Physician-based transparency approaches have been advanced as a strategy for informing patients of the likely financial consequences of using services. The structure of health care pricing and insurance coverage, and the low uptake of existing tools, suggest these approaches are likely to be unwieldy and unsuccessful. They may also generate new ethical challenges.

Drug-related illness (DRI) is a common problem in the elderly. Misuse of medications and inappropriate prescribing account for over half of all hospital admissions for DRI and both are potentially preventable. Physicians are the gatekeepers to prescription medication access and, in this role, they have the opportunity to prevent exposure to unnecessary and inappropriate medication and influence the use of medications by their elderly patients. Effective interventions to improve physician prescribing have been identified but they are costly to introduce, they require ongoing maintenance to maintain their effectiveness, they do not address the problems created by multiple prescribers or the challenges of keeping up-to-date on the growing number of new drugs that enter the market each year. Computer-based drug information networks and expert decision-making support systems are proposed as one means of providing (1) an accurate record for the prescribing physicians of drugs currently dispensed to their elderly patients, (2) a review of problems in existing and new prescriptions, and (3) an expert resource to select drug treatment. Canada is in an ideal situation to pioneer the development of these systems, but to do so, policies need to be put in place to address three problems. First, there is inadequate information available about the risks and benefits of drugs in the elderly because older sicker adults are often excluded in clinical trials of drug-effectiveness. Requirements for drug approval need to be amended so that sufficient evaluation of the risks and benefits of new drugs are carried out in the elderly. Second, computerization in the health care sector is central to the development of electronic decision-support systems in health care delivery. Future policy needs to be directed to the development of an effective infrastructure to facilitate the transition to an integrated computerized health sector. Third, the ethical and legal issues related to the access of prescription data through electronic networks need to be identified and clear guidelines for use of this new technology need to be developed.

In a time of increased patient loads and emergency department (ED) exit block, the need for strategies to manage patient flow in the ED has become increasingly important. In March 2002 we contacted all 1282 members of the Canadian Association of Emergency Physicians and asked them to delineate strategies for enhancing ED patient flow and ED productivity without increasing stress levels, reducing care standards or compromising patient safety. Thirty physicians responded. Their suggested flow management strategies, which ranged from clinical decision-making to communication to choreography of time, space and personnel, are summarized here.