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.