Human Rights Tribunals: privacy and transparency

Added Nov 15, 2015: An Interim Decision was made on October 8, 2015.  See more in the note below, at the end.

The purpose of this is to explain part of the process of the Human Rights Tribunal, using one aspect of my own experience and how that relates to privacy laws in health care, and accountability of physicians and other health care workers, and the accountability and transparency of those organizations meant to resolve problems that occur. The example I am using is of my own Application to the Human Rights Tribunal, April 14, 2015, of discrimination on the grounds of my sex, family and marital status, and age (for more details, see Health care among single, older women – a case of discrimination for OHRT).

On Aug 26, 2015, I made a Disclosure to the lawyer of the Respondent. The Disclosure was required according to the Rules of Procedure, providing him with copies of the documents I would be relying on at the hearing, as “arguably relevant” documents.

I received nothing from the other side by the deadline (September 1, 2015) given by the HRT, in the Rules as being three weeks after they notified us (on August 11) of the dates of the hearing (February 10 & 11, 2016). September 1st  was the date by which both sides were to have sent to the other a list and copies of documents they thought may be relevant to the issues raised in the case.

Backing up for a moment, I must say here that only one item had been listed in the Important Documents section of the Respondent’s Response to my Application (received July 27, 2015).  That one item was my Medical Chart, for all the time I was with the doctor in question, from September 2012 until spring of 2014. I submitted my Form 3 reply to the new points raised in the Response on Aug 12 (having had an extension, due to the original due date, August 7, being less than 2 weeks away from when I received the Response) though not responding to the idea of having his entire Medical Chart about me being available for him to pick and choose from at the hearing, or for it to possibly influence the adjudicator. Since no items – appointment dates, specialist reports, etc – were listed, I had no idea whether what was included was a complete set, or whether what would be sent to me, finally, was complete. And at the same time, more or less, received the notice from the HRT about the dates of the hearing, requiring me to then send a Disclosure to the Respondent by Sept 1, which I did, as noted in the previous paragraph.

But now, having not received a Disclosure of arguably relevant documents from the Respondent by September 1, and not agreeing anyway with the idea of my privacy into my medical records being made available in that manner, I discovered that I could complete a request for an Order on a Form 10 and submit it to the HRT, using the Production of Documents part to request a copy of the document - my Medical Chart. To me, the chart wasn’t “arguably relevant,” at least not in its entirety, but I decided to submit Form 10 anyway, requesting that the Dr itemize the Medical Chart and send only those items he was planning on using at the hearing in February. Also, I requested under ‘Other’ that for privacy reasons, the entire chart not be produced at the hearing, thus, not sent to the HRT’s adjudicator (see excerpt from PHIPA, Personal Health Information Protection Act, 2004). Formally, these were the requests I made in writing, and sent to the lawyer for the Respondent and to the HRT:

Request for an Order for the Production of Documents
I am requesting, first, with conditions, that the Respondent, the Dr, produce relevant sections of the document he named in his Response (July, 2015).  I also request that he particularize those sections of the Medical Chart that he plans to use at the hearing.  

Other Request: that the Medical Chart of Ms McPherson not be used in its entirety
I am requesting that the Respondent not rely on the Medical Chart of Ms McPherson in its entirety, for this Application at the hearing, as that would be an invasion of privacy under the law, such as under PHIPA, the Personal Health Information Protection Act, 2004. I request that he selects only those items he plans to use, explains why each is important, and provides a copy of them for the Applicant. (Question 3, Form 10, September 9, 2015)

I wrote out a detailed explanation of my reasons for making these requests in Form 10, Question 4, and sent a copy of the Form 10 to both the Respondent’s lawyer and to the Human Rights Tribunal Registrar/caseworker.

About two weeks later (September 17th) I received a copy of the Medical Chart from the lawyer, obviously not itemized as there was no list, and no explanation of why the Respondent thought each entry in it was important, or arguably relevant, or whether it was complete at all, and of course, reaching me well after the due date for a Disclosure.

