aylmer

3 Dr. C. Cressey, Palmerston

4 Dr. D.M. Goodwin, Niagara Falls

Dr. V. Tandan, Hamilton

5 Dr. S. Whatley, Mount Albert

Dr. J. Tracey, Brampton

6 Dr. J. Ludwig, Peterborough

7 Dr. A. Steacie, Brockville

8 Dr. G. Beck, Ottawa

Dr. A. Kapur, Ottawa

9 Dr. P. Bonin, Sudbury

10 Dr. M.S. Kennedy, Thunder Bay

11 Dr. S. Chris, North York

Dr. C. Jyu, Scarborough

Dr. C. Pinto, Etobicoke

Dr. S. Strasberg, Downsview

Dr. A. Studniberg, Scarborough

Elected by Council

Dr. A. Donohue, Ottawa

Dr. W. Tanner, Toronto

Dr. V. Walley, Peterborough

Dr. D. Weir, Toronto

Dr. S. Wooder, Stoney Creek

Academic Representative

Dr. R.K. Edwards, Kingston

CouncilChair

Dr. A. Hudak, Orillia

Vice-Chair

Dr. E. Barker, Wiarton

Insurance Check-Up Have You Had One Lately?

Surprisingly, many physicians have not reviewed their insurance coverage in several years.

Your health is not the only thing that changes over time. Events take place during a lifetime that can alter your financial situation.

MarriageChildrenBuying a home and/or cottagePractice matures and income increasesRetirement.

Your insurance may not have kept pace with your changing needs. A regular review of your insurance is essential to providing adequate protection for you and your family. The OMA provides the services of professional non-commissioned Insurance Advisors.

Contact OMA Insurance today by phone (1.800.758.1641 / 416.340.2918) or e-mail ([email protected]) and arrange to have your insurance needs reviewed.

The best time to find out if you have enough insurance is before you need it.

7 Editorial: regional physician engagement strategy In the fall of 2007, the OMA Board endorsed a bold and innovative strategy

designed to enhance the role and influence of physicians in local health-care planning and decision-making, and to promote improved participation and connection among grassroots members regarding Association initiatives. The experience to date, and impact of the program, have been very positive.

14 Sport and Exercise Medicine Today’s focus on health finds the general population, and baby boomers in

particular, actively involved in all types of sports and exercise. With this thrust to better health, there is also an increase in injuries. The sport and exercise medicine physician is becoming recognized as the doctor with specialized knowledge that will help the patient resume a healthy active lifestyle.

16 Sport Med 2010 Symposium Key topics addressed during the recent Sport Med 2010 Symposium

included exercise in kids, skin infec tion in athletes, psychology during and post sport, nutrition in sport, and the results from several research papers outlining the latest findings in the field of sport and exercise medicine.

25 Interpretive Bulletins: specialist assessments and consultations; member queries on recent EPC topics

The joint Education and Prevention Committee has prepared two Interpretive Bulletins this month. “Specialist Assessments and Consultations” appears on pages 25-27, and “Questions and Answers to Recent EPC Bulletins, Including Special Visit Premiums, Most Responsible Physician Premiums, and Smoking Cessation,” appears on pages 30-34.

36 Successful EMR adoption: optimizing your workflow In order to successfully introduce electronic medical records (EMRs) into the

practice, physicians must first conduct a detailed analysis and assessment of each component related to their practice workflow. Dr. Stephen McLaren offers helpful tips and techniques to assist the “workflow focus.”

38 Political Action Update: Dr. Eric Hoskins offers inside look at life as a physician MPP

The OMA is encouraging physicians who are interested in politics to consider getting involved in the 2011 provincial election. The OMA recently spoke to Dr. Eric Hoskins, Minister of Citizen ship and Immigration, about his decision to enter politics, his work as an MPP, and his experiences at Queen’s Park.


www.oma.org

10 “OMA Advantages” affinity program offers exclusive benefits and discounts for membersFollowing extensive member research, and guided by Board policy, the OMA has developed an affinity program called “OMA Advantages,” which offers bene-fits and discounts tailored to meet member needs and preferences. The program, which currently includes five partner organiza-tions, will be closely monitored, and revised and expanded as needed, to help ensure member satisfaction. OMA Advantages partners include Campbell Moving Systems, Park ‘n Fly, Porter Airlines, Sea Courses Inc., and Via Rail. Complete program details are available online at: www.oma.org/Advantages.


www.oma.org

Interpretive BulletinsSpecialist assessments and consultations; member queries regarding recent EPC Bulletin topics

EditorialOMA regional physician engagement strategy

Practice ManagementPoint-of-service terminal offers enhanced practice efficiency

Sport and Exercise MedicinePhysician role reflects specialized knowledge,diverse patient requirements

Electronic Medical RecordsSuccessful EMR adoption: optimizing workflow

Political Action UpdateDr. Eric Hoskins provides an inside look at life as a physician MPP

PM41

1445

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Dedicated to Doctors. Committed to Patients.

OMA Advantages exclusive benefits and discounts for members

Publications Mail Agreement # 41144507Undeliverables, please return to: Ontario Medical Review 150 Bloor St. West , Suite 900 Toronto, Ontario M5S 3C1

FEATURES

September 20103ONTARIO MEDICAL REVIEW

Take OMAdvantage of OMA’s growing team of affinity partners.

OMA Advantages is a new OMA affinity partner program providingspecial offers and services. It is designed exclusively for all OMA members.

Visit www.oma.org/Advantages to learn more about this new program and how it can benefit your personal and professional life.

www.oma.org/Advantages

42 Practice Management: point-of-service terminal facilitates “real-time” payment, practice efficiency

Installing an electronic point-of-service (POS) terminal in your practice is one of the most effective ways to help improve the efficiency of your uninsured services program (USP), and will help take your USP from being an after-thought or a necessary burden to an indispensable part of the practice. A POS system can accept credit card or debit card payments, and costs little to set up and maintain. POS terminals can make things easier for your practice and convenient for patients.

44 Insurance Update: mortgage life insurance — options to consider when buying a home

If you are a homeowner, or thinking of becoming one, it is likely that you have been strongly encouraged to purchase mortgage life insurance from your lending institution. It is important to know that you are not obligated to take this insurance from the bank where you obtained your mortgage, and that there are other options available that can offer much greater flexibility with regard to terms of payment, as well as how, and to whom, the proceeds of your insurance policy will be paid.

COLUMNS


Editor Jeff Henry

Managing Editor Elizabeth Petruccelli

Associate EditorMatthew Radford

Advertising/Circulation Co-ordinatorKim Secord

Production Co-ordinator Angelica Santacroce

Classifieds Co-ordinator Margaret Lam

Art Direction Artful Dodger Communications Inc.

Publisher’s Notes

Published 11 times yearly by the Ontario Medical Association 150 Bloor St. West Suite 900 Toronto, Ontario M5S 3C1 Tel. 416.599.2580 or Toll-free 1.800.268.7215 Fax 416.340.2232 E-mail: [email protected] OMA website: www.oma.org

ISSN 0030 302X

Any opinions expressed in articles and claims made in advertisements are the opinions of the authors/advertisers and do not imply endorsement by the Ontario Medical Association.

The Ontario Medical Review welcomes readers’ views. Letters to the editor should be addressed to Ontario Medical Review, 150 Bloor St. West, Suite 900, Toronto, Ontario M5S 3C1; fax 416.340.2232; e-mail: [email protected]. Note: letters may be edited for space and clarity. Please include name, address and daytime phone number.

(Additional “Publisher’s Notes” appear on page 6)


www.oma.org

CAPSULE NEWS

8 OMA President’s Tour coming to various locations across Ontario

8 “Team OMA” raises more than $10,000 for Heart and Stroke

13 Call for Nominations 2011 OMA Awards

24 Smokers’ Helpline Quit Connection: fax referral service available to physicians with patients who smoke

35 PAIRO names 2010 award recipients

DEPARTMENTS

1 OMA Executive, Board, Council, Committee Chairs

6 OMA Section Chairs

40 Health Policy Report

41 In Memoriam

51 Classifieds

56 Medectoon/Advertisers’ Index

Addiction Medicine Dr. R. Cooper

Allergy and Clinical Immunology Dr. B. Wong

Anesthesiology Dr. S.C. Bodley

Cardiac Surgery Dr. V. Rao

Cardiology Dr. W. Hughes

Chronic Pain Physicians Dr. H. Jacobs

Clinical Hypnosis Dr. M. Dales

Clinical Teachers Dr. R. Edwards

College and University Student Health Dr. D. Lowe (Acting Chair)

Community Health Centre & Aboriginal Health Access Centre Physicians Dr. K. Mardell

Complementary Medicine Dr. R. Banner

Critical Care Medicine Dr. L. Milosevic

Dermatology Dr. S. Gupta

Diagnostic Imaging Dr. M. Prieditis

Emergency Medicine Dr. M. Haluk

Endocrinology and Metabolism Dr. J. Shaban

French-Speaking Physicians Dr. T. Dufour

Gastroenterology Dr. D. Baron

General and Family Practice Dr. R. Male

Genetics Dr. L. Velsher

Geriatrics Dr. A. Baker

GP Psychotherapy Dr. D. Cree

Group Practice Dr. G. Maley

Hematology and Medical Oncology Dr. P. Kuruvilla

Hospitalist Medicine Dr. K. Rhee

HSO Physicians Dr. J. Craig

Hyperbaric Medicine Dr. A.W. Evans

Independent Physicians Dr. J. Szmuilowicz

Infectious Diseases Dr. N. Rau

Internal Medicine Dr. M. Wilson

Interns and Residents Dr. A. Toren

Laboratory Medicine Dr. C.M. McLachlin

Medical Students Ms. C. Nowik, Mr. K. Cullingham

Nephrology Dr. B. Nathoo

Neurology Dr. R. Yufe

Neuroradiology Dr. S. Symons

Neurosurgery Dr. F. Gentili

Nuclear Medicine Dr. C. Marriot

Obstetrics and Gynecology Dr. B. Mundle

Occupational and Environmental Medicine Dr. M. Cividino

Ophthalmology Dr. N. Nijhawan

Orthopedic Surgery Dr. D. Fleming

Otolaryngology - Head and Neck Surgery Dr. O. Smith

Palliative Medicine Dr. A. Franklin

Pediatrics Dr. H. Yamashiro

Physical Medicine and Rehabilitation Dr. D. Berbrayer

Plastic Surgery Dr. D.S. Woolner

Psychiatric Hospitals, Schools Dr. J. Fareau-Weyl

Psychiatry Dr. D. Brownstone

Public Health Physicians Dr. H. Shapiro

Radiation Oncology Dr. G. Morton

Reproductive Biology Dr. C. Librach

Respiratory Disease Dr. H. Ramsdale

Rheumatology Dr. P. Baer

Rural Practice Dr. R. Dawes

Sleep Disorders Dr. A. Soicher

Sport Medicine Dr. W. Elliott

Surgery, General Dr. A. Maciver

Surgical Assistants Dr. D. Esser

Thoracic Surgery Dr. R. Zeldin

Urology Dr. F. Papanikolaou

Vascular Surgery Dr. D. Szalay

Section Chairs


Publisher’s Notes continued

REPRINTING OF ARTICLESMaterial in the Ontario Medical

Review may not be reproduced in whole or in part without the express written permission of the Ontario Medical Association. Requests for reprinting or use of articles should be forwarded in writing to the OMA c/o the Editor.

SUBSCRIPTION RATES The Ontario Medical Review is distributed to all members of the Ontario Medical Association. Others may subscribe to the Review at the following rates: in Canada $55; in the United States $62; in other countries $79 (Canadian funds). Single copies are $6, back issues $7.HST applicable as of July 1, 2010.

ADVERTISING Current display advertising rate card, effective January 1, 2010, available on request. Advertising representative: Marg Churchill Keith Communications Inc.1599 Hurontario Street, Unit 301Mississauga, Ontario L5G 4S1Tel. 905.278.6700 / 1.800.661.5004Fax: 905.278.4850 E-mail: [email protected]

Classifieds advertising inquiries should be directed to: Margaret Lam Tel. 416.340.2263 / 1.800.268.7215, ext. 2263Fax: 416.340.2232E-mail: [email protected]

The Ontario Medical Review is required to comply with the provisions of the Ontario Human Rights Code 1990 in its editorial and advertising policies, and assumes no responsibility or endorses any claims or representation offered or expressed by advertisers. The Ontario Medical Review urges readers to investigate thoroughly any opportunities advertised.

EDITORIAL

ONTARIO MEDICAL REVIEW September 20107

IN THE FALL OF 2007, THE OMA BOARD OF DIRECTORS ENDORSED A BOLD AND INNOVATIVE STRATEGY

DESIGNED TO ENHANCE THE ROLE AND INFLUENCE OF PHYSICIANS IN LOCAL HEALTH-CARE PLANNING AND

DECISION-MAKING, AND TO PROMOTE IMPROVED PARTICIPATION AND CONNECTION AMONG GRASSROOTS

MEMBERS REGARDING ASSOCIATION INITIATIVES.

The commitment to Member Outreach, to revitalizing OMA Branch Society and District energies, and nurturing a decentralized image of the Association in the eyes of our members, reflected the findings of member surveys and rec-ommendations from physician leaders.

Also, with the advent of the Local Health Integration Networks (LHINs), the OMA Board recognized the need to put in place resources at the regional level that would provide support for local physician groups, and serve as an important conduit to foster link-ages between the medical community, LHINs, local hospitals and other health-care stakeholders.

As part of our strategy, the OMA hired seven regional managers across the province to work closely on a day-to-day basis with local physician leaders to advance the interests of the members at the community and regional level.

Effective health-system planning and improvement requires real input from local physicians. OMA regional man-agers have played an integral role in

establishing communication channels and face-to-face dialogue between the LHINs and local doctors. In fact, during the past three years, the OMA has facili-tated 61 joint workshops throughout Ontario involving almost 1,700 physi-cians and their respective LHIN officials.

The consultat ion process has proved useful in allowing physicians and the LHINs to exchange ideas and perspectives on issues regarding patient access to care, quality of care, and health resource allocation. More joint workshops are in the planning stages, and we will continue to develop avenues for members to offer advice and genuine input to the LHINs on local health priorities.

Recently, the OMA Board approved a report on the OMA’s regional phy-sician engagement strategy, which describes the experience to date, successes and challenges, and areas for continuing improvement.

Prepared by an independent firm, the report is based in part on feedback obtained from more than 100 LHIN leaders, OMA physician leaders, and

other health-care executives across Ontario, who provided comment on the impact of the OMA regional physician engagement strategy.

Overall, the impressions are very positive. We have made some impor-tant strides in establishing foundations and principles to bring together local physicians with the LHINs in health-care planning.

The OMA regional managers have established a strong presence in their respective territories and are a valuable network supporting the local member-ship, and raising awareness among physicians of various Association programs and services.

The full report, “Engaging Physicians in LHIN-based Health System Planning,” is available on the secure OMA mem-bers’ home page (www.oma.org).

Next month, the OMR will profile the many facets of the OMA regional phy-sician engagement strategy, what we have learned, and some recommenda-tions for future directions.

Dr. Mark MacLeod

OMA President

OMA regional physician engagement strategy bears positive results

ONTARIO MEDICAL REVIEW 8 September 2010

On August 20, more than two dozen OMA staff members, along with President Dr. Mark MacLeod, took part in the Heart and Stroke’s “Big Bike” fundraising event. In matching T-shirts, the members of “Team OMA” took to the streets of downtown Toronto on a bicycle built for 29. The OMA came out as the top fundraiser for the day, raising more than $10,000, including a generous gift of $3,000 from the Association. In addition, two of the day’s top-five individual fundraisers were from the OMA. Team members were proud of their fundraising success, and for putting their hearts into a great cause.

Team OMA raises more than $10,000 in Heart & Stroke “Big Bike” fundraiser

OMA President’s TourComing to various locations around Ontario

Please join OMA President Dr. Mark MacLeod and local OMA Board members for a complimentary dinner and discussion on local matters and interests.

As health care continues to evolve, it is important that we come together to discuss the challenges and solutions we face as physicians.

Please visit www.oma.org for event location and confirmation.

E-mail [email protected], or call 1.800.268.7215, ext. 3114, for more information.

Dates & Locations:Thunder Bay - September 9, 2010 *Toronto - September 15, 2010Brockville - September 30, 2010 *Hamilton - October 5, 2010 *Ottawa - October 18, 2010 *Mississauga - October 21, 2010 *Oshawa - October 27, 2010 *Kitchener/Waterloo - November 4, 2010 *Peterborough - November 11, 2010Simcoe - November 17, 2010 *Windsor - November 18, 2010 *

* Held in conjunction with District AGM

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BETTER HEALTH FOR YOU AND YOUR FAMILYThe OMA Physician Health Program is a confidential

service for physicians, residents, medical students

and their family members who may be experiencing

problems ranging from stress, burnout, emotional

or family issues, through to substance abuse and

psychiatric illness. The OMA Professionals Health

Program is a confidential service provided to health

professionals.

Confidential Toll-Free Line 1 800 851 6606

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FEATURE

ONTARIO MEDICAL REVIEW

“The OMA knew tha t members wanted additional member benefits, but it needed to validate and prioritize those through formal research,” said Dr. Virginia Walley, Chair of the OMA Member Services Board Co-ordinating Committee.

Feedback indicated that OMA mem-bers wanted programs that offered bet-ter value than current market discounts (or which provided exclusive benefits).

The research also suggested that members want the OMA to commu-nicate with them about revitalized ser-vices or new offerings as soon as they are available.

Before any new services/arrange-ments could be considered, the OMA recognized that a transparent, con-sistent and accountable process — aligned with the OMA mission, vision, goals and strategies — was essential.

To ensure that all discount and ben-efit programs meet OMA criteria, includ-ing financial and legal reviews, the OMA Board developed a “Policy on External Programs, Services, Partnerships and Sponsorships/Endorsements,” which was closely followed. With this process in place, the OMA moved forward with developing an affinity program — called “OMA Advantages” — for members.

Before engaging any partner, the

OMA considered the scope of programs and services to be offered to members, as well as the potential partner’s ongo-ing quality and accountability evaluation, key service indicators, decision-making processes, and the associated revenue or endorsement fee expectations.

Flexible, responsive and member-driven Because of its customization and responsiveness to member prefer-ences, the OMA Advantages program is unique compared with programs offered to other professionals.

For example, OMA members indi-cated high interest in air travel and CME travel. In response, the OMA entered into two key partnerships: Porter Airlines and Sea Courses Inc.

“Committed to offering speed, con-venience and service as part of a pre-mium travel experience, we believe Porter’s image correlates strongly with our members’ needs,” said Dr. Walley.

Additionally, through a carefully researched and negotiated partner-ship with Sea Courses Inc., an Alaskan cruise offering courses in Respirology, Sports Medicine and Internal Medicine sailed in July 2010. A Caribbean cruise offering continuing education in Sexual Health is planned for November 2010.

Park ‘n Fly at Toronto’s Pearson Air-port, as well as Via Rail, also offer OMA members a discount on all their rates.

For physicians who find themselves having to relocate as they progress through their careers, a partnership with Campbell Moving Systems offers reduced rates for moving, relocation and storage services.

Current and future member AdvantagesThe OMA continues to explore provid-ing other services suggested by the member survey, with a view to offer-ing a comprehensive affinity program aligned with member needs and prefer-ences.

In its ongoing commitment to help members better manage all aspects of their lives, the OMA Advantages pro-gram will deliver tangible value through an ever-growing array of special rates and services specifically tailored to member needs.

Fo r more i n fo rmat ion on the Advantages program, or to provide feedback or suggestions, please call 416.599.2580 or 1.800.268.7215 and speak to an OMA Response Centre Specialist, e-mail [email protected], or visit the OMA website ( www.oma.org/Advantages).

September 201010

www.oma.org/Advantages

OMA Membership has its “Advantages”exclusive affinity program offers benefits and discounts

tailored to member needs and preferences

by OMA Member Services

IN THE FALL OF 2008, THE OMA HIRED AN INDEPENDENT RESEARCH FIRM TO CONDUCT A QUANTITATIVE AND

QUALITATIVE STUDY, IN PART, TO BETTER UNDERSTAND MEMBER NEEDS AND PREFERENCES WITH REGARD TO

THE IMPLEMENTATION OF AN AFFINITY PROGRAM THAT WOULD OFFER BENEFITS AND DISCOUNTS TO MEMBERS.

Gold Tee

Media

Bronze Tee

On June 18, 2010 theOntario Medical Student Bursary

Fund (OMSBF) Charity GolfTournament raised more than

$150,000 towards medical student bursaries.On behalf of the medical students of Ontario and the Ontario Medical Foundation we would like

to extend our thanks to our generous sponsors for making this an overwhelming success!

