Sunday, July 31, 2011

I ♥ Calgary's online ER wait times project

I have a huge (data-) crush on Calgary's Health Region!

They have captured and posted online the ER wait times at the city's healthcare facilities.

The website shows estimated wait times for 4 hospitals and 2 health centres.  The information is automatically updated every 2 minutes.  There's a comprehensive disclaimer that reminds people that ERs are unpredictable places, that wait times may change significantly within a short period, and that patients will be see according to the severity of their condition.

Health region representatives said they hope that making this information easily available will help patients to decide whether to go to the closest ER, or the one with the shortest wait time, and thus distribute the workload more evenly.

There's an interesting "behind the scenes" page linked to the main page.  It explains more about the online system and how the wait times are calculated.  The wait times displayed online are calculated based on the number of patients waiting to be seen, their disease acuity, and the number of medical staff available to see patients.

The times are automatically calculated by Calgary Health's IT system, so there's no additional clerical work needed.  Nice!

A few thoughts on this national first:

I'd be interested to see how the calculated wait time correlates with the actual patient experience.  This will likely be studied and posted as part of the evaluation phase of this project.

Might patients be discouraged from seeking urgent medical care if they see how long the wait will be?  People already realize they will have to wait for ER attention, but if they have already invested the time and effort to get to the ER, I suspect they are more likely to stick around until they are seen.  Will advance knowledge of ER wait times change patient's behaviour?  If so, is this necessarily a bad thing? That is, might some people be more likely to seek care for less urgent problems from their family physician if the ER is "less convenient"?  This would be a tough one to measure because the patient's experience won't be captured at an ER visit.  Maybe family medicine clinics will anecdotally report that patients are deciding not to go to the ER.

Power to the people!  Now that this information is available publicly and in real-time, I'm keen to see who will be the first to use it for other than its stated purpose.  I don't mean using the information for a nefarious reason (although there may be some way to do that...), I mean a mashup, combining online data sets to produce new functionality beyond the original intent.  For example, someone could combine Calgary traffic and transit system data with the ER wait time to show the patient's real wait time experience.  (Similar to how we now consider patient's entire wait for surgery to be "Wait 1" - wait for consultation with surgeon - plus "Wait 2" - the time from the OR booking being submitted to the actual date of surgery.)  
Depending on where someone lives and the transportation available to them, it might make more sense to visit the ER that nominally has a longer wait time, because the total patient wait (combined transit + ER wait) is actually shorter.  If that were the case, and it resulted in more congestion in an already busy ER, perhaps Calgary Health IT would communicate with Calgary Transit and more buses could be put on the routes that lead to the less congested ER.   (Mmm, mmm, mmm! System integration!)
Some enterprising computer science student will create an app that pulls the data to smart phones, so a single click will let people know which ER they should head for.  As long as that app is in the works, why not link it to a health advice FAQ site (official Alberta Health, of course) that gives suggestions for self-management of common conditions that often lead to low-acuity ER visits.  
Similarly enterprising engineering or business students will track the publicly posted data and identify trends of ER congestion.  Queue theory experts insist that, even in the unpredictable world of the ER, there is enough predictability to guide staffing plans.  Analyzing the trends in Calgary's ERs would be a great student project.

The greatest thing about this project is just that they did it.  Plain and simple, they did it!  Alberta has shown that meaningful, real-time health system data can be collected and displayed in a way that helps the public make better decisions about their health care.  Once the bugs are worked out, this can be spread across Alberta.  Soon, people in other provinces will come to expect this service.

We can use the Alberta's ER model to help manage other health care congestion, for example, hospital beds.  Hospital ward managers tell me they spend a big part of their day figuring out which patients are ready for discharge and then facilitating discharge or transfer.  Sometimes, a message will be posted in the OR: "Please arrange patient discharge as soon as possible today.  Wards are full and surgery may be cancelled."  By the time word gets around, it's at least 10 am, and the prime opportunities for deciding about discharge have passed.