This wasn’t what I had hoped for. After all that explaining, the lawyer had simply sent off what appeared to be an unsorted file of my medical records, not particularized, and with no acknowledgement in the cover letter that I had sent to her a completed Form 10 with pages of info and explanations. There was a brief email discussion between the lawyer and myself, which also went to the caseworker.  But in the end, the caseworker said that the Form 10 Orders would go to a ‘decision maker’ to resolve.  Already, I can picture another person getting involved in this situation who knows nothing about the Application, and would have to start from scratch reading up on it, and being pressured to make a fair decision on whether my Medical Chart should be allowed to be taken into consideration and whether it needs to be particularized.  What’s more, the lawyer now has the opportunity to respond to my Form 10 request before the decision maker considers it, and the decision maker gets to see what she says about it, including the fact that she has sent me a copy of the Medical Chart already, by that point.

One might ask, at this point, why did the lawyer quickly send me a copy of the Medical Chart, when it was overdue by practically two weeks, and when it was not what I asked for?

I feel that her sending the ‘document’ to me – the Medical Chart – altered the dynamics of the situation, whereby a ‘decision maker’ might just as easily say, Well, it’s been sent to the Applicant now, so leave it at that. And the Applicant did make out a Form 10 request for Production of Documents . . . . .

The Rules of Procedure say the Respondent must send their ‘arguably relevant’ documents by a certain date, but don’t say what happens if they are not sent by that date, except that I can request them if I choose to, through submitting a Form 10, in this case for Production of Documents.

I don’t want this to end up being a matter later interpreted by the Respondent as me being the one to request the Medical Chart. Details are so easy to skim over, and if the fact is that I submitted a Form 10 for the Production of Documents, which I did, the assumption could well be that I considered them ‘arguably relevant’.

This Application to the Human Rights Tribunal is supposed to be about the actions and behaviour of the Respondent, not about me having to defend myself against false accusations and distortions of the truth made by the Respondent and his colleagues in documents in my Medical Chart. My response to Question 4 of the Form 10 goes into more detail about the idea of truth, and who gets to be believed in this world and who doesn’t. It also brings in the matter of the longer transcript of the April 28, 2014 office appointment, and the accusations made against me by the Respondent in his Response to my Application, that I shouted at his staff after the appointment ended.

I have presented in my Application only 2 examples of discrimination, both of which I believe I have the evidence to uphold. I could write at length, too, about the behaviours of the Respondent, but I have no proof of much of it. But when the Dr says something, and writes it down, it seeme from what I have seen elsewhere that it is taken as truth.

I might not have known about Form 10 and the right to request a production of documents and the right to request privacy of medical information, had not the Respondent failed to make a Disclosure of the ‘document’ named in the Response – the Medical Chart.  I have no access to a lawyer who can foresee such issues arising and be able to advise me. Of course, the other side of that is that no mention of the reason for the importance of the Medical Chart was mentioned in the Response, and its relevance might have been difficult to explain. I have never said the doctor did not provide some good health care towards me. If he hadn’t done something worthwhile, it wouldn’t have taken me so long to acknowledge the unprofessionalism and poor judgement in his treatment of me, and he would have been seen, at least by me, as not worthy of being a physician. Rarely is someone totally one or the other – all bad or all good.

A physician is someone who is subject to certain standards in his profession. Too many errors of judgement, incidents of rudeness, trivializing the patient’s concerns, and judging me on the basis of my sex, and family and marital status, and age is what can lead to the realization that he is discriminating against me. Saying, “The report is back. You’re fine,” isn’t serious on its own, but amongst so many other incidents, it becomes relevant, an indication that he doesn’t care, and isn’t doing his job.  When I go to him about ankle pain, or a swollen knee, and the first question he asks is How does that affect your driving,” one has to wonder. And when medications I have been taking for a number of years are questioned, and changed, for no good reason or without informing me when I go to him to have prescriptions renewed, it made me wonder. And why was I treated like a walk-in patient, having to have my prescriptions renewed by hand, with the risk of mistakes being made, and being denied having access to Tylenol 2 with codeine, 2 per day, as though that was a large amount and I might abuse the privilege of having relief from pain. Read in my blog, Health care among single, older women – a case of discrimination for OHRT, for details about that and the unnecessary pelvic renal ultrasound he sent me for. He wasn’t behaving like a family doctor should.