Platinum Tee

Silver Tee

White Tee

For more information about the OMSBF and future Golf Tournaments please contact Sandra Zidaric, Senior Director.Phone: 1-800-268-7215 ext. 2985 or 2259, e-mail: [email protected],

http://omsbf.oma.org/Student/tournament/golftournament.htm


CMA Honorary MembershipAwarded to members having made outstanding contributions to the CMA on its Board of Directors, Committees, or General Council and/or have had significant involvement in Canadian medicine who have reached the age of 65 and has been an active member of the CMA for the preceding 10 years.

OMA Life MembershipAwarded to members who have made an outstanding con-tribution to the work of the Association in the interest of the medical profession. In addition to OMA-related involvement, work done to advance medical science and other positive work done at the provincial level can be considered. OMA Life Membership is awarded to members who have reached the age of 65 as of December 31 in the year preceding the annual meeting that the awards are to be presented. (Under excep-tional circumstances, candidates under 65 years of age may be considered.)

OMA Honorary MembershipOrdinarily awarded to a non-physician for having achieved eminence in science and/or humanities, such as outstanding service to the OMA, the medical profession, medical science or common good at the provincial level.

OMA Centennial AwardAwarded to a non-physician in recognition of outstanding achievements through lengthy service and/or distinguished acts in serving the health and welfare of the people of Ontario. One Centennial Award may be presented annually.

Distinguished Service AwardAwarded to a member of the Association for exceptional long-standing service to the OMA and the patients of Ontario. One award may be presented annually.

Advocate for Students AwardAwarded to a physician or non-physician in recognition of outstanding contributions that have significantly benefited the medical students of the province of Ontario. One award may be presented annually.

Presidential AwardAwarded to a member of the Association in recognition of exceptional and long-standing humanitarian service to the greater community (in Ontario or elsewhere) that brings honour to the medical profession. The award recipient, by his or her actions, expresses the highest qualities of service by a physi-cian that we all admire. One award may be presented annually.

Glenn Sawyer Service AwardAwarded to OMA members in recognition of significant service to the OMA, medical profession or public at the com-

munity level. One nomination from each branch society will be accepted, a maximum of 15 awards may be presented annually. The Glenn Sawyer Service Award may be awarded to any OMA member who has not yet received OMA Life Membership or CMA Honorary Membership. Community Service AwardAwarded to non-physician members of a community for sig-nificant contribution to the health and welfare of the people of a local community as defined by involvement in community health and public welfare, including length of involvement, roles fulfilled in local organizations, and personal achieve-ments. One award per Branch Society may be awarded annually.

Medical Student Achievement AwardAwarded annually to one student from each of the six provin-cial medical schools based on significant contributions at the political and/or community level that helps advance the life and/or education of all medical students. Nominations will be accepted from medical students via the Section representa-tives from each of the medical schools.

Resident Achievement AwardAwarded annually to one resident from each of the six pro-vincial medical schools for outstanding contribution to the advancement of postgraduate training. Nominations may be made by university professors, teaching faculties, the OMA Section of Interns and Residents and PAIRO. All nominations will be reviewed by the OMA Section of Interns and Residents and the Section will forward its recommendation(s) to the Awards Committee.

T.C. Routley Challenge ShieldAwarded to the Branch Society which most adequately fulfils its purpose of service to its members, community and profes-sion through programs and activities. Branch Societies apply through their District Executive with a report outlining their activities. Only one Shield is awarded annually.

Most awards will be presented during the 2011 OMA Annual

General Meeting, to be held in Toronto on Saturday, April 30,

2011.

Nominations should be submitted in writing with an attached

curriculum vitae by November 1, 2010 to:

Ms. Mary Ng

OMA Constituency Services

150 Bloor St. West, Suite 900

Toronto, Ontario M5S 3C1

Fax: 416.340.2244

E-mail: [email protected]

Call for Nominations 2011 OMA AwardsThe OMA is now accepting nominations for its 2011 Awards Program, in the following categories:

FEATURE


Dr. Renata Frankovich of Kanata wanted to be a sport medicine physi-cian from the day she entered medi-cal school. Her skills and passion have taken her to the Olympics in 2004 and 2008, and to the position of assis-tant chief medical officer, Health and Science Team, in the 2010 Olympics.

“My patients are not all elite athletes. I see people from rural areas, people who are trying to keep fit but they encounter strains and sprains, people who sustain work injuries, people with acute non-surgical problems, elderly patients who want to exercise for health, and people who have musculo-skeletal problems that are not respond-ing to first-line treatment,” she said.

Dr. Frankovich remarked that in the last few decades, lifestyles have changed, and Canadians have become more sedentary. On average, they have lower overall baseline fitness levels. When they do proceed to add activity to their lives, they’re often overzealous and end up overdoing it.

She feels that with the population

now so in need of keeping fit, it is only natural that doctors should provide exceptional specialized care. However, she feels that medical and surgical col-leagues have not always understood the role of the sport and exercise medi-cine doctor. Those thoughts are echoed by many physicians for whom sport-related injuries comprise a majority of their practice.

Dr. Dave Robinson of Stoney Creek is a family physician who holds a degree in kinesiology, and has a special interest in sport and exercise medicine. He has been the team doctor for the Hamilton Bulldogs hockey team for the past 11 years, and manages a variety of sports injuries.

He agrees with Dr. Frankovich. He said that the “weekend warrior” who may sit in an office all week and then attempt to exercise full force on the weekend is different from the profes-sional athlete who is active seven days a week.

“Those injuries sustained by non-professionals are often less serious,

but are just as disabling to the athlete. Musculoskeletal injuries account for up to 25 per cent of family practice vis-its, but a lot of family doctors are not always comfortable treating sports inju-ries. The advantages for the patient in seeing a sport and exercise medicine doctor are very real — reduced waiting times, sometimes less travel time, and effective treatment,” he said.

Dr. Robinson feels that the correct diagnosis is vital to getting the correct therapy. “Recognition is more likely with someone who sees these injuries on a regular basis,” he said.

Dr. Justin deBeer, assistant clini-cal professor, McMaster University, and ortho pedic surgeon at Hamilton Health Sciences Corporation, endorses sport and exercise medicine as a vital practice.

“In some cases, we are not talking about sports surgery, we are talking about sports medicine,” he said, noting that while some specialty-trained physi-cians and surgeons are very equipped to manage sports injuries, most have a different orientation and focus.

September 201014

Sport and Exercise Medicine:physician role reflects specialized knowledge,

diverse patient requirements

by Barbara Klich

TODAY’S FOCUS ON HEALTH FINDS THE GENERAL POPULATION, AND BABY BOOMERS IN PARTICULAR,

ACTIVELY INVOLVED IN ALL TYPES OF SPORTS AND EXERCISE FROM JOGGING, SWIMMING, WALKING, AND

GOLF, TO ORGANIZED TEAMS OF HOCKEY, SOCCER, AND TENNIS. WITH THIS THRUST TO BETTER HEALTH, THERE

IS ALSO AN INCREASE IN INJURIES, AND THIS MEANS THAT DOCTORS WHO SPECIALIZE IN THE TREATMENT AND

PREVENTION OF SUCH CONDITIONS ARE IN GREAT DEMAND. THE SPORT AND EXERCISE MEDICINE PHYSICIAN IS

BECOMING RECOGNIZED AS THE DOCTOR WITH SPECIALIZED KNOWLEDGE THAT WILL HELP THE PATIENT RESUME

A HEALTHY ACTIVE LIFESTYLE.


Sport and Exercise Medicine

15 September 2010

Dr. deBeer said that with every sports injury, you have an athlete who wants to get back into activity quickly. It makes sense for them to see a sport and exer-cise medicine specialist, whether they were trained as primary care physicians or Royal College-trained (e.g., some orthopedic surgeons).

Dr. deBeer pointed out that both categories of doctors are exceptionally skilled in diagnosis, treatment, rehabili-tation, prevention of injuries, as well as nutrition, training routines, bracing, and return to play decision-making. He feels that unless a physician or surgeon has specific training, the primary care sport and exercise medicine physician is the way to go.

Dr. Frankovich has been working with the OMA for over 10 years in an effort to have sport and exercise medi-cine recognized as a focused practice. Sport and exercise medicine has not been integrated into the current primary health care model in Ontario. However, she sees tremendous potential for the utilization of sport and exercise medi-cine physicians, working together with family physicians, to provide timely access for patients with musculoskel-etal problems who may not require the services of a traditional orthopedic sur-geon or rheumatologist.

Recently, the College of Family Phy -sicians of Canada has recognized sport and exercise medicine as an official focused practice. Sport and exercise medicine has long been recognized in the United States and in many European countries as a specialty.

There is currently a certification pro-cess in Canada through a diploma exam from the Canadian Academy of Sport and Exercise Medicine (CASEM.) This examination process is available to primary care physicians and specialty-trained physicians and surgeons alike.

Dr. Frankovich said that, in Canada, we are catching up with Europe and the United States when it comes to actual accreditation of sport medicine training fellowships, and the recognition of sport and exercise physicians as having a dis-tinct set of skills.

Dr. Wade Elliott, Chair of the OMA Section on Sport Medicine, noted that sport and exercise medicine is

increasingly recognized worldwide and has been a full specialty in the United Kingdom since 2005, has full spe-cialty status in Spain, Ireland, and New Zealand, and 19 European countries offer Sport and Exercise Medicine spe-cialization. In Canada, physicians have access to nine university primary care fellowship programs and orthopedic surgeons have several sub-specialty training options.

Dr. Elliott said that by establishing sport and exercise medicine as a spe-cialty, there will be more convenient access to care, avoidance of unneces-sary referrals to other specialists, and a resultant decrease in wait times to see the most appropriate “specialist.”

“In group practices, there will be an opportunity to incorporate sport and exercise medicine physicians to exist-ing and future group practice models. This will improve collegiality between group family physicians and sport and exercise medicine physicians,” he said, adding that it will also improve access to care for musculoskeletal problems for group practice patients.

Dr. Cathy MacLean, President of The College of Family Physicians of Canada, offered the following informa-tion in relation to recognition of sport and exercise medicine physicians.

“Family physicians with an interest in sport and exercise medicine have recently had their application approved for a program within the CFPC’s Sec-tion for Family Physicians with Special Interests or Focused Practices. The pro-gram will offer networking, advocacy, and continuing education activities for CFPC members who care for patients with sport or exercise related challenges.

“Once established, the program may consider applying for College Board approval for accredited enhanced skills training in sport and exercise medicine, which would support a limited number of R3 positions across Canada for fam-ily physicians that already hold certifica-tion in Family Medicine.”

This information was well received by Dr. John Bowman, a sport and exercise medicine physician who owns the Collingwood Sport Medicine and Rehabilitation Centre.

He said that there is a relat ive shortage of sport and exercise medi-cine physicians, and these changes should help attract more doctors to the field.

Dr. Bowman noted that although his community was once recognized as a destination for winter sports, it now offers a whole range of year-round rec-reational opportunities, and this has led to an influx of active retirees.

He hopes that policymakers recog-nize that sport and exercise medicine physicians also provide care for many patients who are not athletes. Sport and exercise medicine training focuses on the treatment of a broad range of musculoskeletal problems, including the management of acute and chronic neck and back pain.

“We can also counsel patients who have chronic health problems on appropriate physical activities,” he said, adding that not only are these valuable services for patients, they are also cost-effective by avoiding referrals to other specialists.

Barbara Klich is a Toronto-based freelance

writer.

FEATURE


Exercise in KidsDr. John Philpott, assistant profes-sor, Section of Community Pediatrics, University of Toronto, discussed the topic “Exercise in Kids.”

Dr. Philpott told delegates that less than half of Canadian children under the age of five are getting the recom-mended minimum of two hours of physical activity every day, which is essential to good health.

“We must note that 90% of children today begin watching television before their second birthday. Things have changed considerably since 1971, when the average age for children to start watching TV was four years old. In 2010, the average age is five months,” said Dr. Philpott. He added that, on weekdays, children are watching on average six hours of television a day, and seven hours a day on weekends.(Source: Active Healthy Kids Canada.

2010 report card overview: report card settings and indicators: how do the pieces of the puzzle fit together? [Internet]. Toronto, ON: Active Healthy Kids Canada; 2010 Apr 27. Available from: http://www.activehealthykids.ca/ReportCard/2010ReportCardOver view.aspx. Accessed: 2010 Aug 26).

He referred to a cartoon that sug-gested that years ago the familiar phrase for youngsters playing outdoors was “pass the ball;” now, as children sit on the couch and watch television or play video games, the phrase is “pass the chips.”

Dr. Philpott reported that, from a sci-entific rationale, exercise is positive:

“The biological effect of physical activity on the brain includes increased cerebral capillary growth, increased blood flow, increased oxygenation, enhanced production of neutrophins, neurogenesis, and enhanced neu-

rotransmitter levels. Associated physi-ological changes include improved at tent ion, improved in format ion processing, storage and retrieval, enhanced coping, and reduced sensa-tions of craving and pain.”

School activities such as phys-ed classes, recess play, classroom activ-ity, and extracurricular activities have been shown to enhance children’s academic performance by improving cognitive skills, as well as attitudes and academic behaviours.

Dr. Philpott urged doctors to con-sider the importance of the role that exercise plays in the development of children and teens. He suggested the following resources as guidelines:1. Graves L, Stratton G, Ridgers ND, Cable NT. Energy expenditure in ado-lescents playing new generation com-puter games. Br J Sports Med. 2008 Jul;42(7):592-4.

September 201016

Sport Med 2010 Symposium:key topics — exercise in kids, skin infection in athletes,

psychology during/post sport, nutrition in sport,

Sandy Kirkley Research Session presentations

by Barbara Klich

THE CANADIAN ACADEMY OF SPORT AND EXERCISE MEDICINE (CASEM) AND THE OMA SECTION ON SPORT

MEDICINE CO-HOSTED THE ANNUAL SPORT MED SYMPOSIUM, HELD JUNE 10-12 IN TORONTO. ABOUT

300 PHYSICIANS, THERAPISTS, COACHES AND TRAINERS FROM AROUND THE WORLD ATTENDED THE MANY

LECTURES, PLENARY SESSIONS, AND PRACTICAL WORKSHOPS OFFERED AT SPORT MED 2010. KEY TOPICS

ADDRESSED AT THIS YEAR’S EVENT INCLUDED EXERCISE IN KIDS, SKIN INFECTION IN ATHLETES, PSYCHOLOGY

DURING/POST SPORT, NUTRITION IN SPORT, AS WELL AS THE RESULTS FROM SEVERAL RESEARCH PAPERS

OUTLINING THE LATEST FINDINGS IN THE FIELD OF SPORT MEDICINE.


Sport Med 2010

17 September 2010

2. Ratey JJ. Spark: the revolutionary

new science of exercise and the brain. New York, NY: Little, Brown; 2008.3. Daley AJ. Can exergaming contrib-ute to improving physical activity lev-els and health outcomes in children? Pediatrics. 2009 Aug;124(2):763-71.4. Phi lpott J , Wi lson E, Luke A. The importance of exercise: know how to say “go”. Pediatr Ann. 2010 Mar;39(3):162-4, 166-8, 171.

Skin Infections in Athletes Dr. Andrea Moldes, a physician at the David Braley Sport Medicine and Rehabi l i tat ion Centre, McMaster University, conducted a workshop on “Skin Infections in Athletes.”

Dr. Moldes told attendees that skin infections occur commonly in athletes.

“The environments in which they compete, practise, and receive therapy provide opportunities for the transmis-sion of infectious organisms, and a breach in the skin from cuts or abra-sions further increases the risk of infec-tion,” she said.

Dr. Moldes reviewed guidelines from the National Collegiate Athletic Association (NCAA) for return-to-play criteria for athletes suffering with skin infections. She then added a word of caution, recommending that physi-cians double-check with the governing body of the sport in which the athlete is involved for completeness as there may be slight variations in the guide-lines among associations.

She outlined some of the common problem areas, noting that herpes sim-plex virus (HSV) infection appears to be epidemic among wrestlers and rugby players: “In wrestlers it’s called ‘Herpes Gladiatorum,’ and in rugby it’s called Herpes Rugbeiorum (Scrum Pox),” said Dr. Moldes.

The incubation period is five to 10 days. Lesions appear on the head, face and neck, and may involve the eyes; lesions can be extremely painful, there may be fever, malaise, and myalgias.

Clinical diagnosis can be confirmed with viral cultures, and symptom-atic treatment is with antiviral agents. Athletes with a history of recurrent her-pes infection could be considered for prophylaxis. With eye involvement, an

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Sport Med 2010

18 September 2010

ophthalmologist should be consulted. Dr. Moldes then outlined return-to-

play recommendations for athletes with HSV:

free of any new lesions for 72 hours; moist lesions and all lesions must have a firm, adherent crust.

of antiviral medication for 120 hours before, and at the time of, competi-tion.

be covered to allow participation.She reported that molluscum is

caused by pox virus, transmitted through towels, pool decks, and equip-ment, and the incubation period is two to seven weeks; it is typically found on hands, forearms, and face. In general, molluscum is self-limited, but may per-sist for six months, and then undergo spontaneous regression.

Return-to-play recommendations for molluscum:

before competition.

can be covered with a gas-perme-able membrane and tape.Impetigo is a highly contagious bac-

terial infection spread by skin-to-skin contact. There are two types of impe-tigo: bullous and non-bullous. The condition may resolve spontaneously, or may require systemic oral antibiot-ics for 10 days when lesions are wide-spread. Local debridement with soap and water may help. Complications include cellulites, lymphangitis, furun-cles, and scarring.

Return-to-play recommendations for impetigo:

athlete must take antibiotics for 72 hours before a competition, and be free of any new lesions for 48 hours.

non-permeable bandages during contact sport.

-ommend no contact sport until all lesions are resolved.Dr. Moldes warned that there is

growing concern about the presence and spread of methicill in-resistant staphylococcus aureus (MRSA) in

sport, with most cases being reported in college or pro football, and some outbreaks in wrestling and rugby. Since MRSA is resistant to penicil-lin and cephalosporins, severe cases may progress extremely rapidly from the initial presentation, with resulting endocarditis, necrotizing fasciitis, and septicemia.

Return-to-play guidelines for bac-terial skin infection were revised in June 2008, and state that:

any new skin lesions for 48 hours before a competition.

-dative or purulent lesions at meet or tournament time.

covered to allow participation.Dr. Moldes reported that fungal

infections include ringworm, athlete’s foot, jock itch, and may result from occlusive clothing, footwear, and hot and humid conditions.

Studies indicate that 24% to 77% of individuals on wrestling teams have fun-gal infections. Swimmers, runners, soc-cer, water polo, and basketball players experience tinea pedis (athlete’s foot) in epidemic proportions.

Dr. Moldes said that prevention of skin epidemics is key to avoiding unnec-essary morbidity, and minimizing disrup-tion in team practices and competitions.

Psychology During/Post Sport Dr. Douglas Misener, a kinesiologist and psychologist with the Toronto-based READ Clinic, specializing in rehabilitation and clinical psychology, presented on the topic of “Psychology During/Post Sport.”

Dr. Misener told delegates that the role of the sport psychologist should include providing athletes and danc-ers with the opportunity to express their feelings of doubt, concern and frustra-tion relative to their career lifespan, and to explore ways of broadening their social identity and role repertoire.

He said that it is important for ath-letes and dancers to develop a new non-sport, non-performer identity, and to assist them in experiencing feelings of value and self-worth throughout their careers and beyond.

“It helps if an athlete can identify with a role in addition to their professional role, for example, as a wife, husband, daughter, son, or parent,” said Dr. Misener.

He told delegates that doctors treat-ing athletes must guard against cogni-tive traps, such as poor communication with patients, buying into fad diagno-ses, bowing to economic pressures, and succumbing to pharmaceutical company influences.

“Athletes and dancers often do not consider their vulnerability should something happen to them that could affect their performance, and simply discussing those possibilities can be important,” he said.

Dr. Misener noted that while main-taining a work-life balance is vital for everyone, it is particularly important for the athlete.

He recommended that doctors who treat athletes and dancers watch for signs that trouble is imminent, “Such as when an individual is working too hard, avoiding work, not sleeping enough, sleeping too much, not eating, eating too much, being over anxious, being too relaxed, being irritable and avoiding friends, being too social, checking work over and over, being sloppy and miss-ing details, unable to let go of ideas, an inability to concentrate, exercising daily to the point of exhaustion, or not exer-cising at all.

“These are important signs that could indicate the person is out of bal-ance,” he advised.

Dr. Misener said that age is just one of many reasons why an athlete or dancer may choose to end a career. He reported that, according to the Dancer Transition Resource Centre in Toronto, the mean retirement age for dancers is 35 — with retirement typi-cally occurring later for contemporary dance, and sooner for ballet. The aver-age retirement age for the elite athlete is 33; National Football League player, 28; world-class wrestler, 24; and gym-nast, 19.

“For some athletes, the achievement of specific goals is a reason to retire — they want to leave while they are at the top of their game. While in other cases, retirement may result from injury. Some


Sport Med 2010

19 September 2010

athletes say that they are simply tired of a lifestyle that allows little privacy, and involves too much travel, too much time away from home, and dealing with the media. For others, the influence of family and friends may play a role as well, or they may simply feel that ‘it’s time to grow up,’ ” said Dr. Misener.

