Two weeks ago, we reported on some of the difficulties around referrals to specialists.
Shortly after our story ran, the Canadian Institute of Health Information (CIHI) released a report based on The Commonwealth Fund’s 2016 international survey that highlighted this continued issue. According to the survey, Canada maintained its position as the worst of all 11 countries surveyed when it came to access to specialists. Fifty-six percent of us are waiting longer than a month to see a specialist—well over the international average of 36 percent.
That’s the problem. This week, Healthy Debate is focusing on solutions. Here are four innovations that could improve the referral process and access to specialists:
1. Do virtual consults, not visits
Some patients don’t actually need to see a specialist—their primary care provider just needs some guidance. A virtual consult system can help.
The Rapid Access to Consultative Expertise (RACE) is a phone based system available in much of British Columbia. Family physicians call a central phone number during business hours from Monday to Friday, and a specialist will call them back within a couple of hours. Fee codes mean that both parties are paid for their work. It was originally developed for urgent care, and is now being used for non-urgent care as well.
A 2012 analysis of the pilot found that 80% of calls were returned within 10 minutes, most of the consults were less than 15 minutes long, and specialists and family doctors reported “universal satisfaction.” It also led to a 50 percent reduction in referrals for face-to-face consults and a 24 percent reduction in emergency department visits. Calgary has recently started a similar program, modeled on RACE, called Specialist Link.
The success of RACE inspired a similar program in Ontario, called The Champlain BASE e-Consult service. In this system, primary care providers complete a form that includes patient information and their query. They can also attach test results or images if helpful. That information is then sent on to a specialist. The secure messages can be answered in bulk, which makes it possible for specialists to address them at their convenience.
“The difference [from RACE] really is that this is asynchronous, so you don’t have to schedule a time like you would for a phone call,” says Clare Liddy, a family doctor and co-creator of BASE. “The answers we get are amazingly detailed, we can have a little bit of a back and forth conversation, and that really enables me to deliver really good care to my patients. Often, that enables me as your family doctor to deliver the care to you.”
An analysis of BASE’s use from 2010 to 2015 supports that. Over that time, the BASE service was used in over 10,000 consultations in the Champlain region. There was an average wait time of two days (all specialists are asked to respond within a week). And in 40 percent of those cases, the primary care provider originally intended to do a face-to-face referral but didn’t think it was necessary after the econsult. Three percent went the other way, with an unexpected referral for a face-to-face visit with a specialist.
Based on that success, the Ministry of Health and Long-Term Care is currently rolling out the BASE model to other areas of the province. That’s being done through a collaboration with OntarioMD and the Ontario Telemedicine Network, which has adapted the BASE model for use as one of its eConsult options.
2. Add physician directories and e-referrals
Alberta is currently offering paperless referrals by introducing e-Referrals to their province-wide electronic health record (EHR) system. The system includes specialists who treat breast cancer and lung cancer, kidneys, and hip and knee joint replacements. It lets doctors see the specialists wait times before submitting a referral—and they can chose a specific provider, or specify the next available appointment. They can also see that the referral has been received, and track its status. “A lot of what motivated it was safety, and transparency,” says Jodi Glassford, who leads the program, called Alberta Netcare eReferral.
Its use was evaluated from 2014 to 2015, and while it was generally liked, there were problems getting specialists to participate. Breast cancer had the highest adoption rates, at 40%, and knee replacement the lowest, at 2%. Users cited an unwillingness to work with a new system as the main issue. Some said it was easier to fax a referral with less information than to fill out the detailed request form.
A potential issue with e-Referrals is that you need buy-in from specialists for it to be effective. “For primary care to get a benefit from e-Referrals, there needs to be a critical mass of [specialists] receiving them. Otherwise it is just another communication tool to add to the mix,” says Glassford. The U.K. couldn’t overcome that issue with its Choose and Book system, an online portal that allowed patients to see available appointments from a shortlist of providers their doctors had selected for them, and choose the one that suited them.
It was implemented in 2004, but replaced in 2015 due to low uptake from many specialists, primary care providers and patients, partially because it was time consuming and difficult to navigate. Many doctors and even entire specialties weren’t on the system. It was replaced with a similar NHS e-referral service, that was designed to be easier to use.
Ontario’s e-Referral system has an extra hurdle in implementation. Many local health integration networks (LHINs) have purchased different eReferral software systems. Unfortunately, that doesn’t work seamlessly because family doctors often refer across LHIN boundaries, especially in areas like the Greater Toronto Area, which contain multiple LHINs. There are multiple players in a “very nascent market,” says Darren Larsen, the Chief Medical Information officer at OntarioMD.
A simpler approach can be found in B.C’s up to date physician directory, called Pathways. The website includes listings for all specialists, their areas of practice, and updated wait times. The tool, which is now used by about 2,500 physicians, began as a pilot and is now in the process of being rolled out across the province.
3. Try pre-assessment in specialized clinics
Another approach is adding an assessment step in between the referral and the specialist. One such program is the Interprofessional Spine Assessment and Education Clinics (ISAEC), for people with serious low back pain.
Under ISEAC, patients see a specially trained physiotherapist or chiropractor for assessment and education. Most patients will not need to see the specialist and are offered exercises and referrals to other doctors. Those who need to see a specialist benefit from shorter wait times and being able to have a more informed conversation.
Spine surgeon Raja Rampersaud started the project, which now runs clinics in Toronto, Thunder Bay and Hamilton. “It was inspired by the fact that only one in 10 people I see are people I can really help [with surgery],” he says. “I help educate them, and send them to another specialist. They’ve waited a year for me to say you need to see some other specialist.”
