Sunday, June 20, 2010

It's a start

Congratulations to Sask Health on a big step in the right direction.

I mentioned in a previous post that I think pooled referrals should be facilitated not by "forcing" patients to see the first available specialist, but rather by providing them with accurate, up-to-date information about specialist wait times. Each person will then make their own informed decision. Sask Health has made a start toward achieving that. A website that lists specialist wait times has recently been released for public viewing. Now that we have transparency covered, we need to work on accuracy.

The website contains information on how long you could expect to wait for surgery with a given surgeon, had also how long he would wait for initial consultation with that surgeon. The surgery wait time information is updated monthly and is based on accurate information from health region databases. The consultation wait time information, only other hand, is self-reported by physicians. The biggest problem with this is that most physicians don't really know how long patients are waiting to see them. Also, physicians may be using different measures to estimate wait times.

For example, the "industry standard" for reporting patient wait times is the 3rd next available appointment (3rd NAA). This requires some basic understanding of Advanced Access principles and also takes some effort to calculate. There is no explicit incentive to make the effort to calculate 3rd NAA time.

Some electronic medical record programs have the ability to calculate 3rd NAA. However, when we tried it in our EMR, we got a result that was very different from our hand-calculated number. When we investigated that further we found that it was due to the way we book appointments in the electronic scheduler. Because our practice consists of scheduling office, cystoscopy, OR, lithotripsy and outpatient visits, the EMR software was finding openings in bookings other than just office appointments. It would have saved us a lot of time if we could just press a button and have a reliable 3rd NAA measurement but we are still unable to do that. Perhaps family physicians or specialists who only work in their office would have more luck. Unfortunately, virtually all surgeons will be working in more than one location.

Until all surgeons are involved with Advanced Access (someday soon!), the wait times listed on the website are unlikely to be reliable. Even so, that unreliability of the data is likely to be unintentional. There may be reasons why surgeons might"cook the data".

In our urology practice, we have the luxury of being the only group in Saskatoon. We are not competing for work. In fact, as I mentioned in my last post, there may even be a disincentive for us to improve our wait times because it will likely generate more and more consultations from outside of our traditional practice area. However, some specialty groups may be in direct competition with each other. In that case, they may gain a competitive advantage if they were to list consultation wait times as being shorter than reality.

Who will audit the wait times? How will they audit the wait times? If we agree that 3rd NAA should be the provincial standard, then an auditor would need to have access to each surgeon’s office scheduling records. They will likely need to do a manual calculation because EMR programs don't seem to be able to churn out accurate 3rd NAA figures (given complex schedules that are the norm in surgical practices). I suppose that the website managers could mandate that each surgeon's office must submit an accurate 3rd NAA figure on a monthly basis (and then do random audits to ensure compliance), but it would also be necessary to provide some financial reimbursement for surgeons to make that effort.

All of this presumes that the website actually has some value for patients and family physicians. The purpose of disseminating this information is to allow patients, along with their family physicians, to make better decisions as to which specialist they wish to be referred to. In order to be sure that this information is useful, and being used, the administrators would need to sit down with some focus groups to see what conclusions patients draw from this information, and how it influences their choice of specialist. Without knowing how consumers really use this information, and how they navigate the website, it's impossible to know whether it's of any value.

So, unless an investment is made in gathering accurate and timely wait time information, and also in determining how to make the website valuable for consumers, this is an exercise in public relations. Consumers need to know how the information is gathered (e.g. calculated 3rd NAA versus "best guess") and when it was last updated.

Let me revise my initial statement: Sask health has taken a baby step. But, it's still in the right direction!

Monday, June 7, 2010

Come one, come all

We’re still riding the crest of the backlog blitz’s success. Or maybe, the trough, given the curve on our 3rd NAA chart:

This shows an average of all our urologists’ 3rd NAA. Many patients are being scheduled within 10 days of referral. I wonder if it will last? Summer holidays temporary drop our capacity. Backlog may creep up again.

A factor outside our control is demand from outside our traditional service area. While patients can be referred from anywhere in Saskatchewan, most of our referrals are from the “north” of the province. Early on in our Advanced Access project, however, publicity around our quest for improved access garnered us attention from referring physicians in the south. Seeking prompt urologic consultation for their patients lead some of them to refer patients to Saskatoon rather than somewhat urologically under-serviced Regina.

As our new, shorter wait times become widely known (perhaps someone should keep his blogging mouth shut!), this will likely recur. Each patient will have an individual tipping point (based on pain and suffering, or perception of disease seriousness) that will convince them to travel the extra miles to see us. As our access improves, more patients will be referred to us. Our efforts will be “rewarded” with more work!

The outstanding success stories of Advanced Access are achieved in closed systems, known as capitation. Physicians or, more often, large practice groups are assigned a set number of patients for whom they have responsibility for providing care. They receive set funding and so have strong motivation to develop systems that are efficient, while still satisfying patient needs. If these physicians successfully implement Advanced Access (and more broadly, Clinical Practice Redesign), they may be rewarded with financial bonuses and less hectic practices.

But, if their practices are open to any and all new patients, any time freed up by effective practice management will be quickly filled. So, why would they make the effort in the first place?

As our docs are essentially private contractors being paid fee-for-service, there’s no geographic boundary on which patients can be referred to us. If we did negotiate an “alternate payment plan” (a term used to allay physician’s distaste of “salary”) with the government, it would include clear boundaries for how many patients and for what health regions we were to service. That would be a big motivation for us to pursue further CPR efforts, because, although we wouldn’t be paid more, our practice could be less busy and we could have more time off.

But, what would happen in areas of Saskatchewan that were under-serviced? There would be a lot of pressure on local healthcare administrators, and on the government, to deal with the problem at the regional level, rather than relying on our group to pick up the slack. That might get pretty uncomfortable for them.

I wonder if the government realizes what a sweet deal they are getting with fee-for-service physicians?