“There are those who become tired of the politics, such as dealing with the management of sport governing bodies. Financial situations may also influence retirement. Having interests other than sport, or simply being bored with a sport that no longer offers any fun, could also be cited as reasons to retire,” he said.

Dr. Misener noted that some individ-uals may “retire several times” because they are dissatisfied with their life when they are no longer engaged in sport or dancing.

“Whether the athlete is still active in sport or is retiring, it is wise to try and find balance. This comes from work-ing hard, sleeping enough, being moti-vated to do work, remaining calm, being somewhat social, being careful at work, focusing on tasks, and being energized,” he said.

Dr. Misener concluded his presen-tation by reminding delegates that developing good coping strategies, and maintaining a sense of humour, are very important for athletes and dancers both during their career, and in retirement.

Sandy Kirkley Memorial Lectureship: Nutrition in Sports, Running on EmptyThe 2010 Sandy Kirkley Memorial Lectureship, entit led “Nutrit ion in Sports, Running on Empty,” was pre-sented by Beth Mansfield, an Ottawa-based registered dietitian and certified exercise physiologist.

Ms. Mansfied told delegates that female athletes, especial ly those involved in endurance sports and weight class sports, are at risk of chronic energy deficiency through a reduction in their energy intake versus their energy output.

She said that this energy deficiency may occur “intentionally, compulsively, or inadvertently.” The athletes who do this intentionally may have body weight

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Sport Med 2010

20 September 2010

concerns (esthetic or performance related), and tend to follow restrictive eating patterns, restrained eating pat-terns, or disordered eating patterns; those athletes who do it compulsively have a tendency to supply needed energy after it is required, and there-fore “exercise to eat” versus “eating to exercise;” those who may be inadver-tently following an energy deficiency pattern may have a poor biological drive to match energy intake to energy expenditure, and may be on a tight food budget. Poor grocery shopping skills or food preparation skills may also play a role.

Ms. Mansfield reported that by reducing their dietary energy intake, or by increasing their exercise energy expenditure, athletes may lower their energy availability to the point where the body’s other processes cannot function properly (resulting in condi-

tions such as hypoestrogenemia). “Since female athletes appear to eat

less than would be expected for their level of physical activity, their diet and exercise habits tend to distribute them along a spectrum of energy availability between energy balance and extreme low-energy availability.

“Ninety per cent of athletes state they are not eating properly, 84% do not eat an hour before working out, 76% wait an hour or longer to eat fol-lowing exercise, only 10% eat six times a day, and 45% report having days when they don’t have enough energy to exercise,” said Ms. Mansfield.

She described the risk factors for low energy availability (LEA) as any factor that increases expenditure or reduces energy intake, such as prolonged exercise training to develop greater endurance or to promote weight loss; restrictive eating behaviours; dieting to

lose weight or fat for health, or for par-ticipation in sports that require a thin body, or to improve appearance in bathing suits, bikinis; and an attitude that excessive exercise and weight loss are normal, or even desired, character-istics of good athletes.

She suggested that doctors treat-ing female athletes should help develop and manage energy availability with the following guidelines:l. Design a baseline energy budget

using the following valid body com-position test or resting metabolic rate test:

(fat-free muscle) for weight loss;

growth and CHO loading;

times.2. Focus on micronutrients of concern,

e.g., iron, calcium, and vitamin D.3. Make changes in diet and eat-

ing behaviours to match seasonal changes in the training program.“In female athletes, a diagnosis of

functional hypothalamic amenorrhea is a bioassay for under-nutrition — ‘the dead canary in the physiological mine-shaft,’ ” she warned.

Ms. Mansfield concluded her presen-tation by listing the following important points that should be addressed with the female athlete: the ability to train without undue fatigue, fast recovery between training sessions, and main-tenance of body composition, optimal biological functioning, and absence of health and performance issues.

Sandy Kirkley Research SessionsSeveral research papers covering a wide range of topics were presented during the Sandy Kirkley Research Sessions at Sport Med 2010. Following are brief excerpts from a selection of the papers presented, which outline the latest important research in the field of sport medicine:

Does an Athlete’s Level of Fitness Impact the Report of Concussion Symptoms?This study, which was carried out at the Glen Sather Sports Medicine Clinic,

Tips for Treating Physically Active Patients

“When competing at altitude, athletes should avoid caffeinated beverages and

alcohol. Remember, ‘the happy mountaineer pees clear.’ ”

Dr. Michael Koehle, assistant professor, University of British Columbia

“In female athletes, a diagnosis of functional hypothalamic amenorrhea is a

bioassay for under nutrition — the dead canary in the physiological mineshaft.”

Beth Mansfield, registered dietitian, Ottawa

“No Canadian provinces or territories are meeting the Canadian physical activity

guidelines of 90 minutes of exercise each day for children.”

Dr. John Philpott, assistant professor, University of Toronto

“The Medical Code of Ethical Practice Guidelines is to protect the athlete, prevent

malpractice, and prevent unethical care.”

Dr. Margo Mountjoy, IOC Medical Commission

“Appropriate surveillance of the frequency of skin infections will allow sports

medicine staff to promptly identify outbreaks, and take necessary measures to

contain further transmission and prevent future outbreaks.”

Dr. Andrea Moldes, McMaster University

“The take home message is that, even basic perception, when it is working

well, can still be lousy — we all make mistakes.”

Dr. Douglas Misener, psychologist, Women’s College Hospital


Sport Med 2010

21 September 2010

University of Alberta, measured the relationship between an athlete’s level of fitness, and self-report of concussion symptoms. Study findings concluded that conditioning may play a significant role in an athlete’s report of concussion symptoms. Further study considering the impact of deconditioning on sub-jective symptoms following concussion may be helpful for clinical decision-making when progressing an athlete back to play.

The Efficacy of Hip Strengthening Exercises Compared to Leg Strengthening Exercises on Knee Pain, Function, and Quality of Life in Patients with Knee OsteoarthritisThis study, which was undertaken by the Dalhousie University Faculty of Medicine and the University of Calgary, compared the efficacy of isolated hip and leg strengthening exercise pro-grams on pain, function, and quality of life of knee osteoarthritis (OA) patients. The study concluded that isolated hip and leg strengthening exercise pro-grams appear to similarly improve pain, function, and quality of life in OA patients, with a trend for greater improvement with the completion of leg exercises.

Does Pre-Surgery Wait for Total Knee Replacement Affect Pain, Function, and Health-Related Quality of Life Six Months After Surgery?This study from Laval University, Quebec, concluded that longer pre-surgery wait time has a negative and clinically important impact on health-related quality of life, and contralateral knee pain six months after surgery. The study not only emphasized the impor-tance of wait-time reduction, but sug-gested that further research should evaluate the effect of optimized con-servative management and preventive rehabilitation on the outcome of total knee replacement surgery.

The Efficacy of Sclerotherapy With a Solution of Dextrose and Lidocaine to Treat Chronic Achilles Tendinopathy: One Year Follow-UpResults of this study from the University of Calgary and Foothills Medical Centre

These six additional serotypes caused up to 48% of residual IPD in 2007 in children <5 years.1

Serotypes 19A, 6A and 3 have emerged as the predominant pneumococcal serotypes causing IPD in Canadian children, accounting for approximately 1/3 of residual IPD in 2007 in children <5 years.†1

19A is increasingly likely to be resistant to commonly used first-line antibiotics.1

Very common ( 10%) and common ( 1% and <10%) adverse events associated with Prevnar® 13 include fever, any injection-site erythema, induration/swelling or pain/tenderness, decreased appetite, irritability, drowsiness, increased sleep, restless sleep/decreased sleep, diarrhea, vomiting, rash.1

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As with all injectable vaccines, appropriate medical treatment and supervision must always be readily available in case of a rare anaphylactic event following administration of the vaccine.1

Minor illnesses, such as mild respiratory infection, with or without low-grade fever, are not generally contraindications to vaccination. The decision to administer or delay vaccination because of a current or recent febrile illness depends largely on the severity of the symptoms and their etiology. The administration of Prevnar® 13 should be postponed in subjects suffering from acute severe febrile illness.1

As with any intramuscular injection, Prevnar® 13 should be given with caution to infants or children with thrombocytopenia or any coagulation disorder, or to those receiving anticoagulant therapy.1

Prevnar® 13 will not protect against Streptococcus pneumoniae serotypes not included in the vaccine. Prevnar® 13 will not protect against other microorganisms that cause invasive disease, pneumonia, or otitis media. This vaccine is not intended to be used for the treatment of active infection.1

As with any vaccine, Prevnar® 13 may not protect all individuals receiving the vaccine from pneumococcal disease.1

The use of the pneumococcal conjugate vaccine does not replace the use of 23-valent pneumococcal polysaccharide vaccine (PPV23) in children 24 months of age with sickle cell disease, asplenia, HIV infection, chronic illness, or who are otherwise immunocompromised.1

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Product Monograph available on request.

1. Prevnar® 13 Product Monograph. Wyeth Canada, December 21, 2009. 2. Prevnar® Product Monograph, Wyeth Canada, December 22, 2008. 3. Synflorix™ Product Monograph, GlaxoSmithKline, May 5, 2009.

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Sport Med 2010

22 September 2010

concluded that the long-term effects of sclerotherapy appear to decrease over the course of one year. The study sug-gested that sclerotherapy be evaluated for its efficacy and safety as a mainte-nance therapy option whereby patients are permitted further injections when symptoms resurface.

Measuring Self-Report Symptoms in Concussion: Data Collection Variables This study from the Glen Sather Sports Medicine Clinic, University of Alberta, investigated the differences in report-ing of concussion symptoms among college athletes. It concluded that self-report may be an optional method for obtaining concussion symptoms in athletes.

Knee Joint Kinematics of Anterior Cruciate Ligament (ACL) Deficient Subjects During Closed Kinetic Chain ExercisesThe results of this study from Medical

Sciences, Ahvaz, and Tehran, Iran, indicate that ACL deficient knees are unstable at low flexion angles while per-forming leg-press exercises. Extreme caution is suggested when prescribing leg-press exercise at low flexion angle for ACL rehabilitation, particularly at the early stages after injury and/or recon-struction. Further studies are needed to investigate the safety of various closed kinetic chain exercises for rehab of ACL deficiencies.

Predicting Patient Outcome on Non-Operative Treatment for a Chronic Rotator Cuff TearThis study was presented jointly by the University of Calgary and University of Western Ontario. It concluded that baseline rotator cuff quality-of-life questionnaire score can predict which patients will be successful with non-operative treatment, and which patients will fail non-operative treat-ment for chronic, full-thickness rotator cuff tear.

Examining the Effect of Three Different Stability Categories of Footwear on the Presence and Severity of Running-Related Injuries: A Prospective, Randomized Cohort StudyThis study was the work of the Allan McGavin Sports Medicine Centre, University of British Columbia. Study findings demonstrate that wearing motion-control shoes in neutral or pro-nated foot types carries a significant risk of experiencing running-related pain in women runners. The Prevalence of Bicycle Helmet Use in Ontario in the Absence of Comprehensive Legislation: An Observational StudyThis study was the work of research-ers from the University of Toronto, York Univers i ty , and Think F i rst Canada. The study concluded that, in the absence of legislation requiring bicyclists of all ages to wear a helmet, half of users in Ontario are opting to ride without head protection. The sig-nificant variance in helmet-use prev-alence between morning commuter bicyclists and midday bicyclists sug-

gests that campaigns to improve hel-met use could have the most impact i f targeted at the non-commuter cyclist. Societal-level interventions are warranted to improve helmet use in Ontario.

Assessment of the Relationship Between Incremental Blood Lactate Profiling and Competitive Performance in Elite SwimmersThe University of Toronto, Hospital for Sick Children, and Canadian Sport Centre presented the results of this study, which concluded that critical velocity as derived from the 7 x 200 protocol provides useful information concerning competition performance. No other variables could be correlated to performance, which may indicate a need for re-evaluation of the stand collection of additional extraneous variables.

Intra-Articular Lidocaine Versus Intravenous Sedation for the Reduction of Anterior Shoulder Dislocations in the Emergency Department This study, presented by the University of Western Ontario, found that while previous studies have shown success rates with intra-articular lidocaine (IAL) similar to those with intravenous seda-tion, the UWO study did not support this, with physicians recording inade-quate analgesia as the most common reason for failure of IAL.

R. Tait McKenzie and Kinemedics AwardHeather Hines of London, Ontario, was the recipient of the R. Tait McKenzie and Kinemedics Award. This award is presented annually to the best research paper written and presented by a sports medicine fellow, resident, medical school student, or graduate student. Ms. Hines won for her paper entitled, “Intra-Articular Lidocaine Versus Intravenous Sedat ion for the Reduction of Anterior Shoulder D is loca t ions i n the Emergency Department.”

Barbara Klich is a Toronto-based freelance

writer.

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Smokers’ Helpline Quit Connection: fax referral service available for physicians with patients who smoke

Physicians can agree that quitting smoking is one of the best decisions a person can

make for his or her health. Physicians are in a unique position of influence to help

patients quit their use of tobacco products.

The majority of tobacco users want to quit, and patients often respond posi-

tively to their physician’s advice. Research indicates that success rates for quitting

tobacco can increase significantly when there is even brief clinical intervention — and

an intervention by a physician can take as little as three minutes.

A brief intervention with a patient can be as simple as following the “5As” model:

your patient if he or she uses tobacco.

your patient to quit.

your patient’s readiness to quit smoking.

your patient to quit smoking.

a follow up by obtaining a patient’s consent to fax a signed form to

Smokers’ Helpline for counselling.

The Smokers’ Helpline Quit Connection is a free, confidential telephone referral

service offered by the Canadian Cancer Society. Staffed by trained tobacco cessa-

tion specialists known as “Quit Coaches,” the service uses proven tools to integrate

brief interventions by physicians with more intensive counselling for patients.

Referral to the Smokers’ Helpline is quick and easy, enabling physicians to spend

their time as efficiently as possible. With the patient’s consent, the physician simply

completes the Smokers’ Helpline Quit Connection Confidential Fax Referral Form

(available online at: www.smokershelpline.ca) on the patient’s behalf, and faxes it to

1.877.513.5334.

Once the form is received, a Smokers’ Helpline Quit Coach will aim to contact

the patient within 24 hours of referral. Once contact has been made, and the patient

agrees to participate in the program, the Quit Coach will assess the patient’s readi-

ness to quit. The Quit Coach will use established protocols to provide appropriate

services related to the patient’s tobacco use and stage of change.

Quit Coaches counsel patients by phone using a “motivational interviewing” and

“stages of change” model. They will assist patients with developing a personal-

ized quit plan, finding information about quit aids, coping with cravings, withdrawal

symptoms and stress, and finding local resources in their community. All patients

are offered free self-help materials and proactive follow-up counselling.

Smokers’ Helpline services also include an online program and text messaging

support. Smokers’ Helpline is available in English, French, and through an interpreter

service by phone.

As health-care professionals, physicians have access to free materials for their

patients, as well as resources to assist them in referring patients for free counselling.

To learn more about Smokers’ Helpline, or to download a Smokers’ Helpline

Quit Connection Confidential Fax Referral Form, visit the Smokers’ Helpline web-

site at: www.smokershelpline.ca. For more details, contact a Smokers’ Helpline

Co-ordinator in your region at 1.877.513.5333, or e-mail: smokershelpline@ontario.

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INTRODUCTIONWhat is the Education and Prevention Committee (EPC)?The Ministry of Health and Long-Term Care and the Ontario Medical Association (OMA) have jointly established the Education

and Prevention Committee (EPC). The EPC’s primary goal is to educate physicians about submitting OHIP claims that accu-

rately reflect the service provided so that the need for adjustment of inappropriately submitted claims is reduced.

What is an Interpretive Bulletin?Interpretive Bulletins are prepared jointly by the Ministry and the OMA to provide general advice and guidance to physicians

on specific billing matters. They are provided for education and information purposes only, and express the Ministry’s and

OMA’s understanding of the law at the time of publication. The information provided in this Bulletin is based on the July 1,

2010 Schedule of Benefits – Physician Services (Schedule). While the OMA and Ministry make every effort to ensure that this

Bulletin is accurate, the Health Insurance Act (HIA) and Regulations are the only authority in this regard and should be referred

to by physicians. Changes in the statutes, regulations or case law may affect the accuracy or currency of the information pro-

vided in this Bulletin. In the event of a discrepancy between this Bulletin and the HIA or its Regulations and/or Schedule under

the regulations, the text of the HIA, Regulations and/or Schedule prevail.

EPC Bulletins and all other Ministry bulletins are available on the Ministry website at: http://www.health.gov.on.ca/english/

providers/program/ohip/bulletins/bulletin_mn.html.

September 2010

Education and Prevention Committee Interpretive Bulletin - Volume 8, No. 6

Specialist Assessments and Consultations

25

PurposeThe purpose of this Bulletin is to provide information to spe-cialists on the proper billing of assessments and consulta-tions specifically with regard to practising:

-tising as a family/general practitioner).

Concerns identifiedTwo primary concerns have been identified by the Ministry:1. Some specialists are submitting claims for services listed

in a specialty section of the Consultation and Visits sec-tion of the Schedule when working in a primary care set-

2. Some specialists are submitting claims for assessments listed in the “Family Practice & Practice in General” list-ings of the Schedule when practising within the scope of their specialty.

What is a specialist?The Schedule defines a specialist on page GP5. For OHIP



26

billing and payment purposes, your specialty designa-tion is determined by the documentation (i.e. certification from the College of Physicians and Surgeons of Ontario) that you provided when you registered for an OHIP billing number, or when you notified the Ministry of additional specialty credentials which allow you to bill for services listed under identified specialties under the Consultations and Visits section of the Schedule.

Specialist billing for assessments and consultationsGeneral payment rules are listed on page GP10. They describe when a specialist should use fee codes list-ed under one of the specialty-specific listings of the Consultations and Visits section of the Schedule, and also when the specialist should use fee codes under the “Family Practice & Practice in General” listings.

When should specialists use the general listings under “Family Practice & Practice in General”? When an insured service rendered by a specialist does not fall within the scope of the specialist’s practice and/or the specialist is providing primary care in a family or general practice setting, the service is only eligible for payment when the claim is submitted using the appropri-ate code from the “Family Practice & Practice in General” listings. When should specialists use the specialty listings? When a service rendered by a specialist comprises part of an insured consultation or assessment that falls within the scope of the specialist’s practice, the specialist should use the appropriate specialty listing in the Consultations and Visits section of the Schedule. Certain categories of services that may be billed by all specialties are stated on page GP10, and include services such as counselling and psychotherapy. These services are not listed in the Consultations and Visits section of the Schedule but are defined within the General Preamble.

Examples

Example 1A gynecologist sees some patients on an annual basis for a “well-woman check,” whereby she performs a history and physical examination consisting of vital signs, breast exam and pelvic exam. Can she claim a general assessment for the service?

No, the gynecologist is practising within the scope of her specialty and should claim the appropriate assessment within the specialty.

Example 2A physician who is an internal medicine specialist works at a busy walk-in clinic one day a month and sees children and adults for a variety of problems typically seen in this setting. As the physician is providing primary care in a gen-eral practice setting, the services are only eligible for pay-ment when the claims are submitted using the appropriate code from the “Family Practice & Practice in General” part of the Consultations and Visits section of the Schedule, such as intermediate or minor assessments (A007, A001), or A888.

Example 3Dr. Anes sees a patient in a pre-operative clinic one day prior to surgery, where he will provide the anesthesia. The patient has not been referred for a consultation. Can Dr. Anes bill a pre-dental/pre-op general assessment for the assessment rendered?

No, part of the anesthetic service includes a pre-anes-thetic evaluation. Specialists may only claim A903 if they are acting outside of the scope of their specialty, and all required elements of a general assessment are rendered. A903 is a fee code within the “Family Practice & Practice in General” part of the Consultation and Visits section of the Schedule, and is a fee code that is intended to be billed by family/general practitioners when they render the service. The required elements of a general assessment are listed on page GP18 of the Schedule and include a full history and physical examination.

Example 4Dr. Specped is a pediatrician who works part time in the local after-hours clinic. For adult patients seen in the after-hours clinic, Dr. Specped is not eligible for pay-ment of services listed under the Pediatrics heading of the Consultations and Visits section of the Schedule (i.e. A265, A260, A662, etc.). He and the other physicians working in the after-hours clinic should claim the services listed in the “Family Practice & Practice in General” part of the Consultation and Visits section of the Schedule (i.e. A001, A007, A888).



Your feedback is welcomed and appreciated!The Education and Prevention Committee welcomes your feedback on the Bulletins in order to help ensure that these are effective educational tools. If you have comments or questions on this Bulletin, or suggestions for future Bulletin topics, etc., please submit them in writing to:

Physician Services Committee Secretariat150 Bloor Street West, 8th Floor

Toronto, Ontario M5S 3C1Fax: 416.340.2961

E-mail: [email protected]. Jane MacNaughton, Co-Chair

Dr. Larry Patrick, Co-ChairEducation and Prevention Committee

The PSC Secretariat will anonymously forward all comments/suggestions to the Co-Chairs of the EPC for review and consideration.

