Four ways Canada can shorten wait times for specialists


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30 comments

  1. Billie Thurston

    Why are physicians allowed to block significant changes that would improve the system?

      • Maureen Taylor

        Don’t want to speak for Billie, but the article talks about needing “buy in” from specialists in order for these ideas to work, and in the UK, whole specialties refused to participate. That could be interpreted as “blocking”.

  2. Diane

    All of these are potential failed pilots, except central intake. One idea that should have been presented: creating a private system that operates alongside the public system.

    Also, please do not withhold effective opioid medications to patients with pain.

    I look forward to reading more in the series.

    • Vanessa Milne

      What do you mean by potential failed pilots? That they’re unproven?

  3. Leslie

    Like the centralized intake and ore screening. Many times people are referred inappropriately or referred to the incorrect/ most appropriate specialist

  4. Gordon Saunders MD (ret'd)

    What type of process was used to include stakeholders before these programs were launched. If buy-in was part of the process, then attach a payment penalty for failure to participate. For most docs the almighty dollar is still the biggest motivator.

    • Kathy Tomlinson

      Hi Dr. Saunders. I am a reporter with the Globe and Mail, and I’m interested in your comment re the “almighty dollar”. I’m just starting an in-depth look at doctors across Canada who bill both the private and public systems. We want to dig deep into current practices and, most importantly, we want to find out and expose how they affect patients and the public purse. If you are willing to help in any way, on the record or not, please email me. ktomlinson@globeandmail.com Thanks so much!

  5. Diane

    What I mean is that central intake seems to me, as a consumer, most likely to improve the current system in Ontario than the other projects mentioned.

    The LHINS have purchased different software? What a disaster.

    I need a portal that I can log into to view consult reports and notes, test results, referral statuses, etc. I need to manage my own health information, not leave that job up to my family doctor who has thousands of patients and works at the clinic, at best, part-time.

  6. Kathryn Walker

    Central intake in my area for 2 programs – ortho service, and mental health, have not gone smoothly and it is my opinion that they have greatly increased the wait times for my patients, in some cases. They have also added to my workload with an additional referral sheet, that also requires additional information.. so I end up writing a regular referral and then also adding the central intake form! I have had requests for additional imaging – such as a MRI before being seen (ortho).. for a concern, that frankly, does not need an MRI. I do not think that is going to save the system resources. The psych service – Here 24/7 has not improved access..(yet) but created a bog in the system and delayed care..
    There is a lot of potential for these services.. but the specialties developing the “central intakes” needs to work with family med to create these processes and referral systems.. All elements of the process need to run smoothly in order to improve patient care and timely access to a specialist service. E-referral and phone consults also have to be thought out.. Unless there is time in my day to do this, how would a call system work well?! If I was sitting doing paperwork, it is one thing.. but to take 15 minutes in the middle of a day of seeing patients, to take a phone consult for 15 minutes.. that is not appropriate or reasonable for a non-urgent concern.. anyone who suggests that this is easy to do, is in academic medicine and/or not seeing a full slate of patients.

    • James Pookay

      My experience is quite similar with central intake for psych and ortho locally.

      Patients languish forever on Psych lists without any updates and it’s impossible to get patients with any complaints other than candidates for THA/TKAs seen by ortho. Half the time, my referrals directly to ortho surgeons for other pathologies (like FAI of the hip) get dumped into the joint replacement streams and they get rejected by the screening PT without even getting to see an orthopod.

  7. Paul Dorian

    Excellent article , thank you.
    Another advantage of e referrals/virtual consultations is that it cuts down or “reflexive” test ordering by specialists whereby all patients get certain tests whether they are indicated or nor, prior to seeing the specialist.
    Paul Dorian

  8. Dr. PJ Shukle, Ottawa

    1. Our EMR (Canadian Health Solutions “EMR Advantage” allows family docs to see our (specialist’s) schedule; when there is a no-show (up to 20% of bookings), they can book into our clinic from their office. As long as some pre-specified rules are followed (such as no paediatric patients to an Internist, or no cardiac patients to a rheumatologist), the patient is booked in the same day. Because the chart is replicated to the specialist’s EMR, no paperwork is lost and the specialist has access to the whole chart. The bookings are seamless, and often the specialist is unaware of the fact that a different patient was booked into the no-show spot. I once had an afternoon booked by patients who were flying in from the Arctic. The flight was cancelled, resulting in an entire afternoon clinic being marked as “no-show”. With the exception of the 1 PM slot, all of my other slots were filled and I ended up seeing 6 new consults that afternoon.
    2. No government involvement. Every time government gets involved, there are a lot of people offering silly input that wastes tremendous time. In the military, we called them the “good idea fairies”. Leave the planning and implementing to doctors, and companies owned and run by doctors. We know what’s best for our offices, and our patients.
    3. Have the tests done at the same office as the specialist. It does us no good if the echocardiogram is done at the Heart centre, and we see them at the office (or vice versa). It is better to see the images and the patient at the same time. If I do the echo and the visit on the patient, I can review the images myself (or I may even remember them), and I will make better decisions. No matter how detailed the report, the images are always better. The same goes for cardiac monitors, chest x rays, PFT’s, stress tests, and other studies. I have looked at the echo images with the patient using my tablet, and explained what surgery they required with far greater effectiveness.
    4. Get rid of the idiotic rule that the stress test and the consult must be done on a different day. Why can’t we just do the test and the visit on the same day? Why do we have to call back patients to review the tests? If I do an Stress test, and say, a chest X ray, and I see the patient in one day and review all tests, I waste less of my time, less of the patient’s time, and use less taxpayer’s money.
    5. Get rid of specialist silos and move specialists into the community. Put specialists in the same clinics as the family doctors and allow the specialists to get to know the family doctors that refer to them. The most inefficient specialist practices are hospital based ones (I moved from a hospital to my own office).

