Friday, May 16, 2008

Going Up

My wife and I spent last week in New York City. And I couldn't stop thinking about Advanced Access!

Our hotel had 49 floors and 16 elevators. I was intrigued by the elevator triage system. Rather than pressing the button and waiting for an elevator to show up, you punched in your floor number and the display directed you to the next elevator that was going to that floor. The lobby was so busy that the traditional system (pick an elevator, stand in front of the doors and elbow your way in when it shows up) would have been chaotic and inefficient. Some people would have long waits, both in the lobby and in the elevator, as it made a milk run to the 49th floor.

The hotel's automated (dare I say "expert"?) system grouped people according to their destinations, for example, batching all those going to floors 30-39 together, so the lower floors could be bypassed.

Part of my fascination with the elevators was pure yokel, i.e., in Saskatoon, we ain't got no real tall buildings. But I was also interested in the similarities between waiting for an elevator and waiting to see a specialist. In the traditional system, customers line up for an elevator/specialist without any idea of how busy that elevator/specialist is or how long they will wait. Some users, such as hotel staff/health care workers, may have inside information that helps them choose the shortest queue.

Users shouldn't need expert knowledge of the system in order to gain rapid access. There's an inherent inequity in a system that rewards expert/inside knowledge. The system should provide the expertise needed to get the user to their destination efficiently.

That's what our office is trying to do with our pooled referral system. We assign patients to the next available physician, unless they need a service only provided by a specific physician. It would be maddening to get on an express elevator that bypasses your floor, or to wait to have your sore knee looked at by an orthopedic surgeon who only deals with shoulders, and then need to get on a new wait list to see the appropriate physician. The system should look after matching the service to the user's need.

This works well in our group practice, as it functions as a central intake for all urology services in Saskatoon Health Region. I'm not privy to the inner workings of other specialist departments, but I suspect that referred patients are at the mercy of their family physician's expert/inside knowledge of individual specialist practice. In order for a group of specialists to give their patients the benefit of central intake, they need to cooperate and agree to share referrals. Under the current reimbursement system (fee-for-service), that presents some challenges.

An important aspect of the hotel's elevator system is that the elevators are essentially interchangeable. You’re confident that you’ll get the same result no matter which elevator you ride on.

How would we match that in medicine?  Physicians would follow best practices in order to give consistent, high-quality care to every patient, every time.  A challenge here is that physicians zealously guard their clinical autonomy, i.e., I don’t practice cookie-cutter medicine.

If the engineers who designed the hotel elevator system applied those principles to health care queues, I think it would look like this: You submit your clinical problem (say, chest pain or blood in the urine). Our expert system (computer or human) evaluates the most recent wait time for the most appropriate specialist to manage your problem, and assigns you to the shortest line. All specialists participate and cooperate in this system, for the patients’ benefit. The service you receive has been standardized so you’ll receive the same care with specialist A as you would with specialist B.

Other industries have given wait list management a lot of thought. I suppose their livelihood depends on it. Is health care so unique that we couldn’t learn from them?


  1. Originally posted by Denise (health care provider in Saskatchewan) 05/20/08 1:30 PM

    I just finished reading Kishore's blog regarding his visit to NYC. While in theory this practice would be ideal. As one of those people with 'inside knowledge' so to speak.... what this equation does not include is the patient's desire to see a specific or specific doctors.

    We all know that there are different levels of skills among physicians just as there are in any profession and some might not be one of the ones with the skills set you'd want to see.

    With the type of system described I would not have a choice in which physician I would get to see. I have in fact at times chosen consciously to wait a little longer to see a physician on the basis of my confidence in that physician's skill level.

    Although overall this theory would work most times, there needs to be the option for the patient to 'wait for the next elevator' should they so desire knowing the wait might be a little longer to get them to their floor.

  2. Originally posted by Ken 05/20/08 1:31 PM

    What you failed to mention is that, in your obsevation, all of the elevators are equal in that they essentially provide the identical level of service. In waiting for a specialist those doctors with the shortest waiting lists could perhaps be those doctors that have not endeared themselves to the public. ie: all elevators are equal but not all physicians are !

  3. Originally posted by Ian Furst 06/06/08 8:30 AM

    Hey Kishore you’re giving me whiplash but I'm glad you've decided to keep blogging. Re elevator analogy. Our experience is that any specialist that has passed his/her board exams can deal with 90% of referrals. Yes we all have subspecialities but that is rarely the bread and butter of group practice. You made the right decision (as your stats prove I believe) to make any urologist that default unless specified. Yes Dr. A may be nicer than Dr. B but they both do a TURP the same. A study recently came of the UK saying that the top having a choice of days was as important as having a short wait time so options are good for patient satisfaction.