For specific inquiries on Schedule interpretation, please submit your questions IN WRITING to:Health Services Branch, Physician Schedule Inquiries

370 Select Drive, P.O. Box 168Kingston, Ontario K7M 8T4

NOW INDICATED FOR THEPREVENTION OF MAJORCARDIOVASCULAR EVENTS1

CRESTOR® and the AstraZeneca logo are trade-marks of the AstraZeneca group of companies. Licensed from Shionogi & Co Ltd, Osaka, Japan. © AstraZeneca 2010

CRESTOR is also indicated as an adjunct to diet, at least equivalent to the Adult Treatment Panel III (ATP III TLC diet), for the reduction of elevated total cholesterol (Total-C), LDL-C, ApoB, the Total-C/HDL-C ratio and triglycerides (TG) and for increasing HDL-C; in hyperlipidemic and dyslipidemic conditions, when response to diet and exercise alone has been inadequate, including: primary hypercholesterolemia (Type IIa including heterozygous familial hypercholesterolemia and severe nonfamilial hypercholesterolemia); combined (mixed) dyslipidemia (Type IIb); or homozygous familial hypercholesterolemia where CRESTOR is used either alone or as an adjunct to diet and other lipid-lowering treatment such as apheresis.

In the JUPITER trial, there were no statistically significant treatment differences between the CRESTOR and placebo groups for death due to cardiovascular causes or hospitalizations for unstable angina.

The majority of patients are controlled at the 10 mg dose.

A dose of 20 mg once daily has been found to reduce the risk of major cardiovascular events.

CRESTOR is contraindicated in patients who are hypersensitive to any component of this medication; in patients with active liver disease or unexplained persistent elevations of serum transaminases exceeding 3 times the upper limit of normal; in pregnant and nursing mothers and in patients using concomitant cyclosporine. CRESTOR 40 mg is contraindicated in patients with predisposing factors for myopathy/rhabdomyolysis and in Asian patients.

Rare cases of rhabdomyolysis with acute renal failure secondary to myoglobinuria have been reported with CRESTOR and with other HMG-CoA reductase inhibitors.

CRESTOR, as well as other HMG-CoA reductase inhibitors, should be used with caution in patients who consume substantial quantities of alcohol and/or have a past history of liver disease.

Patients who develop any signs or symptoms suggestive of myopathy should have their CK levels measured. CRESTOR therapy should be discontinued if markedly elevated CK levels (> 10 x ULN) are measured or myopathy is diagnosed or suspected.

In the JUPITER trial, CRESTOR 20 mg was observed to increase plasma glucose levels, which were sufficient to shift some prediabetic subjects to the diabetes mellitus status.

Most commonly reported adverse events in hypercholesterolemia vs. placebo were headache (1.4% vs. 2.2%), abdominal pain (1.7% vs. 2.2%), flatulence (1.8% vs. 2.7%) and nausea (2.2% vs. 1.6%).

Most commonly reported adverse events in prevention of major cardiovascular events vs. placebo were urinary tract infection (8.7% vs. 8.6%), nasopharyngitis (7.6% vs. 7.2%), back pain (7.6% vs. 6.9%) and myalgia (7.6% vs. 6.6%).

See the Product Monograph for full contraindications, warnings, precautions, dosing and administration.

Reference: 1. CRESTOR® Product Monograph. AstraZeneca Canada Inc. April 28, 2010.

CR977E 05/11

COUNT ON

In adult patients without documented history of cardiovascular or cerebrovascular events, but with at least two conventional risk factors for cardiovascular disease, CRESTOR is indicated to:

▪ Reduce the risk of nonfatal myocardial infarction▪ Reduce the risk of nonfatal stroke▪ Reduce the risk of coronary artery revascularization


INTRODUCTIONWhat is the Education and Prevention Committee (EPC)?The Ministry of Health and Long-Term Care and the Ontario Medical Association (OMA) have jointly established the Education and Prevention Committee (EPC). The EPC’s primary goal is to educate physicians about submitting OHIP claims that accu-rately reflect the service provided so that the need for adjustment of inappropriately submitted claims is reduced.

What is an Interpretive Bulletin?Interpretive Bulletins are prepared jointly by the Ministry and the OMA to provide general advice and guidance to physicians on specific billing matters. They are provided for education and information purposes only, and express the Ministry’s and OMA’s understanding of the law at the time of publication. The information provided in this Bulletin is based on the July 1, 2010 Schedule of Benefits – Physician Services (Schedule). While the OMA and Ministry make every effort to ensure that this Bulletin is accurate, the Health Insurance Act (HIA) and Regulations are the only authority in this regard and should be referred to by physicians. Changes in the statutes, regulations or case law may affect the accuracy or currency of the information pro-vided in this Bulletin. In the event of a discrepancy between this Bulletin and the HIA or its Regulations and/or Schedule under the regulations, the text of the HIA, Regulations and/or Schedule prevail.

EPC Bulletins and all other Ministry bulletins are available on the Ministry website at: http://www.health.gov.on.ca/english/providers/program/ohip/bulletins/bulletin_mn.html.


Questions and Answersrelevant to recent EPC Bulletins, including:

Special Visit Premiums (Vol. 7, No. 1),

Most Responsible Physician Premiums (Vol. 8, No. 1),

and Smoking Cessation (Vol. 8, No. 2)

30

PurposeThe purpose of this Bulletin is to share several ques-tions and answers submitted to the Physician Services Committee (PSC) by physicians for response by the EPC. As noted at the end of EPC Bulletins, the PSC forwards questions anonymously to the EPC, which in turn provides the answers to the PSC for response to the physician.

Although most of the following questions and answers have been included in their original form, some have been edited, where necessary, to clarify meaning and/or provide additional context.

Special Visit PremiumsQuestion 1There have been numerous rejections by OHIP on the billing of these codes during after hours and weekends by myself and others I know. For example:You are on-call on the weekend and are called in from home to the hospital to see two or more patients: what are the bill-ing codes for a consultation, plus the special visit premium, plus the travel premium? Similarly, what are the billing codes after 5:00 p.m. during weekdays?



31

Response 1The EPC cannot specifically respond to questions on why claims are being rejected. If you have questions about specific services, or why a service may have been reject-ed, you should contact your local OHIP claims office.

With regard to your questions on what the appropriate fee code(s) would be, the answer would depend on the service(s) rendered (e.g., specialty specific assessment or consultation) and, for the special visit premium(s), the location of where the service is rendered. The following may be helpful:

Location TableSchedule Page

Emergency department (non-ED physician)

Table 1 GP57

Hospital outpatient Table II GP57

Hospital inpatient Table III GP58

LTC home Table IV GP58

Emergency for ED physician on-call to the ED

Table V GP59

Home Table VI GP60

Palliative care home visit Table VII GP61

Physician office Table VIII GP61

Other (non-professional setting)

Table IX GP62

As stated on page GP56, use the “A” prefix assessment fee code from the General Listings when claiming a special visit premium. Specific to physicians on-call for the emergency department, you must also record on the patient’s common medical record the time of the request and the reason for the request for attendance. For all other locations, the time the special visit was rendered must be on the patient record.

When travel is required from one location to another (e.g., from home to the hospital), the travel premium may be eli-gible for payment. A first person seen premium may also be eligible when travel is required, and if additional patients are also seen during that visit, the additional person seen premium may also be eligible for payment (up to the maxi-mum) if a request is made for a special visit to the additional person(s) seen.

An example — assuming you are an internal medicine spe-cialist (13) on-call for the Hospital Inpatients (see Table III): Your first call comes on Saturday at 8:00 a.m. to consult

on a hospital inpatient. You are eligible for the Consultation (A135 for internal medicine), the travel premium and the first person seen (C963 and C986). While there, you are asked to see another patient. You are eligible for the additional person seen (C987). You return home. You are called again on Saturday at 6:30 p.m. to see three patients who have deteriorated that day. Assuming you render the service described by a medical specific assessment, you are eli-gible for three A133s for the assessments, the travel premi-um, the first person seen and two additional persons seen (C963, C986 and two C987s). With regard to your question on which special visit fee codes are eligible for weekdays after 5:00 p.m., please refer to the appropriate table based on the location of the visit.

Question 2In reading Vol. 7, No. 1 of the Interpretive Bulletin wherein you discussed special visit premiums, I need to know more of the B962. I would very much appreciate further informa-tion on this code. I provide in-home service and often have to travel 45 minutes each direction to get to a patient’s home. This is a cost-prohibitive service, so this transit fee would be most welcome. Response 2EPC Bulletin Vol. 7, No. 1 references the October 1, 2009, version of the Schedule of Benefits for Physician Services, however, a newer version, effective July 1, 2010, now exists. The most current and up-to-date Schedule is always available electronically on the Ministry website at: http://www.health.gov.on.ca/english/providers/program/ohip/sob/sob_mn.html. With regard to fee code B962, this is the travel component of the special visit premium for non-elective home visits (evenings, Monday through Friday). A premium may be eligible for payment when you are required to travel from one location to another location (the destination location) in order to see a patient.

See Table VI on page GP60 of the Schedule for the appro-priate special visit fee codes for Home visits.

Example 1: If you are making a non-elective visit to a patient’s home (e.g., apartment building) and are required to travel from one location to the patient’s home to provide the service on an evening from Monday to Friday, you are



32

eligible for payment of the house call assessment (A901), a special visit premium for the first person seen (B994), and the travel component (B962). If you see other patients at the same home or multiple-resident dwelling (see the “Note” on page GP60), you are not eligible for payment of the special visit premiums for the other patient(s) seen.

If you see two patients who reside in the same apartment building (whether in the same unit or not) on the same visit, you are only travelling once to the apartment build-ing. Therefore, you are only eligible for one travel premium (B962) and one first person seen premium (B994). You are eligible for the appropriate assessment code for the second person seen (other than a general assessment). If you must then travel to another location (i.e. not the same home, dwelling or building complex), then you are eligible for the travel premium component, the first person seen and A901. Please note that there is a maximum of two travel premiums (B962) payable for non-elective special visits per day (evenings, Monday through Friday), and a maximum of 10 first person seen premiums (B994) per day. This means that, while you may still be required to travel from one loca-tion to another, you cannot claim more than two travel pre-miums; however, you may still be eligible for the first person seen premium at a new location, provided the requirement to travel from one location to the destination location has been met, and you have not exceeded the maximum. See Example 1 in the EPC Special Visit Premium Bulletin. You must also record, on the patient’s chart, the time of the special visit in order for the services to be eligible for payment.

Smoking Cessation Counseling (E079 and K039)

Question 1Re: your excellent explanation for E079 and K039.But in my practice, as a community cardiologist, more than 10% of my patients do not have a family doctor. Many of my patients still smoke! What code should I use if I do smoking cessation counselling?

Response 1E079 and K039 are Family/General Practice codes listed on page A25 of the Schedule of Benefits. These services are eligible for payment to the primary care physician most

responsible for the patient’s ongoing care. If you are see-ing a patient as a cardiologist and you provide counselling for smoking cessation, you may be eligible for payment of a K013/K033 counselling service, provided the require-ments of counselling are met. However, note that counsel-ling codes are not payable in addition to an assessment or consultation. Question 2Re: E079 in Bulletin Vol. 8, No. 2.In Examples 1 and 2, is E079 eligible for payment if the patient seen does not have a family physician to provide ongoing care? Response 2No, if a patient does not have a primary care physician who is most responsible for providing ongoing care, the service is not eligible for payment to any physician.

Question 3I wanted to comment on the Bulletin in the February 2010 OMR regarding E079/K039. I am a practicing family physi-cian and I noticed many of my E079 codes were getting rejected by OHIP. I started covering a walk-in clinic on the weekends, and the front desk told me the other physicians in the walk-in all add an E079 automatically to ALL smok-ers, regardless of reason for the visit. This annoys me to no end! So, I am the one counselling these patients for 20 to 30 minutes in my office and see them regularly, yet I can’t get reimbursed for it because they went to a walk-in at some point in the last year! I think the E079 and K039 should be for enrolled patients only, that way, walk-in doctors can’t claim it on a five-minute appointment for a cold! The hon-our-system is obviously not working! Response 3Thank you for your comments. Unfortunately, the EPC is not able to address your concerns specifically; however, we will forward your comments to the Medical Services Payment Committee (MSPC), a joint OMA/Ministry com-mittee tasked with, among other things, making recom-mendations for fee codes and payment requirements. If you would like to make a complaint to the Ministry regard-ing the specific patients for whom your claims for the smok-ing cessation services were disallowed and paid at zero with an explanatory code M1 (maximum fee allowed or maximum number of services has been reached by same/any provider), please provide:



33

-ing cessation claims have not been paid, in writing, to: Health Services Branch, Manager, Payment Integrity, 370 Select Drive, P.O. Box 168, Kingston, ON, K7M 8T4.

Alternatively, a copy of the remittance advice highlighting these unpaid claims may be submitted.

Question 4For smoking cessation codes, do I have to bill an E079 every 365 days to claim two subsequent K039 that year following each E079? Or can I bill K039 twice a year after billing an E079 once ever? Response 4A smoking cessation follow-up visit (K039) is eligible for pay-ment up to two times in the 12-month period following the initial visit (E079). K039 is not eligible for payment, unless an initial discussion has occurred in the 12-month period prior to the claim. The simple answer to your question (“Or can I bill K039 twice a year after billing an E079 once ever?”) is no. If the patient continues to smoke, the initial discussion must occur again no sooner than 12 months after the ser-vice was last provided.

Most Responsible Physician (MRP) admission assessment and subsequent visit premiums (E382 and E083)

Question 1I admit a patient for a bladder tumour resection. This is a Z-code. Can I charge E082 on day of admission, and E083 for subsequent hospital visits and discharge?

Response 1Provided the patient is an inpatient and you are the MRP, and you have rendered the admission assessment and are not receiving additional remuneration for the provision of clinical MRP services (as stipulated on page GP32 and GP37), and provided the patient is not receiving a non Z-code surgical procedure in conjunction with the Z-code procedure, then you are eligible for payment of E082 for the admission assessment and for E083 for the subsequent visits and discharge assessment, provided the services are rendered in accordance with the Schedule. Question 2I admit a patient for a prostate resection. This is an S code.

Can I charge E083 for subsequent post-op visits and day of discharge?

Response 2As stated on page SP1 of the Schedule, for non Z-prefix services, the specialty-specific subsequent visit may be claimed only for the first and second in-hospital post-op vis-its. The E083 premium may be eligible on the first two post-op visits, provided you are the MRP and are not receiving additional remuneration for the provision of clinical MRP services (as stipulated on page GP37). Similarly, the pre-mium also applies to the discharge assessment, which, if you are the MRP, would be billed as C124.

Question 3Please take a look at the following scenario and clarify the legitimacy of claiming the E codes:

A hospitalist group works days, Monday to Friday, cover-ing inpatients and getting a weekly stipend. It is clear that when billing the E082 and E083 codes, the group members should expect a decrease in the hospital stipend by the amount of these E codes.

Here’s the question:For any nights and weekends that these physicians work on-call as MRPs (not as hospitalists), they should be able to bill the E082/083 codes just as any other non-hospitalist would, correct? If, on the other hand, these physicians cannot bill these premiums independent of the hospitalist stipend, then why should another internist or family doctor doing call bill these?

Response 3Fee codes E082 and E083 are premiums for eligible servic-es provided by the Most Responsible Physician. The MRP is defined on page GP4 of the Schedule as “the attend-ing physician who is primarily responsible for the day-to-day care of a hospital inpatient.” If a physician receives direct or indirect remuneration from the hospital (or hospital foundation) for rendering inpatient clinical services, then the remuneration must be reduced by at least the amount that would be eligible for payment from the premium. This applies regardless of the time or day that the service is pro-vided. As previously stated, the premium is only eligible for payment to the patient’s MRP, therefore, another physician performing on-call duties, who may not be the MRP, is not eligible for payment of the premium.



Your feedback is welcomed and appreciated!The Education and Prevention Committee welcomes your feedback on the Bulletins in order to help ensure that these are effective educational tools. If you have comments or questions on this Bulletin, or suggestions for future Bulletin topics, etc., please submit them in writing to:

Physician Services Committee Secretariat150 Bloor Street West, 8th Floor

Toronto, Ontario M5S 3C1Fax: 416.340.2961

E-mail: [email protected]. Jane MacNaughton, Co-Chair

Dr. Larry Patrick, Co-ChairEducation and Prevention Committee

The PSC Secretariat will anonymously forward all comments/suggestions to the Co-Chairs of the EPC for review and consideration.

For specific inquiries on Schedule interpretation, please submit your questions IN WRITING to:Health Services Branch, Physician Schedule Inquiries

370 Select Drive, P.O. Box 168Kingston, Ontario K7M 8T4


PAIRO names 2010 award recipients

The Profess ional Associat ion of Internes and Residents of Ontario recently named the recipients of the 2010 PAIRO Awards.

Excellence in Clinical TeachingThis award acknowledges the essen-tial role that clinical teachers play in the training of new physicians. Residents are asked to outline the qualities that make their nominee an excellent teac h er. The recipients of the 2010 award are:

Ophthalmology

Lois H. Ross Resident AdvocateThis award is presented to one indi-

-

Residency Program Excellence

who are expertly trained to deal with the challenges in their upcoming careers.

FEATURE


Regardless of what you read, two common themes emerge: the first is “speed, speed, speed” of the perfor-mance of your overall IT solution; the second is “focus on workflow.” You need to address both so that your EMR does not slow you down while you work toward the ultimate goal of a chartless office.

Speed assessment requires site vis-its and examining a real-life install that closely resembles your office in size and scope (we’ll discuss the “speed” aspect of EMRs in a future article).

The second prominent theme — workflow assessment — is described below.

Workflow assessmentOne time-tested and proven approach to assist workflow focus is the tech-nique of taking something apart, piece by piece, and then reassembling it from its component parts to understand how it works. It is something we have all done, although usually outside the context of our practice, perhaps with a hobby or athletic skill. This technique is helpful when looking for a suitable EMR,

implementing it, upgrading with new modules, and optimizing as the years go by.

Understand your existing workflow by deconstructing itTo best understand your current office workflows, you need to deconstruct them. The purpose in deconstructing is to gain knowledge of how things work and, more importantly, to expose areas of weakness or inefficiency, bottlenecks in the flow of paper, patients or staff, and areas of high risk for error or omission.

This is a kitchen table exercise. Include those who work with you —the office manager, office assistants, allied health professionals, and any IT resources you currently have. This will ensure that all perspectives are brought to the table.

You will need a sketch of your office floor plan, some coloured markers, an open mind and a critical eye.

Pick a standard practice workflow (see sidebar on p. 37) and complete its life cycle. For example, if you look at appointment workflow, start from the initial request through to appointment

follow-up and capture each step in between (arrival, health card validation or direct pay clarification, roster status and demographic validation/updates, patient movement from reception to waiting room then exam room, clinical team member movements, and then back out to reception to schedule follow-up). Sketch it out, draw a schematic, follow the patient and staff through the office, and really take it apart.

Critically deconstruct your workflow from the perspective of the patient, the provider, and the health-care system.

Each viewpoint is valid, and within a workflow the focus may shift from one viewpoint to another. When in doubt where to weight your decisions, I sug-gest the patient’s perspective will ulti-mately serve all well.

Reconstruct your workflow to optimize ITNow that you understand the details of a workflow, you must reconstruct it with desirable EMR features in mind. Aim for substantial improvements and think about the complete life cycle of the workflow.

September 201036

Electronic Medical Records

Successful EMR adoption: optimizing your workflow

by Stephen McLaren, BSc, MD, CCFP, FCFP

MUCH HAS BEEN WRITTEN ABOUT THE ADOPTION OF ELECTRONIC MEDICAL RECORDS. IF YOU GOOGLE “EMR

BENEFITS,” “EMR ACQUISITION,” OR ANYTHING RELATED TO EMRs, YOU WILL HAVE A WEEKEND OF READING

AHEAD OF YOU. IF YOU ARE LOOKING FOR A HELPFUL WORKBOOK APPROACH TO EMR ADOPTION, THEN REFER

TO ONTARIOMD’S TRANSITION SUPPORT PROGRAM FOR A HOST OF VALUABLE TOOLS (VISIT ONTARIOMD.CA AND

FOLLOW THE LINKS).


Successful EMR Adoption

37 September 2010

You identify desirable features when you envision what an EMR could do or how it could help. When you start think-ing about where a feature would be used, you have moved to reconstruct-ing a workflow with an EMR.

Most workflows involve more than one person, so seek to maximize clinical time for clinicians, and to shift administrative activities to non-clinical staff. You may find that a certain EMR feature seems laborious, adding time or effort at some points of a workflow, but other parts end up being so improved

that the reconstructed workflow is demonstrably superior.