The HRT caseworker had assured me a while back that if the due date were approaching and I hadn’t sent a required document, that he would request it. That was in response to my requesting confirmation when he received documents I sent to him. But he didn’t request from the Respondent the ‘important document’ named by the Respondent in his Response, which surely must have been intended to be sent as an ‘arguably relevant’ document to me as a Disclosure. The caseworker accepted my Form 23, declaring I had sent my own Disclosure to the Respondent, but it didn't jog his memory to ask the Respondent for his list of arguably relevant documents in a Disclosure. And my sending my Disclosure to the Respondent didn’t lead him – or her, the lawyer – to send their own Disclosure to me.

For me to do the requesting of my Medical Chart, through a Form 10, resulting in a conglomeration of largely unexplained and unidentified items quickly being sent to me (although more than two weeks overdue, not the ‘documents’ I asked for, and not mentioning they were in response to my Form 10), would have made it appear that it was me who believed they were ‘arguably relevant,’ unless the decision maker took more time to read what I wrote than the lawyer did. It is possible the lawyer was attempting to cover up a mistake, and was hoping the ‘decision maker’ would overlook it and accept her sending of the documents, though past the deadline, without examining closely what I wrote in Question 4 of Form 10.  But the lawyer wouldn’t have realized her error of omission had I not pointed it out when I sent her the Form 10. And then what?

It’s too easy for the Human Rights Tribunal to take short cuts, to not be transparent in its process, and to simply make important decisions without the Applicant knowing what’s going on, for instance, who the decision maker is in terms of position if not by name, and his expertise, especially in the area of privacy in health care. This situation has now been left in the hands of the Respondent’s lawyer, who gets to write a response to my Form 10, and the decision maker for the HRT, who makes a judgement on the Form 10 I submitted. He could have her send a list of itemized documents from the Medical Chart, and agree with me that the privacy of my medical records is important, or he could just say, Well she has sent it now, so that’s good enough. And then she will send a copy to the HRT in December, the relevance of which the Respondent will not be obliged to explain, even if it gives a false impression of me, while falsely presenting him in a better light.

Note: Added Nov 15, 2015: 

An Interim Decision was made on October 8, 2015, granting the Respondent and lawyer their requests, regarding their Disclosure – my medical chart.  It was declared by Laurie Letheren, an adjudicator with the HRT, that my requests were premature. The material was delivered to me, although not organized properly, some of it not relevant and none of it argued to be relevant, and not itemized, no reason stated for its importance other than it demonstrated the care I received from the doctor, and it was sent a little late. But at least I got them, I think she was saying. 

If the Respondent decides to particularize the documents, s/he may do so when required to send the documents to the Tribunal (deadline December 29th) in preparation for the hearing early in February. But again, s/he may not. There has been no warning given by the adjudicator to the lawyer to itemize the documents. It’s just a collection of undecipherable documents, much of it, with no explanation of why each page of the seemingly random collection is relevant. At least, that much should have been done. Then, by the end of December, s/he would be able to decide, presumably, which documents she is going to use at the hearing. 

Also added to List of Resources, on Nov 15, ‘Health-care system in need of more transparency, report says’ (The Star, Nov 12, 2015).