  9. Julie Thorne

    Great article. I have some quesrions:
    1) will triaging patients to see a physiotherapist or chiropractor first lead to re-installing OHIP coverage for these services? How are those programs in existence managing those without 3rd party insurance?
    2) what kind of documentation do the e-consult programs allow for? Will compensation change at all (this is not a financially attractive option for many, compared to in office consults….never mind that our billing system needs a major overhaul). How does legal liability change?

    Thanks!

    • Ed Weiss

      Correct me if I’m wrong, but I believe the physio or chiro assessments are paid for by the program offering the triage service, not the patient. Obviously this would require a sustained model of funding were it to go larger than a pilot program, but the savings from not seeing a specialist for an unnecessary consultation could potentially pay for allied health assessors easily.

      As for e-consults, I use them all the time in my family practice. The two systems I participate in (OTNHub and the Champlain service) both export the entire consultation dialogue into a PDF file at the end, which I can then attach to my patient’s chart in my EMR. (I’m not sure how recordkeeping works for the consultants at the receiving end.) In terms of compensation, I believe OTNHub pays an hourly fee to consultants. I really recommend giving it a try if you haven’t done so already! The CMPA has a quick summary of the liability issues involved: https://dropbox.otn.ca/econsult-help/cmpa-assessment-econsult.pdf

    • Jihad Abouali

      Regarding your second item. Billing for e-consults use the K738 ($16.00) and K739 ($20.50) codes. According to the schedule of benefits (http://www.health.gov.on.ca/en/pro/programs/ohip/sob/physserv/sob_master20160401.pdf) page 119, the conversation should exist in the patient’s medical record. For consulting physicians this may be difficult as they may have not seen the patient in their clinic and therefore they will not have a medical record specific to that patient.

      • Ed Weiss

        Yes, but all they have to do is print the record of the conversation with the referring physician and stick it in a file somewhere, or scan.

    • Jihad Abouali

      Some e-consult systems like Consult Conduit (https://www.consultconduit.com/ – not mentioned in this article), handle the billing aspect and offer a mobile application to make participating in e-consults less cumbersome.

    • Jihad Abouali

      As you say, the billing codes are not super attractive but from my experience, since you are giving advice to another physician, they usually have a specific question that does not necessitate the time required for a full consult so it can be worth it. For surgical specialists like me there is value in reducing the amount of unnecessary consults so that I can see patients in my clinic who are more likely to fill my OR.

    • Jihad Abouali

      I imagine liability would rest more with the referring physician since they have seen the patient, are implementing the therapy and are not asking for a formal consult. There may be exceptions to this and specialists should use judgement as to what is and is not appropriate for e-consult.

  10. Eric Gangbar

    How about the simple answer to a supply and demand issue? More Specialists! Wow. Who would have thought of that? More OR time for surgeons to operate? That all costs money.

  11. Rick

    This will only result in MORE bureaucracy and bureaucrats.
    Paper-pushers sitting in glass offices do NOT provide patient care. Yet, the Liberal government has added layer after layer of bureaucracy.
    If we want to improve our health care system, we should fund it sufficiently.
    If we want to improve our health care system, we should support our front line physicians, not ostracize them.

  12. Clay

    Two other options

    1. Give the patient a list of appropriate specialists that could help them, and let them work it out. (Minimum specifications.)

    2. Invest more in frontline healthcare, or offer a private alternative. (We have waitlists because we are in a single payor – rationed healthcare system.)

  13. Bonnie Hrynkiw

    Interesting – Do Alberta physicians (general practitioners) know about these options? We have a lot of Albertans leaving the province/country to have surgery because of the long wait times here.

  14. Patricia Landriault

    Like the idea of assessment by other fields. But question that physiotherapist and chiropractor determine is someone does not need surgery. Is that not the surgeons call.?

  15. Sallie

    I wouldn’t refer to Chiropractors because of the fact that they are not University Educated and they are not Scientifically oriented. They are alternative practitioners, referring to them could be seen as unethical

  16. Neil Drimer

    Great article. The success of the RACE and BASE innovations has shown that remote consult services are a recognized and proven tool which not only can impact wait times for specialist care, but also improve the care experience for both patients and providers.

    To ensure these innovations are effectively scaled, the Canadian Foundation for Healthcare Improvement, together with national partners, have recently launched a new 15-month program to improve patient access to timely specialist care. Connected Medicine will support teams from across Canada to adopt innovative models of remote consult based on the RACE and BASE experiences. Learn more about it and how to apply here: http://www.cfhi-fcass.ca/WhatWeDo/connected-medicine

  17. Ryan

    I can’t believe it’s 2017 and health providers are just discovering you can do things by (cell)phone and the internet, as a young person and a techie type this is insane to me.

    I hate that I have to waste an entire day, gas and parking money, car wear and tear, to drive into Toronto to have a ten minute follow up appointment with a specialist that could be handled with a simple phone call, a technology that’s been around since 1876!

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