Next stepsWorkflow deconstruct/reconstruct will help you identify EMR features that are the best ones for you to focus on to achieve more desirable workflows, resulting in improved patient care and office efficiency. Having done this hard work, you will be prepared to make an appropriate product selection, increas-ing your chance of EMR selection success. And once selected, imple-

mentation will succeed when you har-ness your EMR’s features by training for workflow to yield superior clinical and business processes.

Even if you are a well-established EMR site, the deconstruct/recon-struct technique remains valid, espe-cially when you have a significant EMR upgrade, or change in practice model, or just desire to optimize a component of your practice.

Dr. Stephen McLaren has been in prac-

tice since 1984 and is a member of the

Markham Family Physicians and Markham

Family Health Team. He has used an EMR

for 11 years. He is an active Peer Leader in

OntarioMD’s Peer Leader Program, funded

by Canada Health Infoway to offer mentor-

ing services to help physicians adopt an

EMR. He has also been a physician advisor

for Canada Health Infoway.

If you would like a Peer Leader to answer

your questions and support your adop-

tion of an OntarioMD certified product, a

service which is free for physicians, e-mail:

[email protected].

The EMR Adoption column is co-ordinated

by OntarioMD, a subsidiary of the Ontario

Medical Association, funded by eHealth

Ontario. For more information on EMR

Adoption, visit www.ontariomd.ca, e-mail

[email protected], or call toll-free

1.866.744.8668.

Dr. Stephen McLaren of Markham is an experienced EMR user and Peer Leader, who

mentors physician colleagues in the adoption of electronic medical records into practice.

Standard Practice Workflow

1. Demographics, billing and tracking

2. Scheduling

3. Incoming document management

4. In-office messaging

5. Encounter notes

6. Laboratory ordering and results

7. Medication and allergy management

8. Consultation requests

9. Third party requests

10. Data output, practice analysis, and population (roster) health

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FEATURE


in politics to consider getting involved in the 2011 provincial election. The OMA can also provide information to physi-cians interested in learning more about seeking a political nomination.

The OMA recently asked Dr. Eric Hoskins, Minister of Citizen ship and Immigration, and MPP for the riding of St. Paul’s, about his decision to enter politics, his work as an MPP, and his experiences at Queen’s Park.

Why did you decide to enter politics and run for elected office?Prior to entering politics, I worked as a family doctor in Toronto, and I helped to run a not-for-profit that worked inter-

nationally to help children who have been affected by armed conflict. That work helped give me a tremendous appreciation for the im por tant role of government in creating peaceful, sta-ble communities with strong health and social programs. It also taught me about the importance of working locally to build strong, resilient societies. I want to be able to contribute to that.

How does your experience as a physician help you in your daily life at Queen’s Park?At the heart of caring for patients is the ability to interact with people from a diversity of backgrounds, and to develop relationships of trust with them. We are taught to be good lis-teners, and, fundamentally, to be empathetic. Those relationships and those skills give physicians excellent insight into the human condition — into the wonderful things that people experience in their lives, but also into the challenges they face. Over the 20 years that I have practised medicine, I have learned that as much as we treat people for their medical needs, there are so many other challenges they face that affect their health. Whether it’s poverty, violence, housing — the so-called social determinants of health —

these are things that we can fix as part of a progressive, caring government, and I’m proud that our government has been able to make tremendous improvements in these areas.

Why would you encourage other doctors to consider running for elected office?Doctors know how to diagnose a prob-lem, come up with a treatment plan, and work collaboratively to make people healthier. That’s exactly what we need from our politicians. The same tools that doctors use to treat patients — helping, healing, strengthening, and listening — are tools that help government serve our citizens in a better way. But in order to apply that set of tools in a political con-text, we have to redefine how we think of “patients.” In the same way that we apply those tools in a traditional medi-cal context to treat individual patients, those are tools that doctors can use to help treat societal problems and make a difference through public service.

What advice do you have for other physicians who are considering running for elected office? My advice would be to bring who you are. Bring and apply your skillset and your empathy to the political process.

September 201038

Political Action Update — MD Candidate Primer

Dr. Eric Hoskins offers inside look at life as a physician MPP:

the challenges and rewards of elected office

by Robyn Cassidy

OMA Public Affairs and Communications Department

A STRONG PHYSICIAN PRESENCE IN THE ONTARIO LEGISLATURE IS AN IMPORTANT ASSET TO THE MEDICAL

PROFESSION, AND HELPS ENSURE THAT PHYSICIAN ISSUES ARE WELL REPRESENTED AT QUEEN’S PARK.

SINCE 2004, FOUR PHYSICIANS HAVE BEEN ELECTED AS MEMBERS OF PROVINCIAL PARLIAMENT (MPPs), WHICH IS

APPROXIMATELY FOUR PER CENT OF ALL MPPS. THE OMA IS ENCOURAGING PHYSICIANS WHO ARE INTERESTED

MPP for St. Paul’s Dr. Eric Hoskins.

Pho

to: M

PP

Eric

Hos

kins

’ Offi

ce

Physician Assistants

The Ministry of Health and Long-Term Care has announced a two-year grant to fund job opportunities for 21 newly graduated McMaster Phys ic ian Ass istants (PAs) . The Health ForceOntario Marketing and Recruitment Agency (HFO MRA) is providing centralized assistance for both potential employers and the PA graduates. The grant will assist approved employers with the costs of employing a new Ontario PA graduate.

Based on calls received by the OMA, it appears that there is signifi-cant physician enthusiasm for working with PAs.OMA Staff Contact: Carol Jacobson (ext. 2984)

Government’s Quality Agenda

The OMA, Ontario Hospital Asso ci ation, and the Registered Nurses’ Association of Ontario (RNAO) have been meeting with the Ministry of Health and Long-Term Care over the summer to provide advice regarding implementation of the “Excellent Care for All Act.” The group is also addressing the implications of gov-ernment’s amendment of Regulation 965 under the Public Hospitals Act

affecting physician participation on hos-pital boards. A report is to be submitted to the Minister of Health and Long-Term Care in September, and an announce-ment is expected to be made shortly thereafter.OMA Staff Contact: Andrew MacLean (ext. 2883)

OMA and OHA to Discuss Prototype Bylaws

The OMA and Ontario Hospital Associ-ation have agreed to meet to discuss the Prototype Bylaws put forward uni-laterally by the OHA earlier this year. All hospitals have been advised by the OHA and OMA to take this develop-ment into consideration, as discus-sions should be completed in the near future. Physicians are advised that if your hospital is still proceeding with a bylaws revision, it is important to con-tact OMA Legal Services as soon as possible for advice regarding possible areas of contention.OMA Staff Contact: Andrew MacLean (ext. 2883)

Auto Insurance

On November 2, 2009, the Ministry of Finance announced 41 auto insurance

reforms based on recommendations contained in the Financial Services Commission of Ontario (FSCO) Five Year Report, released last year. The reforms include a new Statutory Accidents Benefit Schedule (SABS), which is effective as of September 1, 2010. Under section 25(5) of the new SABS, recovery from the insurer for the costs of any one assessment or examination was limited to $2,000. On July 13, 2010, this provision was amended. The $2,000 restriction now also applies to preparing reports in connection with any one assessment or examination.

As the OMA first identified in its May 2009 submission to the Ministry of Finance, the $2,000 limitation on assessments, examinations, and now related reports, is unreasonable. It is the OMA’s position that physicians must retain their discretion to set appropriate payment schemes as out-lined by the “OMA Physician’s Guide to Third Party and Other Uninsured Services.” We will continue to inform members of any developments related to this issue.OMA Staff Contact: Juhee Makkar (ext. 2978)

September 201040

Physician Assistants

Government’s Quality Agenda

OMA and OHA to Discuss Prototype Bylaws

Auto Insurance

by OMA Health Policy Department

HEALTH POLICY REPORTA summary of current health legislation and policy developments


Bagshaw, John Irwin, Hamilton;

University of Western Ontario, 1953.

July 2010 at age 85.

Barton, Harris Lee, Ottawa;

Dalhousie University, 1978.

June 2010 at age 58.

Bryson, William, Fonthill;

University of St. Andrews, 1945.


Cameron, Christopher Stephen,

Bolton; McMaster University, 1979.


Corrin, Bernard Norman, London;



Foley, Patrick Christopher, Ancaster;

National University of Ireland, 1957.

May 2010 at age 79.

Franczak, Edwin John, Scarborough;


May 2010 at age 72.

Goldenberg, Gerald J, Toronto;

University of Manitoba, 1957.


Gordon, Sheldon David, Thornhill;

University of Toronto, 1973.


Gow, Walter Semple, Peterborough;

McGill University, 1949.

May 2010 at age 85.

Hegde, Anand Purushotnam,

Tavistock; University of London, 1966.


Herzenberg, Andrew,

Toronto; University of Toronto, 1996.

May 2010 at age 38.

Lakin, Francis H G, Collingwood;

University of Aberdeen, 1960.


Lamontagne, Gaetan Romain,

Hearst; University of Ottawa, 1956.


Malkus, Edmund,

London; Dusseldorf University, 1948.

May 2010 at age 89.

McPherson, Gordon Ross,

Amherstburg; University of Western

Ontario, 1960.

May 2010 at age 75.

Nault, Michael A,

Kingston; Queen’s University, 2002.


Prentice, Alexander Whiteley,

Mississauga; Society of Apothecaries

of London, 1955.


Radonjic, Dragoljub V,

Ottawa; Beograd University, 1957.

May 2010 at age 78.

Woloschuk, Eugene,

Toronto; Laval University, 1953.



IN MEMORIAMThe OMA would like to express condolences to the families and friends of the following members.

The OMA publishes brief notices about deceased members as a service to their colleagues. Information concerning these members should

be sent to [email protected].


Tools to support your uninsured services program:

point-of-service terminal facilitates “real-time” payment, enhanced practice efficiencyby Jonathan Marcus, MD, CCFP

PRACTICE MANAGEMENT

Is your uninsured services program (USP) working for you? Are you being paid on

time and in full for all the uninsured services you provide? If not, you are essentially

working for free. Installing a point-of-service terminal in your practice is one of the most

effective ways to help improve the convenience and efficiency of your USP.

Providing uninsured services to patients can take up a significant amount of a physician’s time, yet obtaining pay-ment for these services is an issue that is rarely examined or addressed. One reason for this is that many physicians are uncomfortable discussing the topic of money with their patients.

Some physicians choose to deal with their discomfort by providing unin-sured services for free, thus absorbing the administrative costs and burdens; others simply avoid performing certain services they view as optional, such as prescription repeats by phone. Neither of these approaches is ideal.

In a best-case scenario, physicians would respond to patient requests while being paid fairly and expediently for each uninsured service they provide.

Many physic ian off ices s imply mail invoices to patients for any unin-sured services rendered. Payment is received when patients mail back cheques, which have to be deposited and logged. Not only is this process labour intensive and time-consuming,

but unless the medical practice is very diligent about following up on unpaid debts, a significant number of these bills go uncollected.

Fortunately, the availability of elec-tronic point-of-service (POS) terminals has made the task of obtaining pay-ment for uninsured services much more efficient and convenient by allow-ing invoicing and collection to occur at the same time the service is provided (i.e. in “real time”). This increases office efficiency and decreases the number of unpaid bills, minimizing the need for collection of overdue accounts.

POS terminals can accept credit card or debit card payments. They can be used to collect fees either in person or over the phone, which is convenient for both patients and the medical prac-tice. The POS payment process sim-plifies transactions and banking tasks, and, most importantly, significantly increases the collection rate.

It costs little to set up and maintain a POS system. There is an initial one-time set-up fee, a monthly charge to

maintain the account, and a per-trans-action fee that is either a flat fee or a percentage of the transaction. Many financial service companies can pro-vide the service.

Physicians who currently charge for only a few of the uninsured services they provide will find that installing a POS system will make it much easier and convenient to begin charging for all uninsured services offered by the practice.

Charging patients for services that were previously provided at no cost may be a little awkward at first. However, if the charge, and the reason behind it, are explained to the patient prior to the service being provided (e.g., the next time the patient books an appointment), and the practice policy regarding unin-sured medical services is clearly com-municated (e.g., via notices posted in the waiting room, examination rooms, and physician offices), rest assured that patients will soon acclimate.

It is always best for physicians and medical office staff to communicate


PRACTICE MANAGEMENT

positively to patients about uninsured services charges, keeping in mind that being paid for uninsured services ben-efits patients as well as the medical practice.

One context where this communica-tion is particularly important is in charg-ing for missed appointments. This can be awkward as it is the only uninsured service that patients don’t request. Our office explains to patients: “We hate to have to charge you, but it is expensive running a medical practice. And, our no-show rate is about 10%. Because we respect patients’ time and do not double-book appointments, we unfor-tunately have no choice but to charge.” In this manner, patients are made aware of the rationale for the fee, and recognize that it is not a punishment.

It is also best for the practice to be consistent with uninsured services bill-ing. Consider charging for all uninsured services, unless there is good reason not to do so, such as a patient’s inabil-ity to pay. In this case, consider reduc-ing the fee instead of charging nothing. Even if a decision is made not to charge for a particular service, it is important to inform the patient that there normally is a fee involved, which is not being applied, and explain why.

The practice should list a fee for every uninsured service available. Any service that is not part of an insured service is, by definition, uninsured. In order to develop a complete list, physicians are strongly encouraged to review the 2010 “OMA Physician’s Guide to Third Party and Other Uninsured Services,” which is updated annually and posted on the OMA website.1 Physicians should also note what colleagues are doing in this regard, and regularly update the prac-tice’s fee schedule.

Consider using POS with all unin-sured services that are provided in real time, even those that transpire over the phone, such as prescription repeats. For phone services, it is best to obtain payment prior to performing the service.

Some exceptions to using POS to charge for uninsured services in real time may include missed appoint-

ments, block fee payments,2 and trans-fer of medical records. Invoicing for these services by mail is likely a more realistic option, although a patient can choose to call in, or drop by, to pay for mail-invoiced services using the POS terminal.

Obtaining payment at the time an uninsured service is provided will help take your USP from being an after-thought or a necessary burden to an indispensable part of the practice. POS terminals make things easier for your practice and convenient for patients. Take a lesson from the POS terminal itself — there’s no time like now!

Resources

1. The OMA “Physician’s Guide to Third

Party and Other Uninsured Services” is a

valuable practice re source, and provides

guidance for physicians and office staff on

un insured and third party requested ser-

vices, suggested fees, relevant policies,

and interpretations of pertinent regula-

tions. The January 2010 edition of the

Guide is available online at: https://www.

oma.org/Member/Resources/Documents/

ThirdPartyGuide.pdf

2. General information on the topic of block

fees was presented in an article entitled

“Im plementing a successful block billing

plan, and billing for uninsured services:

seven steps for success, tips for educating

staff & patients, FAQs,” which appeared

in the March 2009 edition of the OMR. To

obtain a PDF copy of the article, please

e-mail your request to: [email protected]

Dr. Jonathan Marcus is a family physician,

entrepreneur, and adjunct lecturer in the

University of Toronto Department of Family

and Community Medicine. He writes and

speaks on health-care innovation from the

ground up.

The Practice Management column is pro-

v ided by the OMA Member Serv ices

Department. Do you have a topic or ques-

tion you would like to see appear in the

Ontario Medical Review? Please let the

Practice Advisory Service team know at

416.340.2911, or 1.800.268.7215, ext. 2911,

or e-mail: [email protected].


Mortgage life insurance:options to consider when buying a homeby OMA Insurance Services

INSURANCE UPDATE

If you are a homeowner, or thinking of becoming one, it is likely that you have been

strongly encouraged to purchase mortgage life insurance from your lending institution.

It is important to know that you are not obligated to take this insurance from the bank

where you obtained your mortgage, and that there are other options available.

Mortgage life insurance is purchased in order to guarantee that any outstand-ing mortgage debt you may have at the time of your death will be paid off in full. This certainly sounds good — at least on paper.

But did you know that the mortgage life insurance offered by lending insti-tutions is essentially a Term Life insur-ance policy that names the institution as the beneficiary? In addition, lending institution representatives may have aggressive insurance sales quotas they need to meet, they may be unlicensed, and may not be adequately trained to explain all the details and legalities of their institutions’ insurance plans.

What if you could purchase mort-gage life insurance — essentially, Term Life insurance — directly from the OMA? You can.

The OMA is your Association — we understand your professional and per-sonal needs. OMA Insurance coverage offers product flexibility and competitive rates.

Benefits of purchasing mortgage life insurance through the OMA

You’re in control: when mortgage life insurance is purchased through a lending institution, the only option avail-able for the proceeds from the insur-ance policy is to pay off the mortgage in full. With the OMA Group Term Life policy, not only do you decide how the proceeds of the policy will be paid, but to whom they will be paid. Your desig-nated beneficiary has the option of pay-ing off your mortgage in full, using all or part of the funds to replace lost income, to invest, or to cover other expenses, such as children’s tuition fees.

Get the most for your money: with mortgage life insurance purchased through a lending institution, the premi-ums you pay to the lender remain con-stant, while your death benefit declines with your mortgage. In addition, non-smokers and smokers pay the same rate, whereas with the OMA Group Term Life policy, non-smokers pay sig-nificantly less.

Alban Moran, Senior Consultant, OMA Insurance Services, explains another financial benefit: “Only OMA members are eligible for the OMA Group Term Life program. As a non-profit pro-gram, any surplus may be refunded to members at the end of each year. Since the OMA Life programs were initiated in 1956, our insureds have received a premium refund each December, while also enjoying the OMA’s affordable and comprehensive coverage.”

When purchasing any mortgage life insurance, be sure to fully explore your options before deciding how you wish to protect your family.

For assistance in finding the right insur-

ance solutions to suit your needs, or to find

out more about the OMA’s new Term Life

plan, contact your non-commissioned OMA

Insurance Advisor at 1.800.268.7215, ext.

2971, or e-mail [email protected].

Additional information is also available on

the Insurance Services website (http://www.

omainsurance.com).


As with any vaccine, Prevnar® 13 may not protect all individuals receiving the vaccine from pneumococcal disease.

The use of pneumococcal conjugate vaccine does not replace the use of 23-valent pneumococcal polysaccharide vaccine (PPV23) in children

24 months of age with sickle cell disease, asplenia, HIV infection, chronic illness, or who are otherwise immunocompromised. Data on sequential vaccination with Prevnar® 13 followed by 23-valent pneumococcal polysaccharide vaccine are not available; data on sequential vaccination with Prevnar® (7-valent) vaccine followed by PPV23 are limited.

As with all injectable pediatric vaccines, the potential risk of apnea should be considered when administering the primary immunization series to premature infants. The need for monitoring for at least 48 hours after vaccination should be considered for very premature infants (born

30 weeks of gestation) who remain hospitalized at the time of the recommended administration. As the benefit of vaccination is high in this group of infants, vaccination should not be withheld or delayed.

Immunization with Prevnar® 13 does not substitute for routine diphtheria immunization.

Adverse Reaction Seriousness and Incidence

Very common ( 10%) and common ( 1% and <10%) adverse events associated with Prevnar® 13 include fever, any injection-site erythema, induration/swelling or pain/tenderness, decreased appetite, irritability, drowsiness, increased sleep, restless sleep/decreased sleep, diarrhea, vomiting, rash.

During the 13 controlled clinical trials, Serious Adverse Events (SAEs) that the investigator considered related to study vaccine were reported for 6 out of 4,729 subjects (0.1%) in the Prevnar® 13 group.

To report a suspected adverse reaction, please contact the Public Health Agency of Canada:By toll-free telephone: 866-844-0018By toll-free fax: 866-844-5931By web: http://www.phac-aspc.gc.ca/im/vs-sv/index-eng.php

Primary ImmunizationFor infants, the recommended immunization series of Prevnar® 13 consists of three doses of 0.5 mL each, at approximately 2-month intervals, followed by a fourth dose (booster) of 0.5 mL at 12–15 months of age (3+1 schedule). The customary age for the first dose is 2 months of age, but it can be given as young as 6 weeks of age. The recommended dosing interval is 4 to 8 weeks. The fourth dose should be administered at approximately 12–15 months of age, and at least 2 months after the third dose.

Prevnar® 13 Vaccine Schedule for Infants and Toddlers

Dose Dose 1a Dose 2b Dose 3b Dose 4c

Age at Dose 2 months 4 months 6 months 12–15 months

a. Dose 1 may be given as early as 6 weeks of age.

b. The recommended dosing interval is 4 to 8 weeks.

c. The fourth dose should be administered at approximately 12–15 months of age, and at least 2 months after the third dose.

Previously unvaccinated older infants and children:

For children who are beyond the age of routine infant schedule, the following Prevnar® 13 schedule applies:

Prevnar® 13 Schedule for Previously Unvaccinated Children 7 Months through 5 Years of Age

Age at First Dose Total Number of 0.5 mL Doses

7–11 months of age 3a

12–23 months of age 2b

24 months through 5 years of age (prior to the 6th birthday)

1

a. 2 doses at least 4 weeks apart; third dose after the one-year birthday, separated from the second dose by at least 2 months.

b. 2 doses at least 2 months apart.