Resources

Health care among single, older women – a case of discrimination for OHRT
April 12, 2015
http://suemcpherson.blogspot.ca/2015/04/health-care-among-single-older-women.html

Health-care system in need of more transparency, report says [added Nov 15, 2015]
C.D. Howe Institute says there should be more public reporting on patient experience within Canada’s health-care system.
By Theresa Boyle, Health
The Star
Nov 12, 2015
http://www.thestar.com/life/health_wellness/2015/11/12/more-transparency-needed-in-health-system-report.html

New health legislation will improve transparency

By Olivia Carville, Staff Reporter
The Star
Sept 19 2015
http://www.thestar.com/life/health_wellness/2015/09/19/new-health-legislation-will-improve-transparency.html

Personal Health Information Protection Act (PHIPA), 2004, S.O. 2004, c. 3
Government of Ontario
http://www.ontario.ca/laws/statute/04p03#BK1
retr Sept 17, 2015
see excerpt here: http://suemcpherson.blogspot.ca/p/personal-health-information-protection.html

CPSO: transparency in the complaint process

Update, Sept 22, 2015   

As of Sept 22, 2015, still no response from the CPSO.  For further details see end of this entry for Sept 13, 2015.



In June, 2014, I submitted a complaint with the College of Physicians and Surgeons (CPSO) against my family doctor, who had acted unprofessionally, disrespectfully, and administratively insensitively towards me. At this point, September, 2015, I am waiting for the Inquiries, Complaints and Reports Committee to determine whether they think I have a case worth taking any further. Their decision will be based, in part, on what they receive from the Investigator assigned to my case. In the following look at correspondence and methods of seeking the truth of the matter, I will use the situation of the ENT specialist and my ongoing ear problems as an example of the lack of transparency in the process of the CPSO complaints system, and their inadequate methods of seeking answers. The ear/ENT problem is only one of many behaviours and decisions I was concerned about, but here I will focus only on this one.

Letters, Reports, etc

Two weeks ago, on August 31, 2015, I wrote the following brief letter to the CPSO Investigator assigned to deal with matters to do with the complaint I had brought against my family doctor over a year earlier, in June, 2014. There was nothing left to say, I assumed, and this would be going to a committee who would determine whether my complaint was worth looking into further. My concern now is whether the Investigator herself was biased in her approach to the summary, documents and other evidence she was preparing for the Inquiry Committee for the College of Physicians and Surgeons.

Dear [CPSO Investigator],

Thank you for your letter of Aug 21, 2015 informing me that the committee has met and that I can expect to receive their decision in approximately 4 months. 

I am wondering if I could have a copy of the statement they received about the case from you, and a list of any documents they took into account, also sent to them by you. There is very little transparency in this process, and I need to have more information about what the committee gets to see as I read their decision. 

Sincerely,

Sue McPherson (Aug 31, 2015)

I regret now that I did not ask her specifically, had she received my July 14 response to her previous letter of June 26, 2015. That was my last chance to tell my side of the story and to respond to claims made by my family doctor. She neglected to acknowledge receiving that letter. I will reproduce part of that letter here, just the part that applies to this matter of the ENT specialist and my family doctor/gp’s handling of that situation of my ear problems.

I have not yet received a response to my letter of August 31, 2015.

Backing up in time, to February, 2015, I noted that I had asked the same question, about what the committee got to see and base their decision on. I wrote,

“How much information am I able to have on this procedure, for instance, the report you provide for the Committee or just their final report?” (McPherson, Feb 9, 2015).

The Investigator had responded, less than two weeks later,

“As the investigator in this case, it is not my role to accept, deny, or "uphold" a physician's response, or take one person's word over another. It is my role to gather relevant information, but not to provide my opinion on the information gathered. Nor is it my role to elaborate on, or explain [the doctor's ] response. Consideration of the physician's response rests with the Inquiries Complaints and Reports Committee (ICRC), and I do not participate in their discussion or decision-making. Please note that the ICRC is a screening committee; not an adjudicative body that assesses credibility or makes findings of fact” (Investigator, CPSO, Feb 18, 2015).