Sarah-Lynn Newbery, a family doctor has used ISEAC regularly. She says she appreciates knowing that her patients will be seen within a week or two, which spares her from trying to manage their pain during the long wait to see a specialist—especially when she might know already that they aren’t likely to need surgery. She adds that when family physicians have to manage chronically painful conditions without many resources, “the temptation to escalate pain medications becomes much greater,” including potentially addictive opioid medications.
These assessments can also reduce the number of expensive imaging tests like MRIs. “MRIs are basically being used as triage,” says Rampersaud, when a thorough evaluation from a physiotherapist or a chiropractor could do instead. ISAEC is currently being rolled out in Ottawa as well, and will be expanded throughout the province over the next few years.
Also in Ontario, pilot projects for rheumatoid arthritis successfully decreased wait times by adding physiotherapists to rheumatologists’ offices, and having the physiotherapists do the triage. The Alberta Bone and Joint Institute has a program for hip and knee replacement called “prehabilitation,” where physiotherapists assess and treat people who have been referred for knee replacement before they see a surgeon.
A problem can arise when physiotherapist or nurses determine that a patient doesn’t need to see the specialist, but they don’t offer those patients other services, says Rampersaud. That can leave patients with nowhere to go but back to their family doctors—who are referring the patient precisely because they aren’t successfully managing their issues.
4. Switch to central intake
Pooled referral systems (often called central intakes) let family doctors chose whether to see a specific specialist or the next available one. Some pooled referral systems do triage before the patient is assigned to a specialist, and others assign them to the specialist, who then does triage afterwards.
“We’ve seen tremendous improvements in access for care through centralized intake,” says Danielle Martin, a family physician and vice-president of medical affairs and health systems solutions at Women’s College Hospital. Versions of central intakes are proliferating across the country.
Newfoundland and Labrador recently launched a central intake system for endoscopy services as part of a comprehensive overhaul that successfully reduced wait times; Ontario has had centralized intake for joint replacement since 2011. This fall, Quebec launched its new pooled referral system, which includes the nine most common specialties and will soon include 10 more. And Saskatchewan and Calgary each have a program.
While the evidence is not conclusive, “For those who practice in some sort of group environment, there’s absolutely no question that central referral is the answer,” says Anthony Graham, head of a new central intake system of cardiology at St. Michael’s Hospital.
When his group first switched to that practice, many specialists weren’t very aware of the difference in wait times, says Thomas Parker, physician-in-chief at St. Michael’s. “That was an eyeopener for many of us, both in terms of the duration of the wait time to see a specialist, but also the variability. There were people [on our team] who could see patients within seven days, and other people who could see people within eight months.”
From a queuing theory perspective, central intake makes sense. Chris Simpson, a cardiologist who also chaired the now-defunct national Wait Time Alliance, compares it to choosing your own line at the grocery store versus the single line at the bank.
Some argue that central intake undercuts the important personal relationships primary care providers develop with their networks of specialists. But others, like Rick Glazier, a family doctor at St. Michael’s Hospital’s Academic Family Health Team, argue that time has already passed. “The current consultation system is very impersonal,” he says. “I’ve been referring to people for the past 20 years, and I wouldn’t know them on the street. How do you run a health system based on personal relationships and who you know in a metropolitan area the size of the GTA?”
Can wait times be fixed?
All four of these models will help reduce wait times and streamline the process. That goal is incredibly important, says Larsen. “This is one area where we have the trifecta…it helps patients, it benefits providers, and it definitely helps the system.”
But there are challenges. Canada is notorious for being a land of pilot projects in health care, where good ideas aren’t scaled well. For systems like this, where getting buy-in from many professionals is crucial, that problem is especially important to overcome.
And there’s another layer to all of this: We also have resource problems, with too few specialists in some areas, unequal distributions, and poor operating room availability all factoring in. We’ll explore those issues and more in two weeks, in our final part of this series.
Read the first article in this series: Anatomy of a referral – why wait times for specialists are still too long
The comments section is closed.
Hi, I am from Ontario. My husband’s CT scan showed a lump hinting towards cancer. the specialist asked to get biopsy and few other tests done, which are completed. Its almost a month now with getting all tests done. My family doctor is on 3 week medical leave owing to his surgery. the specialist on and off goes on vacation and is not available until next week.
Given the seriousness of the situation, I am not sure, why is there no one to give priority to such diagnosis. Isn’t it dangerous to put a patient’s health risk, given that they are suspecting cancer and we do not know the impact of it.
What measures do I take to ensure quick feedback and treatment. Last week my husband’s condition worsened and we rushed him to emergency. They checked all the vitals and send us back. I do not even have the reports to go to some other doctor,
I have been waiting since May 27th of this year to get into see an orthopaedic surgeon and I am getting really frustrated with the Medical System. This is ridiculous that people have to wait this long to see a surgeon. I should have seen one when I visted the hospital when my knee gave out.
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!
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
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
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.?
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.
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.)
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.
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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.
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!
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
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.
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.
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.
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.
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.
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).
Touche! Totally agree
I like the idea of having specialists in community clinics. I have first hand experience. I have neurological issues that require follow up. I live in a smaller community with limited access to specialists unless you can travel 40mins to 1 hour away. Tough if you don’t drive. I also feel that we need to give patients direct access to specialists to book appointments without necessarily needing a referral. Doctors are human beings, and sometimes can be biased when it comes to certain types of diagnoses(those that don’t necessarily show on diagnostic tests or rare diseases). This sometimes leads to doctors not referring properly and delayed treatment.
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
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.
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.
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.
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.
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!
Like the centralized intake and ore screening. Many times people are referred inappropriately or referred to the incorrect/ most appropriate specialist
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.
What do you mean by potential failed pilots? That they’re unproven?
Why are physicians allowed to block significant changes that would improve the system?
Block it in what way?
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”.
Well, pitter patter let’s get at ‘er!