Therapeutic ClassificationActive Immunizing AgentIndications and Clinical UsePrevnar® 13, Pneumococcal 13-valent Conjugate Vaccine (Diphtheria CRM197 Protein), is indicated for the active immunization against Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F and 23F, causing invasive pneumococcal disease (including sepsis, meningitis, bacteraemic pneumonia, pleural empyema and bacteraemia), in infants and children from 6 weeks through 5 years of age.

ContraindicationsHypersensitivity to any component of the vaccine, including diphtheria toxoid

Use in Special PopulationsPregnant Women: Safety during pregnancy has not been established.

Nursing Women: Safety during lactation has not been established. It is not known whether vaccine antigens or antibodies are excreted in human milk.

Pediatrics: The safety and immunogenicity of Prevnar® 13 in children below the age of 6 weeks or on or after the 6th birthday have not been established.

Geriatrics: The safety and immunogenicity of Prevnar® 13 in geriatric populations have not been established.

General

As with all injectable vaccines, appropriate medical treatment and supervision must always be readily available in case of a rare anaphylactic event following the administration of the vaccine.

Minor illnesses, such as mild respiratory infection, with or without low-grade fever, are not generally contraindications to vaccination. The decision to administer or delay vaccination because of a current or recent febrile illness depends largely on the severity of the symptoms and their etiology. The administration of Prevnar® 13 should be postponed in subjects suffering from acute severe febrile illness.

As with any intramuscular injection, Prevnar® 13 should be given with caution to infants or children with thrombocytopenia or any coagulation disorder, or to those receiving anticoagulant therapy.

Prevnar® 13 will not protect against Streptococcus pneumoniae serotypes not included in the vaccine. Prevnar® 13 will not protect against other microorganisms that cause invasive disease, pneumonia, or otitis media. This vaccine is not intended to be used for treatment of active infection.

If Prevnar® 13 is given as part of a routine infant immunization program, a three-dose (2+1) schedule may be considered. The first dose may be given from the age of 2 months, with a second dose 2 months later, and a third (booster) dose is recommended between 11–12 months of age. Lower immunogenicity responses for serotypes 6B and 23F were observed when Prevnar® 13 is given as a two-dose (e.g., at 2 and 4 months of age, or at 3 and 5 months of age) schedule in infants up to 6 months of age. After the booster dose, all vaccine serotypes had immune responses consistent with adequate priming with a two-dose primary series.

1. Institut national de santé publique du Québec, Rapport d’activités 2008–2009 du Laboratoire de santé publique du Québec. 2. Prevnar® 13 Product Monograph, Wyeth Canada, December 21, 2009.

3. Prevnar® Product Monograph, Wyeth Canada, December 22, 2008.

4. Synflorix™ Product Monograph, GlaxoSmithKline, May 5, 2009.

SUPPLEMENTAL PRODUCT INFORMATION Adverse Reactions

Expected frequency of adverse reactions is presented in CIOMS frequency categories:Very common: 10%Common: 1% and <10%Uncommon: 0.1% and <1%Rare: 0.01% and <0.1%Very rare: <0.01%

Metabolism and nutrition disordersDecreased appetite – Very common

Psychiatric disordersIrritability – Very common Crying – Uncommon

Nervous system disordersDrowsiness/increased sleep; restless sleep/decreased sleep – Very common

Seizures (including febrile seizures) – Uncommon

Gastrointestinal disordersDiarrhea; vomiting – Common

Immune system disordersHypersensitivity reaction including face edema, dyspnea, bronchospasm – Rare

Skin and subcutaneous tissue disordersRash – Common Urticaria or urticaria-like rash – Uncommon

General disorders and administration site conditions

Fever; any injection-site erythema, induration/swelling or pain/tenderness; Injection-site erythema or induration/swelling 2.5 cm–7.0 cm (after toddler dose and in older children [age 2 to 5 years]) – Very common

Fever greater than 39°C; injection-site erythema or induration/swelling 2.5 cm–7.0 cm (after infant series); injection-site pain/tenderness interfering with movement – Common

Injection-site induration/swelling or erythema greater than 7.0 cm – Uncommon

Symptoms and Treatment of Overdose

Overdose with Prevnar® 13 is unlikely due to its presentation as a pre-filled syringe. However, there have been reports of overdose with Prevnar® 13 defined as subsequent doses administered closer than recommended to the previous dose. In general, adverse events reported with overdose are consistent with those that have been reported with doses given in the recommended schedules of Prevnar® 13.

Product Monograph is available on request, tel. 1-800-463-6001.

Patient Selection Criteria

Prescribing Summary

Safety Information

Serious Warnings and Precautions

Safety and immunogenicity data on Prevnar® 13 are not available for children in specific groups at higher risk for invasive pneumococcal disease (e.g., children with congenital or acquired

splenic dysfunction, HIV infection, malignancy, nephrotic syndrome). Children in these groups may have reduced antibody

response to active immunization due to impaired immune responsiveness. Vaccination in high-risk groups should

be considered on an individual basis.

Administration

Study References


®

Prevnar® Wyeth, owner, now a part of Pfizer Inc.Synflorix™ is a trademark of GlaxoSmithKline.


Prescribing Summary

Patient Selection Criteria

THERAPEUTIC CLASSIFICATION: Lipid Metabolism Regulator INDICATIONS AND CLINICAL USE: Hypercholesterolemia: CRESTOR (rosuvastatin calcium) is indicated as an adjunct to diet, at least equivalent to the Adult Treatment Panel III (ATP III TLC diet), for the reduction of elevated total cholesterol (Total-C), LDL-C, ApoB, the Total-C/HDL-C ratio and triglycerides (TG) and for increasing HDL-C; in hyperlipidemic and dyslipidemic conditions, when response to diet and exercise alone has been inadequate including: Primary hypercholesterolemia (Type IIa including heterozygous familial hypercholesterolemia and severe nonfamilial hypercholesterolemia)

Combined (mixed) dyslipidemia (Type IIb) Homozygous familial hypercholesterolemia where CRESTOR is used either alone or as an adjunct to diet and other lipid-lowering treatment such as apheresis

Prevention of Major Cardiovascular Events: In adult patients without documented history of cardiovascular or cerebrovascular events, but with at least two conventional risk factors for cardiovascular disease (see CLINICAL TRIALS), CRESTOR is indicated to: Reduce the risk of nonfatal myocardial infarction Reduce the risk of nonfatal stroke Reduce the risk of coronary artery revascularizationCONTRAINDICATIONS: CRESTOR (rosuvastatin calcium) is contraindicated: In patients who are hypersensitive to any component of this medication In patients with active liver disease or unexplained persistent elevations of serum transaminases exceeding 3 times the upper limit of normal (see WARNINGS AND PRECAUTIONS)

In pregnant and nursing mothers (see SUPPLEMENTAL PRODUCT INFORMATION) In patients using concomitant cyclosporine (see DRUG INTERACTIONS)CRESTOR 40 mg is contraindicated in: Asian patients Patients with predisposing factors for myopathy/rhabdomyolysis such as: Personal or family history of hereditary muscular disorders Previous history of muscle toxicity with another HMG-CoA reductase inhibitor Concomitant use of a fibrate or niacin Severe hepatic impairment Severe renal impairment (CrCl < 30 mL/min/1.73 m2) (see ADMINISTRATION,

Patients with Renal Impairment) Hypothyroidism Alcohol abuse Situations where an increase in rosuvastatin plasma levels may occur

Safety Information

WARNINGS AND PRECAUTIONS: Before instituting therapy with CRESTOR (rosuvastatin calcium), an attempt should be made to control hypercholesterolemia with appropriate diet, exercise, weight reduction in overweight patients, and to treat other underlying medical problems and associated cardiovascular risk factors. The patient should be advised to inform subsequent physicians of the prior use of CRESTOR or any other lipid-lowering agent.Co-enzyme Q10 (ubiquinone): Ubiquinone levels were not measured in CRESTOR clinical trials. Significant decreases in circulating ubiquinone levels in patients treated with other statins have been observed. The clinical significance of a potential long-term statin-induced deficiency of ubiquinone has not been established. It has been reported that a decrease in myocardial ubiquinone levels could lead to impaired cardiac function in patients with borderline congestive heart failure.Endocrine Function: HMG-CoA reductase inhibitors interfere with cholesterol synthesis and lower cholesterol levels and, as such, might theoretically blunt adrenal or gonadal steroid hormone production. Rosuvastatin demonstrated no effect upon nonstimulated cortisol levels and no effect on thyroid metabolism as assessed by TSH plasma concentration. In CRESTOR-treated patients, there was no impairment of adrenocortical reserve and no reduction in plasma cortisol concentrations. Clinical studies with other HMG-CoA reductase inhibitors have suggested that these agents do not reduce plasma testosterone concentration. The effects of HMG-CoA reductase inhibitors on male fertility have not been studied. The effects, if any, on the pituitary-gonadal axis in premenopausal women are unknown. Patients treated with rosuvastatin who develop clinical evidence of endocrine dysfunction should be evaluated appropriately. Caution should be exercised if an HMG-CoA reductase inhibitor or other agent used to lower cholesterol levels is administered to patients receiving other drugs (e.g., ketoconazole, spironolactone or cimetidine) that may decrease the levels of endogenous steroid hormones.Plasma Glucose: In the JUPITER trial, rosuvastatin 20 mg was observed to increase plasma glucose

levels, which were sufficient to shift some prediabetic subjects to the diabetes mellitus status (see ADVERSE REACTIONS).Lipoprotein(a): In some patients, the beneficial effect of lowered total cholesterol and LDL-C levels may be partly blunted by a concomitant increase in the Lipoprotein(a) [LP(a)] concentrations. Present knowledge suggests the importance of high LP(a) levels as an emerging risk factor for coronary heart disease. It is thus desirable to maintain and reinforce lifestyle changes in high-risk patients placed on rosuvastatin therapy.Hepatic Effects: CRESTOR is contraindicated in patients with active liver disease or unexplained persistent elevations of serum transaminases exceeding 3 times the upper limit of normal.As with other HMG-CoA reductase inhibitors, it is recommended that a liver function test be carried out prior to, and 3 months following, the initiation of CRESTOR or if the patient is titrated to the dose of 40 mg. CRESTOR should be discontinued or the dose reduced if the level of transaminases is greater than 3 times the upper limit of normal.CRESTOR, as well as other HMG-CoA reductase inhibitors, should be used with caution in patients who consume substantial quantities of alcohol and/or have a past history of liver disease.As with other HMG-CoA reductase inhibitors, a dose-related increase in transaminases has been observed in a small number of patients taking rosuvastatin (< 0.5%); the majority of cases were mild, asymptomatic and transient.Hepatic Impairment: In subjects with varying degrees of hepatic impairment there was no evidence of increased exposure to rosuvastatin other than in 2 subjects with the most severe liver disease (Child-Pugh scores of 8 and 9). In these subjects, systemic exposure was increased by at least 2-fold compared to subjects with lower Child-Pugh scores (see ADMINISTRATION, Patients with Hepatic Impairment).Muscle Effects: Rare cases of rhabdomyolysis with acute renal failure secondary to myoglobinuria have been reported with CRESTOR and with other HMG-CoA reductase inhibitors.Effects on skeletal muscle such as myalgia, myopathy and, rarely, rhabdomyolysis have been reported in patients treated with CRESTOR at all doses and in particular with the 40 mg dose.Myopathy, defined as muscle pain or muscle weakness in conjunction with increases in creatine kinase (CK) values to greater than ten times the upper limit of normal, should be considered in any patient with diffuse myalgias, muscle tenderness or weakness, and/or marked elevation of CK. Patients should be advised to report promptly any unexplained muscle pain, tenderness or weakness, particularly if associated with malaise or fever. Patients who develop any signs or symptoms suggestive of myopathy should have their CK levels measured. CRESTOR therapy should be discontinued if markedly elevated CK levels (> 10 x ULN) are measured or myopathy is diagnosed or suspected.Predisposing Factors for Myopathy/RhabdomyolysisCRESTOR, as with other HMG-CoA reductase inhibitors, should be prescribed with caution in patients with predisposing factors for myopathy/rhabdomyolysis. Such factors include: Personal or family history of Age > 70 years hereditary muscular disorders Renal impairment Previous history of muscular Hepatic impairment toxicity with another HMG-CoA Diabetes with hepatic reductase inhibitor fatty change Concomitant use of a fibrate Surgery and trauma or niacin Frailty Hypothyroidism Situations where an increase Alcohol abuse in plasma levels of rosuvastatin Excessive physical exercise may occurIn CRESTOR trials there was no evidence of increased skeletal muscle effects when CRESTOR was dosed with concomitant therapy such as fibric acid derivatives (including fenofibrate and gemfibrozil), nicotinic acid, azole antifungals and macrolide antibiotics. However, an increase in the incidence of myositis and myopathy has been seen in patients receiving other HMG-CoA reductase inhibitors together with these medicines.CRESTOR therapy should be temporarily withheld or discontinued in any patient with an acute serious condition suggestive of myopathy or predisposing to the development of rhabdomyolysis (e.g., sepsis, hypotension, major surgery, trauma, severe metabolic endocrine and electrolyte disorders, or uncontrolled seizures).Renal Impairment: Subjects with severe renal impairment (CrCl < 30 mL/min/1.73 m2) had a 3-fold increase in plasma concentration of rosuvastatin compared to healthy volunteers and, therefore, CRESTOR 40 mg is contraindicated in these patients (see CONTRAINDICATIONS and ADMINISTRATION, Patients with Renal Impairment). In subjects with varying degrees of renal impairment, mild to moderate renal disease had little influence on plasma concentrations of rosuvastatin.During the clinical development program, dipstick-positive proteinuria and microscopic hematuria were observed among rosuvastatin-treated patients, predominantly in patients dosed above the recommended dose range (i.e., 80 mg). Abnormal urinalysis testing (dipstick-positive proteinuria) has been seen in patients taking CRESTOR and other HMG-CoA reductase inhibitors. This finding was more frequent in patients taking 40 mg when compared to lower doses of rosuvastatin or comparator statins. Shifts in urine protein from none or trace to ++ (dipstick) or more were seen in < 1% of patients at some time during treatment with 10 and 20 mg, and in approximately 3% of patients treated with 40 mg. The protein detected was mostly tubular in origin. In most cases, proteinuria was


generally transient and it decreased or disappeared spontaneously on continued therapy. It has not been shown to be predictive of acute or progressive renal disease.Nevertheless, a dose reduction may be considered for patients with unexplained persistent proteinuria during routine testing.Hypersensitivity: An apparent hypersensitivity syndrome has been reported rarely with other HMG-CoA reductase inhibitors. This has included one or more of the following features: anaphylaxis, angioedema, lupus erythematous-like syndrome, polymyalgia rheumatica, vasculitis, purpura, thrombocytopenia, leukopenia, hemolytic anemia, positive antinuclear antibody (ANA), erythrocyte sedimentation rate (ESR) increase, eosinophilia, arthritis, arthralgia, urticaria, asthenia, photosensitivity, fever, chills, flushing, malaise, dyspnea, toxic epidermal necrolysis, erythema multiforme including Stevens-Johnson syndrome. Treatment should be discontinued if hypersensitivity is suspected (see CONTRAINDICATIONS).Special PopulationsPregnant Women: CRESTOR is contraindicated during pregnancy (see CONTRAINDICATIONS).Nursing Women: It is not known whether rosuvastatin is excreted in human milk. Because of the potential for adverse reactions in nursing infants, women taking CRESTOR should not breastfeed (see CONTRAINDICATIONS).Pediatrics (≤ 18 years of age): Treatment experience with CRESTOR in a pediatric population is limited to 8 patients with homozygous familial hypercholesterolemia. None of these patients was below 8 years of age (see ADMINISTRATION, Use in Children).Geriatrics (≥ 65 years of age): There were no clinically significant pharmacokinetic differences between young and elderly patients (≥ 65 years) (see ADMINISTRATION, Use in Elderly). However, elderly patients may be more susceptible to myopathy (see WARNINGS AND PRECAUTIONS, Muscle Effects, Predisposing Factors for Myopathy/Rhabdomyolysis).Race: Results of pharmacokinetic studies, including a large study conducted in North America, have demonstrated an approximate 2-fold elevation in median exposure in Asian subjects (having either Filipino, Chinese, Japanese, Korean, Vietnamese or Asian-Indian origin) when compared with a Caucasian control group. This increase should be considered when making rosuvastatin dosing decisions for Asian patients and the dose of 40 mg is contraindicated in these patients (see CONTRAINDICATIONS and ADMINISTRATION, Race).ADVERSE REACTION SERIOUSNESS AND INCIDENCE: CRESTOR (rosuvastatin calcium) is generally well tolerated. The adverse events seen with CRESTOR are generally mild and transient. CRESTOR clinical trial experience is extensive, involving 9800 patients treated with CRESTOR in placebo-controlled trials and 9855 patients treated with CRESTOR in active-controlled clinical trials. Discontinuation of therapy due to adverse events occurred in 2.6% of patients receiving CRESTOR and 1.8% of patients receiving placebo. The most frequently reported adverse events at an incidence of ≥ 1% and at a rate greater than placebo were arthralgia, upper abdominal pain and ALT increase. See SUPPLEMENTAL PRODUCT INFORMATION. Abnormal Hematologic and Clinical Chemistry Findings: As with other HMG-CoA reductase inhibitors, a dose-related increase in liver transaminases and CK has been observed in a small number of patients taking rosuvastatin (see WARNINGS AND PRECAUTIONS, Hepatic Effects, Muscle Effects).Abnormal urinalysis testing (dipstick-positive proteinuria) has been seen in a small number of patients taking CRESTOR and other HMG-CoA reductase inhibitors. The protein detected was mostly tubular in origin. In most cases, proteinuria decreases or disappears spontaneously on continued therapy, and is not predictive of acute or progressive renal disease (see WARNINGS AND PRECAUTIONS, Renal Impairment).In the JUPITER trial, occurrences of diabetes mellitus as a pre-specified secondary outcome were reported more frequently in the CRESTOR-treated patients (2.8%) than in placebo (2.3%) and a slight increase in the number of subjects whose fasting glucose levels increased to ≥ 5.6 mmol/L (126 mg/dL) was observed in subjects treated with CRESTOR. There was a 0.1% increase in mean HbA1c with CRESTOR compared to placebo. A causal relationship with statins and diabetes mellitus has not been definitely established.Postmarket Adverse Drug Reactions: In addition to the events reported above, the following adverse events have been reported during postmarketing experience with CRESTOR, regardless of causality assessment. Skeletal muscle effects: Very rare: arthralgiaIt has been observed that as with other HMG-CoA reductase inhibitors, the reporting rate for rhabdomyolysis in postmarketing use is higher at the highest marketed dose (see WARNINGS AND PRECAUTIONS, Muscle Effects). Hepatobiliary disorders: Very rare: jaundice, hepatitis Nervous system disorders: Very rare: memory loss Other: Rare: pancreatitis; Very rare: gynecomastiaDRUG INTERACTIONS: In CRESTOR (rosuvastatin calcium) clinical trials, there was no evidence of increased skeletal muscle effects when rosuvastatin was dosed with any concomitant therapy. However, CRESTOR and other HMG-CoA reductase inhibitors may cause dose-related increases in serum transaminases and CK levels. An increase in the incidence of myositis and myopathy has been seen in patients receiving other HMG-CoA reductase inhibitors with cyclosporine, fibric acid derivatives (including gemfibrozil), nicotinic acid, azole antifungals and macrolide antibiotics.Cytochrome P450 Inhibitors: In vitro and in vivo data indicate that rosuvastatin has no clinically significant cytochrome P450 interactions (as substrate, inhibitor or inducer). Consequently, there is

little potential for drug-drug interactions upon coadministration with agents that are metabolized by cytochrome P450. Rosuvastatin clearance is not dependent on metabolism by cytochrome P450 3A4 to a clinically significant extent. This has been confirmed in studies with known cytochrome P450 3A4 inhibitors (ketoconazole, erythromycin, itraconazole).Concomitant Therapy with Other Lipid Metabolism Regulators: Coadministration of fenofibrate and CRESTOR 10 mg did not lead to a clinically significant change in the plasma concentrations of either drug. In addition, neither myopathy nor marked CK elevations (> 10 x ULN) were observed in a study of 128 patients who received CRESTOR 10, 20 and 40 mg plus extended-release niacin or in a second study of 103 patients who received CRESTOR 5 and 10 mg plus fenofibrate. Based on the above data, no pharmacokinetic or pharmacodynamic interaction was observed. No data is available with other fibrates.Based on postmarketing surveillance, gemfibrozil, fenofibrate, other fibrates and lipid-lowering doses of niacin (nicotinic acid) may increase the risk of myopathy when given concomitantly with HMG-CoA reductase inhibitors, probably because they can produce myopathy when given alone (see WARNINGS AND PRECAUTIONS, Muscle Effects, Predisposing Factors for Myopathy/Rhabdomyolysis). Therefore, combined drug therapy should be approached with caution.Lopinavir/Ritonavir: In a pharmacokinetic study, coadministration of CRESTOR and a combination product of two protease inhibitors (400 mg lopinavir/100 mg ritonavir) in healthy volunteers was associated with an approximately 2-fold and 5-fold increase in rosuvastatin steady-state AUC(0-24) and Cmax

, respectively.Increased systemic exposure to rosuvastatin has been observed in subjects receiving CRESTOR with various protease inhibitors in combination with ritonavir. Consideration should be given to both the benefit of lipid lowering by the use of CRESTOR in HIV patients receiving protease inhibitors and the potential for increased rosuvastatin plasma concentrations when initiating and up-titrating CRESTOR doses in patients treated with protease inhibitors (see WARNINGS AND PRECAUTIONS, Muscle Effects, Predisposing Factors for Myopathy/Rhabdomyolysis).Concomitant Therapies Without Clinically Significant Interactions: See SUPPLEMENTAL PRODUCT INFORMATION.Drug-Drug Interactions: See SUPPLEMENTAL PRODUCT INFORMATION.Drug-Food Interactions: CRESTOR can be taken with or without food (see ADMINISTRATION).You can report any suspected adverse reactions associated with the use of health products to the Canada Vigilance Program by one of the following 3 ways:Report online at www.healthcanada.gc.ca/medeffectCall toll-free at 1-866-234-2345Complete a Canada Vigilance Reporting Form and: Fax toll-free to 1-866-678-6789, or Mail to: Canada Vigilance Program

Health Canada Postal Locator 0701C Ottawa, ON K1A 0K9

Postage-paid labels, Canada Vigilance Reporting Form and the adverse reaction reporting guidelines are available on the MedEffect™ Canada website at www.healthcanada.gc.ca/medeffect.NOTE: Should you require information related to the management of side effects, contact your health professional. The Canada Vigilance Program does not provide medical advice.