Skipping a couple of months of letters back and forth, the Investigator wrote on April 13, 2015, documenting in a list the reports, letters and responses she felt were important for the committee to see, saying,

“I am now in the process of preparing the information received for review by the Inquiries Complaints and Reports Committee (ICRC); it will be a review of the documentation gathered and audiotapes, and neither the physician nor the complainant attend” (Investigator, CPSO, Apr 13, 2015).

Despite having claimed earlier that she was objective in her role as Investigator, she wrote, regarding the particular report from the ENT specialist,

“For your interest,  I have learned during the course of this investigation that although you saw [the ENT specialist] in August, 2013; it appears that his report was not sent to [your family doctor] until Mar 5, 2013 (Investigator, CPSO, Apr 15, 2015).

I was dismayed at this. She wasn’t saying that the ENT specialist “claimed” or “explained” that the report did not go out in good time, but says instead in her letter that “it appears that” it was not sent until 7 months after the appointment, implying that was what the situation was.  One of the issues I had, that I referred to before, was that I was never permitted to see the report sent by that specialist, when I asked my gp what the report had said, though he did say he had it there, just not for my eyes to view.

I wrote a response on April 26, 2105 (see excerpt here) to the investigator, but have no idea if that letter got included in the documents sent to the Committee (ICRC), as the list of documents she sent to me was in the letter dated April 13.

Over time, I have expressed many thoughts on the bad treatment I received at the hands of my family doctor, and in this letter, I tried to make clearer what happened in that entire incident of the “ear” problem with the ENT specialist. While the investigator relies on documents and so-called facts, my approach, however, is to look at the circumstances of the incident itself - circumstantial evidence, I believe would bewhat it is called.

The Investigator wrote again on April 30, 2015,

“[The ENT specialist’s] report documented the date Aug 20, 2013, as the date of the appointment. [His] report does not document the date that he wrote the report, however there was only one report written which was faxed to [the family Dr] on March 5, 2014. There is no evidence that [the family Dr] had a report prior to that date” (Investigator, CPSO, April 30, 2015).

This sounds very much as though the investigator is taking the ENT specialist’s word for it - he said he only wrote one report (7 months after the appointment) so that must be way it happened.  What chance do I have at receiving justice if physicians’ words are taken as truth and mine are not?  My family doctor said to me that he had received the report, early on in September or August of 2013, but wouldn’t let hear what was in it. I attempted to find out what the report said on more than one occasion, from my gp, but eventually gave it up as a lost cause.  Now, however, the entire incident has become one more example of the ill-treatment I received at the hands of my gp.

One question I have now is, was my letter of April 26, 2015 (see excerpt) added to the list of documents that I first saw in the letter of April 13, 2015, or was it ignored because it wasn’t an official document or report?  The letter would explain some of the problems over the ENT specialist’s appointment and report - the misunderstandings, the thoughtless choice of ENT specialist in a particular setting which did not apply to me, the two ultrasound reports even though one was redundant, and my family doctor/gp not wanting to allow me to read the report, leading to further confusion in the doctor’s office as I requested another appointment with an ENT specialist, which happened to be for 18 months in the future. Experiencing much pain at the time, I requested that I see an ENT specialist sooner than that, which resulted in another appointment being set up, and confusion overall.

Another question I have is whether the response I wrote on July 14, 2015 (see Ear/ENT excerpt), was added to the list of documents intended for the ICRC, since I received no acknowledgment of it in the Investigator’s letter of August 21, 2015. As I stated in that letter,

“The main problem with the appointment on March 4, 2014 that [my gp] refers to in his letter, in “Audiotape of March 4 Meeting” is not that he raised his voice but that I made it [the appointment] for the purpose of discussing the administration of my ear problem; in fact, I made a point of telling the receptionist that when I made the appointment.  However, at the appointment, as the tape recording indicates, [my gp] immediately moved away from discussing the problems of the 3 ENT referrals to asking once more about my ear and examining it. Strangely, he never once mentioned the non-existent report from [the ENT specialist], even though that ENT appointment had been more than 6 months earlier. At the beginning of that appointment on March 4 I did not mention the report from [the ENT specialist] as on other occasions he had told me it was for his eyes only, saying it was private, not for the patient to read. I had hoped we could move past that” (McPherson, July 14, 2015).