Administration

Patients should be placed on a standard cholesterol-lowering diet (at least equivalent to the Adult Treatment Panel III (ATP III TLC diet)) before receiving CRESTOR (rosuvastatin calcium) and should continue on this diet during treatment with CRESTOR. If appropriate, a program of weight control and physical exercise should be implemented.Prior to initiating therapy with CRESTOR, secondary causes for elevations in plasma lipid levels should be excluded. A lipid profile should also be performed.CRESTOR may be taken in the morning or evening, with or without food.Recommended Dose and Dosage Adjustment Hypercholesterolemia: The dose range of CRESTOR is 5 to 40 mg orally once a day. The recommended starting dose of CRESTOR in most patients is 10 mg orally once daily. The majority of patients are controlled at the 10 mg dose. If necessary, dose adjustment can be made at 2- to 4-week intervals. The maximum response is usually achieved within 2-4 weeks and is maintained during chronic therapy.Initiation of therapy with CRESTOR 5 mg once daily may be considered for patients requiring less aggressive LDL-C reductions or who have predisposing factors for myopathy (see WARNINGS AND PRECAUTIONS, Muscle Effects). Patients who are switched to CRESTOR from treatment with another HMG-CoA reductase inhibitor should be started on 10 mg even if they were on a high dose of the previous HMG-CoA reductase inhibitor. A switch dose of 20 mg may be considered for patients with severe hypercholesterolemia.For patients with severe hypercholesterolemia (including those with familial hypercholesterolemia), a 20 mg start dose may be considered. These patients should be carefully followed.A dose of 40 mg once daily should only be used in patients with severe hypercholesterolemia who


do not achieve their target treatment on 20 mg and have no predisposing factors for myopathy/rhabdomyolysis (see CONTRAINDICATIONS). Consultation with a specialist is recommended when initiating the CRESTOR 40 mg dose.The dosage of CRESTOR should be individualized according to baseline LDL-C, Total-C/HDL-C ratio and/or TG levels to achieve the recommended desired lipid values at the lowest possible dose.Prevention of Major Cardiovascular Events: A dose of 20 mg once daily has been found to reduce the risk of major cardiovascular events (see CLINICAL TRIALS).Dosing Considerations in Special PopulationsPatients with Hepatic Impairment: The usual dose range applies in patients with mild to moderate hepatic impairment. Increased systemic exposure has been observed in patients with severe hepatic impairment and, therefore, in these patients the dose of CRESTOR should not exceed 20 mg once daily (see CONTRAINDICATIONS and WARNINGS AND PRECAUTIONS, Hepatic Impairment).Patients with Renal Impairment: The usual dose range applies in patients with mild to moderate renal impairment. Increased systemic exposure to rosuvastatin has been observed in patients with severe renal impairment. For patients with severe renal impairment (creatinine clearance < 30 mL/min/1.73 m2), the starting dose of CRESTOR should be 5 mg and not exceed 10 mg once daily (see CONTRAINDICATIONS and WARNINGS AND PRECAUTIONS, Renal Impairment).Race: The initial dose of CRESTOR, in Asian patients, should be 5 mg once daily. The potential for increases in systemic exposure must be considered when making treatment decisions. The maximum dose should not exceed CRESTOR 20 mg once daily (see CONTRAINDICATIONS and WARNINGS AND PRECAUTIONS, Special Populations, Race).Use in Children: Pediatric experience is limited to a very small number of children (aged 8 years and above) with homozygous familial hypercholesterolemia. Use in children should be supervised by specialists (see WARNINGS AND PRECAUTIONS, Special Populations, Pediatrics).Use in Elderly: No dose adjustment is necessary in the elderly (see WARNINGS AND PRECAUTIONS, Special Populations, Geriatrics).Concomitant Therapy: See WARNINGS AND PRECAUTIONS and DRUG INTERACTIONS.SUPPLEMENTAL PRODUCT INFORMATIONCONTRAINDICATIONS: Pregnant and nursing mothers: Cholesterol and other products of cholesterol biosynthesis are essential components for fetal development (including synthesis of steroids and cell membranes). CRESTOR should be administered to women of childbearing age only when such patients are highly unlikely to conceive and have been informed of the possible harm. If the patient becomes pregnant while taking CRESTOR, the drug should be discontinued immediately and the patient apprised of the potential harm to the fetus. Atherosclerosis being a chronic process, discontinuation of lipid metabolism-regulating drugs during pregnancy should have little impact on the outcome of long-term therapy of primary hypercholesterolemia (see WARNINGS AND PRECAUTIONS, Special Populations, Pregnant Women, Nursing Women).ADVERSE REACTIONS: Adverse events observed or reported in short- and long-term trials are as follows.Clinical Trial Adverse Drug Reactions: Because clinical trials are conducted under very specific conditions, the adverse drug reaction rates observed in the clinical trials may not reflect the rates observed in practice and should not be compared to the rates in the clinical trials of another drug. Adverse drug reaction information from clinical trials is useful for identifying drug-related adverse events and for approximating rates.Short-term Controlled Trials: Short-term controlled trials involved 1290 patients within placebo-controlled trials of 6 to 16 weeks’ duration (768 of which were treated with rosuvastatin) and 11,641 patients within placebo- and active-controlled clinical trials of 6 to 52 weeks’ duration (5319 of which were treated with rosuvastatin). In all controlled clinical trials, 3.2% of patients were withdrawn from CRESTOR therapy due to adverse events. This withdrawal rate was comparable to that reported in placebo-controlled studies.Associated adverse events occurring at an incidence ≥ 1% in patients participating in placebo-controlled clinical studies of rosuvastatin, are shown in Table 1.Table 1: Number (%) of Subjects with Associated Adverse Events Occurring with ≥ 1% Incidence in any Treatment Group: Placebo-Controlled Pool

Body system/Adverse event Placebo (%)(N=367)

Total rosuvastatin (%) (N=768)

Whole body

Abdominal pain 2.2 1.7

Asthenia 0.5 1.3

Headache 2.2 1.4

Digestive

Constipation 1.4 1.0

Diarrhea 1.6 1.3

Dyspepsia 1.9 0.7

Flatulence 2.7 1.8

Nausea 1.6 2.2

Musculoskeletal

Myalgia 0.5 1.6

Nervous system

Dizziness 1.6 0.5

Insomnia 1.9 0.4

Long-term Controlled Morbidity and Mortality Trials: In the Justification for the Use of Statins in Primary Prevention: An Intervention Trial Evaluation Rosuvastatin (JUPITER) study involving 17,802 participants treated with CRESTOR 20 mg once daily (n=8901) or placebo (n=8901), CRESTOR 20 mg was generally well tolerated. Subjects were followed for a mean duration of 2 years.Discontinuation of therapy due to an adverse event occurred in 5.6% of subjects treated with CRESTOR and 5.5% of subjects treated with placebo. The most common adverse events that led to discontinuation from the study were: myalgia, arthralgia, abdominal pain and constipation. The associated adverse reaction reported in ≥ 1% of patients and at a rate greater than or equal to placebo was myalgia (2.4% CRESTOR, 2.0% placebo).Treatment emergent adverse events regardless of causality occurring at an incidence ≥ 1% and at a rate greater than placebo in patients participating in the JUPITER trial are shown in Table 2.

Table 2: Number (%) of Subjects with Treatment Emergent Adverse Events Regardless of Causality Occurring with ≥ 1% Incidence and > than Placebo: JUPITER


Total rosuvastatin 20 mg (%) (N=8901)

Blood

Anemia 2.1 2.2

Cardiac

Palpitations 0.9 1.0


Total rosuvastatin 20 mg (%) (N=8901)

Gastrointestinal

Diarrhea 4.6 4.7

Constipation 3.0 3.3

Nausea 2.3 2.4

General disorders

Edema peripheral 3.0 3.7

Fatigue 3.5 3.7

Hepatobiliary

Cholelithiasis 0.9 1.0

Infections

Urinary tract 8.6 8.7

Nasopharyngitis 7.2 7.6

Bronchitis 7.1 7.2

Sinusitis 3.7 4.0

Influenza 3.6 4.0

Lower respiratory tract 2.7 2.9

Gastroenteritis 1.7 1.9

Herpes zoster 1.4 1.6

Injury

Contusion 1.4 1.7

Investigation

ALT increased 1.0 1.4

Blood glucose increased 0.7 1.0

Metabolism

Diabetes mellitus 2.5 3.0

Musculoskeletal

Back pain 6.9 7.6

Myalgia 6.6 7.6

Arthritis 5.6 5.8

Arthralgia 3.2 3.8

Muscle spasms 3.2 3.6

Osteoarthritis 1.4 1.8

Bursitis 1.3 1.5

Neck pain 1.0 1.1

Osteoporosis 0.8 1.0

Neoplasms

Basal cell carcinoma 0.9 1.0

Psychiatric

Insomnia 2.3 2.5

Renal

Hematuria 2.0 2.4

Proteinuria 1.3 1.4

Respiratory

Epistaxis 0.8 1.0

Less Common Clinical Trial Adverse Drug Reactions (< 1%): The frequency of adverse events in all clinical trials and considered possibly, probably or definitely drug-related are as follows: Uncommon (≥ 0.1% and < 1%): Pruritus, rash, urticaria, arthralgia, muscle weakness, arthritis, constipation, nausea, dyspepsia, gastroesophageal reflux disease, ALT increase, creatine phosphokinase increase, hepatic enzyme increase, creatinine increase, paraesthesia, tremor, general pain, proteinuria, sinusitis, insomnia, abnormal hepatic function, vertigo, diabetes mellitus Rare (≥ 0.01% and < 0.1%): Myopathy (including myositis), rhabdomyolysis and hypersensitivity reactions including angioedemaThe following additional adverse events were reported in controlled clinical trials, regardless of causality: Accidental injury, back and chest pain, flu syndrome, infection, urinary tract infection, diarrhea, flatulence, gastroenteritis, hypertonia, bronchitis, increased cough, rhinitis and pharyngitis.In long-term controlled clinical trials, CRESTOR was shown to have no harmful effect on the ocular lens.DRUG INTERACTIONS: Concomitant Therapies Without Clinically Significant InteractionsBile Acid Sequestrants: CRESTOR can be used in combination with bile acid sequestrants (e.g., cholestyramine).Ketoconazole: Coadministration of ketoconazole with CRESTOR resulted in no change in plasma concentrations of rosuvastatin.Erythromycin: Coadministration of erythromycin with CRESTOR resulted in small decreases in plasma concentrations of rosuvastatin. These reductions were not considered clinically significant.Itraconazole: Coadministration of itraconazole with CRESTOR resulted in a 28% increase in the AUC of rosuvastatin. This small increase was not considered clinically significant.Fluconazole: Coadministration of fluconazole with CRESTOR resulted in a 14% increase in the AUC of rosuvastatin. This small increase was not considered clinically significant.Digoxin: Coadministration of digoxin and CRESTOR did not lead to any clinically significant interactions.Other Drugs: Although specific interaction studies were not performed, CRESTOR has been studied in over 5300 patients in clinical trials. Many patients were receiving a variety of medications including antihypertensive agents (beta-adrenergic blocking agents, calcium channel blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and diuretics), antidiabetic agents (biguanides, sulfonylureas, alpha glucosidase inhibitors, and thiazolidinediones), and hormone replacement therapy without evidence of clinically significant adverse interactions.Drug-Drug Interactions: The drugs listed in Table 3 are based on either drug interaction case reports or studies or potential interactions due to the expected magnitude and seriousness of the interaction (i.e., those identified as contraindicated).

Table 3: Established or Potential Drug-Drug Interactions

Proper name Effect Clinical comment

Gemfibrozil Coadministration of a single rosuvastatin dose (10 mg) to healthy volunteers on gemfibrozil (600 mg BID) resulted in a 2.2- and 1.9-fold increase in mean Cmax and mean AUC of rosuvastatin, respectively.

Patients taking this combination should not exceed a dose of CRESTOR 20 mg once daily and the concomitant use of CRESTOR 40 mg once daily is contraindicated.


Proper name Effect Clinical comment

Coumarinanticoagulants

As with other HMG-CoA reductase inhibitors, coadministration of CRESTOR and coumarin (e.g., warfarin) may result in a rise in International Normalized Ratio (INR) compared to coumarin alone. In healthy subjects, the coadministration of rosuvastatin 40 mg (10 days) and warfarin 25 mg (single dose) produced a higher mean maxINR and AUC-INR than achieved with warfarin alone. Coadministration of CRESTOR 10 and 80 mg to patients on stable warfarin therapy resulted in clinically significant rises in INR (> 4, baseline 2-3). The mechanism for this effect is unknown, but is likely due to a pharmacodynamicinteraction with warfarin rather than a pharmacokinetic interaction as no relevant differences in the pharmacokinetics of either drug was observed.

In patients taking coumarin, monitoring of INR is recommended at initiation or cessation of therapy with rosuvastatin or following dose adjustment. Rosuvastatin therapy has not been associated with bleeding or changes in INR in patients not taking anticoagulants.

Antacids Simultaneous dosing of CRESTOR with an antacid suspension containing aluminum and magnesium hydroxide resulted in a decrease of rosuvastatin plasma concentration by approximately 50%.

The clinical relevance of this interaction has not been studied. However, the effect was mitigated when the antacid was dosed 2 hours after CRESTOR. This interaction should not be clinically relevant in patients using this type of antacid infrequently. A frequent antacid user should be instructed to take CRESTOR at a time of day when they are less likely to need the antacid.

Oral contraceptives When CRESTOR 40 mg was coadministered with a representative oral contraceptive (ethinyl estradiol [35 μg] and norgestrel [180 μg on days 1 to 7, 215 μg on days 8 to 15, and 250 μg on days 16 to 21]), no reduction in contraceptive efficacy was observed. An increase in plasma concentrations (AUC) of ethinyl estradiol (26%) and norgestrel (34%) occurred.

These increased plasma levels should be considered when selecting oral contraceptive doses.

Immunosuppressants (including cyclosporine)

CRESTOR 10 and 20 mg were administered to cardiac transplant patients (at least 6 months post-transplant) whose concomitant medication included cyclosporine, prednisone and azathioprine. Results showed that cyclosporine pharmacokinetics were not affected by rosuvastatin. However, cyclosporine did increase the systemic exposure of rosuvastatin by 11-fold (Cmax

) and 7-fold (AUC

(0-24)) compared with historical data in

healthy individuals.

The concomitant use of CRESTOR and cyclosporine is contraindicated (see CONTRAINDICATIONS).

CLINICAL TRIALS:HypercholesterolemiaThe following reductions in total cholesterol, LDL-C, TG, Total-C/HDL-C ratio and increases in HDL-C have been observed in a dose-response study, and may serve as a guide to treatment of patients with mild to moderate hypercholesterolemia:

Table 4: Dose Response in Patients with Mild to Moderate Hypercholesterolemia (Mean Percent Change from Baseline)

CRESTORdose

(mg/day)

N Total-C LDL-C TG HDL-C Total-C/HDL-C ratio

ApoB

Placebo 13 -5 -7 -3 3 -8 -3

5 17 -33 -45 -35 13 -41 -38

10 17 -36 -52 -10 14 -43 -42

20 17 -40 -55 -23 8 -44 -46

40 18 -46 -63 -28 10 -51 -54

Prevention of Major Cardiovascular EventsIn the JUPITER study (Justification for the Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin), 89,846 people with no pre-existing cardiovascular disease were screened and 17,802 (19.8%) were double-blindly randomized to CRESTOR 20 mg once daily (n=8901) or placebo (n=8901). The primary endpoint was a composite consisting of the time-to-first occurrence of any of the following cardiovascular events: cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, unstable angina or an arterial revascularization procedure.

Figure 1: Time to First Occurrence of Major Cardiovascular Events

Cum

ulat

ive

inci

denc

e, %

Years

Number at risk

HR 0.56 (95% CI 0.46-0.69)

p<0.001

rosuvastatin 8901 8412 3892 1352 543 1568901 8353 3872 1333 534 173placebo

placebo rosuvastatin

0

1

2

3

4

5

6

7

8

9

0 1 2 3 4 5 6

The results of the primary composite endpoint and the individual components are presented in Table 5. CRESTOR significantly reduced the risk of nonfatal myocardial infarction (p<0.0001), nonfatal stroke (p=0.004) and arterial revascularization procedures (p=0.034). There were no statistically significant treatment differences between the CRESTOR and placebo groups for death due to cardiovascular causes or hospitalizations for unstable angina.

Table 5: Number of First Events by Treatment Group for the Composite Primary Endpoint (ITT Population)

CRESTOR (N=8901) n (%)

Placebo(N=8901)n (%)

Relative risk reduction† (95% CI)

Absolute risk reduction (%)

1.9-year NNT

PRIMARY (composite) ENDPOINT

142 (1.6) 252 (2.83) 44% (31, 54) 1.23 81

COMPONENTS OF PRIMARY ENDPOINT

Cardiovascular death* 29 (0.33) 37 (0.42) 22% (-27, 52) 0.09 1112

Nonfatal stroke 30 (0.34) 57 (0.64) 48% (18, 66) 0.30 329

Nonfatal MI 21 (0.24) 61 (0.69) 66% (44, 79) 0.45 222

Unstable angina 15 (0.17) 27 (0.30) 45% (-4, 71) 0.13 741

Arterial revascularization 47 (0.53) 70 (0.79) 33% (3, 54) 0.26 387

*Cardiovascular death included fatal MI, fatal stroke, sudden death and other adjudicated causes of CV death.†Negative numbers imply a risk increase.CI: confidence interval, ITT: intent-to-treat, MI: myocardial infarction, NNT: number needed to treatSYMPTOMS AND TREATMENT OF OVERDOSE: There is no specific treatment in the event of overdosage. Should an overdose occur, the patient should be treated symptomatically and supportive measures instituted as required. Hemodialysis does not significantly enhance clearance of rosuvastatin.For the management of a suspected drug overdose, contact your regional Poison Control Centre.

Product Monograph available on request.

CRESTOR® and the AstraZeneca logo are trade-marks of the AstraZeneca group of companies. Licensed from Shionogi & Co Ltd, Osaka, Japan. © AstraZeneca 2010

AstraZeneca Canada Inc.1004 Middlegate RoadMississauga, Ontario L4Y 1M4www.astrazeneca.ca


OFFICE SPACE AVAILABLE

Boxgrove Medical Centre — now open: Four-storey, 60,000 sq. ft. medi-cal building located at the 9th Line and Highway 407. Prime medical space available for lease. X-ray, lab, rehab and urgent care on-site. Contact: HowardTel. 416.357.7509

Central Toronto, Forest Hill: 970 sq. ft. medical or dental office. Wait ing room and four examining rooms. Prestige location, available immediately. Free parking, TTC directly out front. Com-fortable ambiance, “just like home.” E-mail: [email protected]

Dufferin/Clark: A turnkey medical office up to 2,500 sq. ft. Great location, four exam rooms and a reception, free parking. Beside dentist, physiothera-pist, dietician, and a pharmacy. Dense residential and commercial area. Contact: HanyTel. 647.501.4269

For psychiatrists, psychoanalysts or psychotherapists: Two office spaces available at Rosedale Medical Centre (Bloor-Sherbourne intersection/across from Sherbourne subway station). Newly

renovated suite with two separate wait-ing rooms; shared staff kitchenette/bath-room. Building with security and parking available. Contact: Dr. Marcia ShapirTel. 416.929.7389E-mail: [email protected]

Hamilton medical offices: Steps to St. Joseph’s Hospital. Turnkey. For FP or specialist.Contact: Mrs. BarryTel. 905.522.2909

Islington Professional Centre — medi-cal space available now: Be a part of a 12-storey medical centre one block north of Islington Ave. and Bloor. On-site: pharmacy, diagnostic imaging, audiology, radiology, laboratory, physio-therapy. Custom-designed suites from 750 sq. ft. Across from Islington sub-way station, surface and underground parking available. Competitive rental rates, nightly suite cleaning, card access security system as well as scheduled site guard. Entirely smoke-free property. Tel. 905.273.7411

Möcelle OfficeMD™ provides luxury furnished small medical office/room and virtual offices at a prestigious, high traffic address. Featuring turnkey sup-

port services such as low cost co-op marketing, on-demand admin./nurse staff, appointment management, mail and fax handling, printing and copying services, etc. Enjoy all the benefits of a full-service office without the capital out-lay, hassles and overhead. To apply or schedule a tour:Contact: Wayne McLennonMöcelle Edan Cosmetic ClinicTel. 416.367.2005Fax: 1.866.655.7686E-mail: [email protected]

Net rent free: Cambridge family phy-sician’s office from 800 sq. ft. to 3,000 sq. ft. in affluent west side of Galt near schools, shopping and seniors home.Contact: Mel de Oliveira, CB Richard Ellis Ltd.Tel. 519.340.2311

51 September 2010

Classifieds

Following are the classified

advertising deadline dates

for the next six issues.

I S S U E D E A D L I N E

November 2010 October 8

December 2010 November 10

January 2011 December 1

February 2011 January 10

March 2011 February 10

April 2011 March 10

GENERAL INFORMATIONAdvertisements are accepted by mail, e-mail

or fax. Copy deadline, notice of cancellation

and/or changes to existing advertisements

must be submitted in writing no later than the

10th of the month prior to the month of publi-

cation. A proof copy of your classified ad will

be faxed to your attention for approval prior to

publication.

Payment: Payment is accepted by VISA, Mas-

tercard or American Express. Please provide

credit card information by phone only to Marga-

ret Lam at 416.340.2263 or 1.800.268.7215,

ext. 2263, at time of booking.

Rates: $50 for first 4 lines (minimum), each line

approximately 35 characters; $5 per line there-

after; $5 for each line of contact information.

Spot colour billed at $20 per issue.

Send advertisements to:Margaret Lam

Ontario Medical Association

150 Bloor Street West, Suite 900

Toronto, Ontario M5S 3C1

Tel. 1.800.268.7215, ext. 2263 or

416.340.2263

Fax: 416.340.2232

E-mail: [email protected]

The Ontario Medical Review is required to com-

ply with the provisions of the Ontario Human

Rights Code 1990 in its editorial and advertis-

ing policies, and assumes no responsibility or

endorses any claims or representation offered

or expressed by advertisers.

Added Value Classified ads are posted online https://www.oma.org/Pages/OntarioMedicalReview.aspx and accessible to OMA members and the

general public.

A Classified Advertisement Insertion Order Form is posted online: www.oma.org/Resources/Documents/AdOrder.pdf

OMR Ads Hit Home!Reach 29,000+

physicians, residents and medical students

every issue.


Office space in North York: Part-time family doctor looking for another part-time family doctor or specialist to cost-share office space. Located in modern medical building with free parking and easy subway access at Yonge/Finch. Contact: Dr. Todd LevyTel. 416.573.8339E-mail: [email protected]

On Steeles near York University: Busy plaza, 1,500 sq. ft. on main floor. Ample free parking, beside a dentist and an optometrist. Reasonable rent at $12 per sq. ft. net.Contact: Sam CohenTel. 416.629.7711

PAR-Med Realty Ltd.: Specializing in medical office building leasing, property management, and building sales. We have over 70 medical office buildings in our portfolio throughout Ontario. For leasing inquiries:Contact: Brad StoneburghTel. 416.364.5959, ext. 403E-mail: [email protected]: www.par-med.com

Space available for a walk-in clinic/family doctor in a pharmacy unit: Very busy location in Milton. You run the clinic as you prefer.Tel. 647.892.3340E-mail: [email protected]

Stouffville Family Health Centre — opening 2011: Connected to large daycare, ideal for pediatrician/doctor. North of Stouffville Road, on 10th Line. If interested now, would have choice of square footage/design. Very competitive lease rate. Contact: SarahTel. 905.479.2571

Woodbine/Hwy. 7: 620 sq. ft. office for lease in medical building anchored by pharmacy. Waiting room, two exam rooms and physician’s office. Current building mix includes family physicians, rheumatologist, dentists, optometrists, physios, naturopaths, and laser clinic. This high-demand Unionville location is next to Tim Hortons with direct access to Hwys. 404/407. Free parking for 200+ cars. E-mail: [email protected]

REAL ESTATE

Attention northern doctors! Beautiful “Ottawa Riverfront” properties ready for building, minutes from Mattawa, Ontario (see Propertyguys.com — search Mat-tawa).Tel. 416.767.7717, 647.272.4490

Disney/Orlando real estate: Un believ- able buying opportunities, former Ontario resident. Contact: Kathy JaworskiCozy Homes Real Estate, Inc.Tel. 352.223.3389E-mail: [email protected]

For sale — attractive suite of 540 sq. ft. in prime quality medical condominium building, Rosedale Medical Centre. Radiology/ultrasound and laboratory services all present. Located in central Toronto, on subway line, with immediate access to Don Valley Parkway. Currently set up for family practice. For further in-formation:Tel. 416.462.9093

Medical unit for sale in a very busy building located at Kennedy/Finch with a densely populated South Asian com-munity. Well upgraded, with five patient observation rooms. Prime location in an excellent professional building. Tel. 416.891.8291 or 416.880.9613

LOCUM TENENS

Family physician — locum wanted Mondays to Fridays from November 12 to December 3, 2010. Extremely busy practice — FHG. 70:30 split. Free park-ing. Steps to subway at 5 Fairview Mall Drive, North York, Ontario. New grads welcome. Flexible hours.Tel. 416.496.0305Fax: 416.496.3392

POSITIONS VACANT

70:30 split or better: South Ottawa. Family medicine or specialists. Flexible schedule, full EMR, excellent nursing and resident support, full time, part time or locum, and opportunity of joining FHO. Enjoy life, earn a phenomenal wage, get home for a hot meal and stop fretting about stuff! Let us do all the adminis-trative work. Contact: Faiza Tel. 613.692.5433 E-mail: [email protected]

52 September 2010

Classifieds

medicalhowdenclinic

www.howdenmedical.ca

R e c r u i t i n gW a l k – i n, F a m i l y,

S p e c i a l i s t & P a r t – t i m e

D o c t o r s

Pharmacy


$200/hour — GP required immediately at Mississauga outpatient clinic. Hours: 8 a.m. to 11 p.m. seven days a week.Contact: AngelaTel. 905.897.8928

$250 per hour — pediatrician, internist, surgeon, subspecialist in busy outpatient clinic in Mississauga. Contact: Dr. SteinTel. 416.464.0238

Alberta, B.C. and Ontario: Physicians required for walk-in clinics within the GTA, low split, excellent incentives including potential for signing bonus and benefits. Wellpoint Health is also look-ing for occupation medicine in Alberta and BC. Guaranteed daily minimum of $1,000 plus special incentives listed above could be included! Contact: Sunil Sharma, Wellpoint Health Mississauga, ON Tel. 647.637.2233 E-mail: [email protected]

Beautiful Ottawa — fluently bilingual FT or PT family physician/general prac-titioner to join East Ottawa FHT; take over 1,000+ established patient base; work within an interdisciplinary team to provide comprehensive primary health care and health promotion; salary, pre-miums and benefits package. EMR- integrated and training. Free parking. For November 1, 2010.Contact: EOCFHTc/o Physician Recruitment3095, St-Joseph Blvd., Suite 202Orléans, ON K1E 3W6E-mail: [email protected] Website: www.esfestottawa.ca

Brampton, Ontario: Full-time/part-time family physicians and GP psy -cho thera pist required for busy fam-ily practice/walk-in clinic. Attractive modern office. Option to join FHG. High fee-for-service split or flat monthly rate. Tel. 416.949.3830Fax: 647.340.2586E-mail: [email protected]

Brampton/south Etobicoke medical centres seeking GPs and specialists. Walk-in shifts and family practice. F/T or P/T. Relocate or start a new practice. EMR or paper. Turnkey. Tel. 647.403.1810 E-mail: [email protected]

Brockville: Full-time general radiolo-gist position available immediately. You will be one of four (three FTE). New, fully digital department (2003). CT, fluo-roscopy, U/S and bone densitometry. FFD mammography performing general and OBSP screening. VR frontend and backend reporting (Dictaphone Power-scribe). 70,000 exams (2008/09), (www.bgh-on.ca). Brockville is a community of 22,000 located on the St. Lawrence River, in the beautiful Thousand Islands region; 45 minutes east of Kingston, and one hour south of Ottawa. Contact: Dr. Jonathan Lasich Medical DirectorTel. 613.345.5645, ext.1256E-mail: [email protected]: Carlene MacDonald Physician RecruiterE-mail: [email protected]: www.brockville.com

Etobicoke — dynamic physician need-ed for a busy, beautifully renovated EMR practice in medical building. Build your practice from huge wait list. Start working at no cost, then 80:20 split or fixed fee. Contact: JoeTel. 416.564.7585E-mail: [email protected]

Family and walk-in doctor: Locum/ part time/full time. Instant full practice. Extremely busy! Congenial colleagues and low overhead (20%). EMR, FHG, partnership option, >700K billing for a five-day work week. Contact: Thomas VanTel. 647.227.5088E-mail: [email protected]

Family physician wanted to take over a retired physician’s practice and share space with experienced MD. Flexible hours, turnkey office, labs and pharmacy on-site, 726 Bloor St. West (at Christie St.), 80:20 split. Tel. 416.516.5244E-mail: [email protected]

FT/PT physicians — attractive oppor-tunity: Join our busy, well-established medical group either in Hamilton or St. Catharines medical clinics, or as associ-ates in our new state-of-the art medi-cal office, which is centrally located at 9 Court St., St. Catharines, ON. Flexible hours. Fully computerized. EMR. Gener-ous split. FHG or group opportunity. Tel. 905.329.8688E-mail: [email protected]

Full-time or part-time medical doctors required for a busy walk-in located in downtown Mississauga. Contact: AdelTel. 416.904.2929 or 905.897.6160 (office)

Gastroenterologist required: Part time, flexible hours for mid-town Toronto GI clinic.Fax: 416.486.8388

GP needed for Spanish and Portu-guese speaking patients in two loca-tions in the GTA. Terms negotiable. Tel. 416.749.2084 or 905.270.2713Fax: 905.270.3626

MedVisit Doctors Housecall Service: Greater Toronto or Ottawa. PT or FT. New higher OHIP fees and housecall bonuses now in effect. Flexible shifts. Drivers available. Contact: Dr. BurkoTel. 416.631.0298E-mail: [email protected]: www.medvisit.ca/doctors

Mississauga west — physician needed full time or part time in a busy medical building. Free parking, on-site lab and X-ray. Brand new office with support staff and full computerization, pharmacy next door. Split or monthly rate; you decide what works for you. Accepting family physicians willing to relocate. Contact: Mr. KariaTel. 416.616.3014E-mail: [email protected]

North York, Ontario: Paperless com-puterized new clinic in a medical build-ing with pharmacy, lab and X-ray. No set-up cost. Part t ime or ful l t ime. Move existing practice or build up from walk-in clinic. Support staff for EKGs, PFTs, venipuncture for income supple-ment. Contact: Mr. SamuelTel. 647.400.0401

Obstetrician/gynecologist — full time/part time: Instant full practice in a group of 14 GPs and 20 plus specialists. Extremely busy. Congenial colleagues and low overhead. EMR, PACS.Contact: Thomas VanTel. 647.227.5088E-mail: [email protected]

53 September 2010

Classifieds


Opportunity for a family physician to join a family medicine clinic in downtown Toronto for walk-in shifts, with possibility to build own practice. Interested candi-dates should send their resumé.Fax: 416.901.8870E-mail: [email protected]

Opportunity in Richmond Hill & mid-town Toronto, Ontario: Well-established family practice of family physicians seeking physician full time or part time. Walk-in shifts also available. No finan-cial commitments, clinics are fully EMR integrated (EMR training included). On-site lab. Above-average compensation package. Tel. 905.884.1017 (direct office line)E-mail: [email protected], [email protected]

Ottawa — family medicine full-time or part-time positions available in an at-tractive building in a beautiful new com-munity. Free parking and on-site lab. Contact: Dr. AshikianTel. 613.822.0171 (9 a.m. to noon, or 1 p.m. to 3 p.m., Monday to Friday)Fax: 613.822.1838E-mail: [email protected]

Ottawa — family physician: Full time or part time, to join well-established group of five family physicians in med-ical building close to the Civic Cam-pus of the Ottawa Hospital. Take over from departing physician, bring own patients or start new practice. Con-verting to EMR, subsidy available. Ef-ficient practice with excellent support staff. Part of a large FHG with no call necessary. Contact: Dr. Karen McIntoshE-mail: [email protected]

Physician needed — enjoy medicine more: Enjoy medicine again! If you have an interest in this important clinical area, we would like you to join our busy clinic. We need family doctors, GPs, GP psychotherapists, psychiatrists, semi- retired, part time or full time. We are open weekends and weeknights. We provide comfortable offices, profes-sional staff, excellent financial arrange-ments, professional supervision, and CME programs are available.Contact: AnnaTel. 416.229.2399 or 1.888.229.8088Website: www.medicalpsychclinic.org

Physicians — Kelowna, BC: Medi-Kel Clinics Ltd. seeks physicians from across Canada for well-established family practice. IMGs also welcome. Kelowna is located in the heart of the Okanagan in south-central BC. Kelow-na has excellent schools, recreational facilities, restaurants, and wineries. Truly a great place to live and work. Contact: Maria VargaE-mail: [email protected]

Physicians opportunity to join a lead-ing medical practice group that is ex-clusively focused on one of the fastest growing and most rewarding fields in medicine today; anti-aging, wellness and rejuvenation medicine. Attractive compensation package, located in mid-town Toronto, treating a highly mo-tivated patient base. Improve your life as well as that of your patients.Contact: Human ResourcesTel. 416.785.1828, ext. 202

Position/space available for MD or specialist to join our Scarborough multi-disciplinary team. We have a 3,000 square foot office in a medical/professional build-ing which can accommodate a medical practice. The ideal medical doctor would be willing to work in collaboration with the other health practitioners on-site to opti-mize patient care. Rent is minimal, terms and conditions are flexible and negotiable. Location: Sports Injury Clinic, 1920 Elles-mere Road, Suite 310, (Ellesmere Rd. and Bellamy, near Markham Rd.) Scar-borough, Ontario. Support services pro-vided: A highly experienced chiropractor, physiotherapist, massage therapist, as well as exercise rehabilitation and gym equipment. Contact: Dr. Samji Tel. 416.854.7970E-mail: [email protected]

Psychiatrists, medical psychothera-pists are needed at a busy private mental health clinic. Contact: Sue. Tel. 416.778.1496

Richmond Hill, Ontario: Richmond Hill After-Hours Clinic requires phy sicians for daytime shifts 9 a.m. to 5 p.m., as well as evenings and weekends. Guar-anteed minimum 70:30 split. Con tact: Dr. Ian ZatzmanTel. 905.884.7711Fax: 905.553.5360E-mail: [email protected]

54 September 2010

Classifieds

WE HAVE THE EXPERIENCE TO PROVIDE YOU WITH THE ADVICE YOU NEED.

LEGAL SERVICES FOR PHYSICIANSHEALTH CARE LAWYERS

462 Wellington St W, Suite 500Toronto, ON, M5V [email protected]

T: 416 955 9501 F: 416 955 9503

ErnestJ. Cappellacci

SERVING THE NEEDS OF HEALTH CARE PROFESSIONALS ACROSS ONTARIO FOR OVER 35 YEARS

CappellacciDaRoza LLP


Scarborough, Ontario: F/T, P/T fam-ily physicians required for medical clinic serving mainly Cantonese and Manda-rin speaking seniors. Open to public. Pharmacy on-site.Contact: Martin ChaiTel: 416.299.0555, ext. 12E-mail: [email protected]

Specialists — Brampton, Ontario: Dermatologist, pediatrician, internist, and psychiatrist required for medical centre with several GPs and large pa-tient base. Attractive modern office with seven days/week reception service. Fee-for-service split or low flat monthly rate. Tel. 416.949.3830Fax: 647.340.2586E-mail: [email protected]

Walk-in/family practice group of three clinics: Eight MDs seeking MD to join in busy clinics in north Etobicoke. Attrac-tive split.Contact: YasminTel. 416.834.2807E-mail: [email protected]

PRACTICES

Downtown Toronto: Obstetrics and gynecology private office practice. Flex-ible hours to share office or for sale. Very well equipped. Three exam rooms, two Ritter tables, two ultrasound machines, colposcopy, cryotherapy and leep. Near major university hospitals. Ideal for new grads and semi-retired gynecologists.Tel. 416.923.7311Fax: 416.923.1287

SERVICES AVAILABLE

Benefit from EMR (electronic medical records)! A complete electronic patient record, scheduling and billing solution. Now that summer is behind us, add efficiencies within your practice. We’ll prove the benefits of our certified EMR solution. Government funding is avail-able. Our fortunate 500 customers trust us, you can too!Contact: Reno Tel. 905.271.8397E-mail: [email protected]

Bi l l ing agent – e lectronic data transfer to MOHLTC for all practices, specialties and locums. Medical Bill-ing and Secretarial Services.Contact: Edith ErdelyiTel. 416.576.6788

Free record storage for closing prac-tices: RSRS is Canada’s leading paper and digital storage provider. No prohibi-tive fees to patients. Physician managed since 1997. Tel. 1.888.563.3732, ext. 221 Website: www.RSRS.com

Going EMR? Need to scan your pa tient records? We can find you an affordable solution that fits your budget. For more information and many references:Contact: Sid Soil, DOCUdavit SolutionsTel. 1.888.781.9083, ext. 105E-mail: [email protected]

Medical Transcription Services: Tele-phone dictation and digital recorder f i les. PIPEDA compliant; excellent quality, next business day service. All specialties, patient notes, letters, re-ports, including medical-legal and IME reports.Tel. 416.503.4003 or 1.866.503.4003Website: www.2ascribe.com

Moving or moved to EMR? Still have lots of paper? RSRS scans your records and offers full electronic access to your active patient records. It’s easier than you think. PHIPA compliant. Contact: RSRS Tel. 1.888.563.3732, ext. 221 Website: www.RSRS.com

Retiring, moving or closing your prac-tice? Physician’s estate? DOCUdavit Medical Solu tions provides free paper or electronic patient record storage with no hidden costs. Contact: Sid Soil, DOCUdavit SolutionsTel. 1.888.781.9083, ext. 105E-mail: [email protected]

Toronto Health Centre — Your one-stop clinic for all your rehabilitation needs. Physiotherapy, chiropractic, massage, low level lasers, orthotics, and compres-sion socks. Located in downtown To-ronto at University and Dundas. 25 years of experience, new patients welcome. Tel. 416.979.3022

UPCOMING EVENTS

Caribbean cruises — four CME sail-ings! Nov. 26 – Dec. 6, Sexual health medicine; Dec. 26 – Jan. 2, Use of pharmaceuticals; Feb. 19 – 27, Clinical medicine for hospitalists; March 12 – 19, Diabetes management. Group rates. Companion cruises free. For info and more CME cruises:Contact: Sea Courses CruisesTel. 1.888.647.7327E-mail: [email protected]: www.seacourses.com

Exotic cruises — four CME sailings! January 16 – 30 to South America; Feb-ruary 13 – 27 to Australia & New Zea-land; April 22 – 29 on the Rhine River; October 29 – November 12 to Istanbul to Luxor. Group rates. Companion cruises free. For info and more CME cruises:Contact: Sea Courses CruisesTel. 1.888.647.7327E-mail: [email protected] Website: www.seacourses.com

FOR SALE

Retiring family MD needs to get rid of exam tables, chairs, syringes, Halogen floor lamp, papers, ear syringes, and scales. Up to 80% off.Tel. 416.857.1891, 905.828.7607

55 September 2010

Classifieds

Use the OMA’s Continuing Medical Education Locating Service to fi nd the right CME opportunity for you.

With access to thousands of courses, conferences and cruises worldwide, we can customize a list of professional development opportunities for you.

You can also search our database and list of quality websites focusing on Canadian CME opportunities.

For more information, contact Corporate Information:tf: 1.800.268.7215, ext. 2915 e-mail: [email protected]: http://www.oma.org/Benefi ts/CMELocating.aspx

Navigating Your CME Opportunities

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