At the end of that office visit about Ear/ENT matters I handed him a letter requesting a copy of the report (see transcript of excerpt of Mar 4, 2014 appointment). And now, there is complete denial on his part, and of the ENT specialist, and of the Investigator, that I asked for the report soon after the original ENT appointment, but did not receive it from my family Dr until very recently, via the Investigator, who seemed to be claiming it was the original – the first and only – report.

Furthermore, my letter expands again on the issues to do with the referral to the ENT specialist and that appointment – see 2nd paragraph from Ear/ENT excerpt from my unacknowledged letter to the CPSO Investigator,  July 14, 2015.

Language - wording of CPSO Complaint Form and in the Investigator’s letters

It’s also regrettable that there was confusion about the wording of the terms on the original CPSO complaint form  - mentioning “other physicians who provided medical care” interpreted by the Investigator to mean “physician witnesses” (not involved in medical care but who had something to add)  whereas I would have been more interested in having “health care witnesses,” such as receptionists and nursing assistants who witnessed or played a part in the incidents themselves.  Left to the CPSO, however, the aim would appear to be (there’s that word again, demonstrating bias) to have only physicians being granted the right to speak, and only physicians the right to be believed, from all appearances.

I have given examples from letters written by the Investigator of how she views the words of a physician more truthful than the words of the patient. I can only hope she didn’t display this attitude in her submission to the Inquiries Complaints and Reports Committee. Lack of transparency isn’t the only problem with the CPSO and the health care system’s ways of dealing with problems, but without transparency -  at the very least sharing with the complainant what the Committee is seeing, what we have is a complaints system in which the Investigator holds the power to influence the Committee if s/he chooses to do so, or even if due to unrecognized biases.

Transparency

Last year, the subject of transparency within the CPSO was introduced by MPP Steven Clark in a private member’s bill – Bill 29 – in Parliament. His concerns were focused on transparency in notifying the public of complaints, and of the investigation results, rather than about the process itself. And his concern was mainly for the families of people who had lost loved ones unecessarily, through carelessness or negligence.  But those aren’t the only kinds of situations that are harmful to patients and their families. And while I would not agree that a physician’s future has always to be dampened or lost completely by being publicly disgraced, through making errors of administration or judgement, there surely are times when the public should have the right to know more details than they are currently allowed to know. My concern, however, is the lack of transparency in the process of making a complaint and having it addressed.

Having to rely on one person – an Investigator – assigned to a deal with a complaint, is less than ideal. If the CPSO Investigator chooses to withold information from letters written, that are not in the format of a ‘report’ made by a physician, she can do so, leaving the complainant virtually helpless to have their voice heard.

Update, Sept 22, 2015. 

I have not yet received a response from the Investigator of my complaint to my letter of August 31, 2015. Today I wrote to Ms Sandy McCulloch, CPSO Director of Investigations and Resolutions (copy to Ms Katja Lutte, Manager of Investigations and Resolutions), explaining the situation and my concern that my complaint may not have been dealt with fairly. Specifically, I mentioned my last two letters (August 31 and July 14, 2015) to the Investigator assigned to my case, to which I have received no response.

List of resources

Bill 29, Medicine Amendment Act, 2014
http://www.ontla.on.ca/web/bills/bills_detail.do?locale=en&BillID=3055&detailPage=bills_detail_status

Bill would require doctor cautions, complaints to be public
By Marco Chown
The Star
Oct 20 2014
http://www.thestar.com/life/health_wellness/2014/10/20/bill_would_require_doctor_cautions_complaints_to_be_public.html

Doctors’ Blame and Shame – Ontario Bill 29
By Shawn Whatley
Oct 25, 2014
http://shawnwhatley.com/doctors-blame-shame-ontario-bill-29/

See also, list of topics on the right of blog screen, for more on this subject.