How about pushing real-time data to each hospital physician?  Include the number of patients he/she has in hospital, the "national expected length of stay" for each patient's condition, the current length of stay, hospital occupancy and an indicator as to whether the physician has indicated a planned date of discharge.  This information could be sent to the physician's phone every evening so discharge planning can be done that night, or early in the morning.  The information is already available; it just needs to be aggregated.

Show us the way, Alberta!

Tuesday, July 19, 2011

Physician funding: Let's try an evolutionary model

Dilbert's Guide to Health Economics!

Yesterday's Dilbert cartoon reminded me of a health care story from Prince Edward Island. In May, PEI's Health Minister took salaried doctors to task for lack of productivity.  Apparently, fee-for-service doctors were seeing many more patients than salaried docs.  The same phenomenon was noted even if it were the same doctor, working after-hours in a fee-for-service clinic, after finishing a day's work in a salaried position.

Paul MacNeill's op-ed illuminates the economic and political issues around the Minister's actions.

Whether or not the accused docs are actually slackers is beside the point.  The reduced throughput for salaried physicians is exactly the result that the Minister should expect from these different payment schemes (neither of which is perfect).  Fee-for-service (FFS) encourages the provision of more services or visits.  Salaried positions are supposed to encourage physicians to provide more preventative care and counselling, spend more time with each patient, and engage in multidisciplinary care.  This means fewer patients will be seen, yet their quality of care should be higher.  Unfortunately, salaried positions are open to abuse, and some physicians (like other human beings!) may be tempted to do as little work as possible.

To judge physician performance, the Minister should look beyond patient volumes.  More appropriate measures would be patient satisfaction, health outcomes and wait times.  Of course, these are more difficult to measure and interpret.

What is the best payment system for docs?  (Oops - that should read "best payment system for patient care"!) Here are some thoughts from an expert.

And here are some thoughts from an amateur:

We can't create a foolproof physician reimbursement system in one shot.  It's too complex.  It should be an experiment where both sides (payer and physician) trust each other and that they have a common goal of excellent patient experience and outcomes.  The system would evolve to suit the needs of patients, physicians and the payer.  Start with our best guess of a suitable payment model, agree on goals, and get going.  Be flexible and make adjustments on the fly.

Don't try to create a definitive system.  Rather, create the conditions that will allow for a suitable system to develop:

  • Physicians are assured of a stable income and work-life balance. 
  • Payer is assured that at least the current level of service will be maintained. (This might mean making baseline measures of the current state using the new measurement system.  See below.) 
  • Agree on appropriate measures that suit the desired outcomes.  As noted above, patient satisfaction, health outcomes and wait times could be measured. 
  • Don't penalize docs when they run up against barriers in parts of the system beyond their control. 
  • Stop measuring volume of service.  Completely stop.  Don't make docs "shadow bill" to make sure that they are keeping up a certain volume of patient visits.  This wastes administrative effort that could be directed to quality improvement and patient service. 
  • Time spent on improving care delivery is as important as care delivery itself.  Quality improvement work is included as part of the physicians' duties.  (Likewise, education, research and administration.)
  • Fail forward.  Encourage reasoned experimentation.  Import best practices from around the world.  Expect failures.  Embrace failures.
I'm sure Dilbert would approve.

Sunday, July 17, 2011

How we keep score determines how the game is played

“Don’t let him in, Dad!”

I was driving my son to his soccer game when we ran into road construction.  Signs indicated that the right lane was closed ahead, so we merged into the left lane.  The very congested left lane. 

As we crawled along, a few cars zipped ahead in the right lane, which wasn’t blocked off for another 10 car lengths.  When these drivers reached the barricade, they signaled their intent to merge into the left lane.  My son’s sense of justice was offended by this “butting in line”, and he exhorted me to keep driving and prevent the right-lane bandit from merging.

To be fair to my son, his attitude has been informed by my own kvetching about drivers who don’t play by the rules.  Well, by my rules, anyway.  Why should this guy get to cut in when I’ve been stuck in this lane for all of 3 minutes?!  He can just sit there for another few minutes. 

I talked tough, but when it came down to it, I let the other driver merge.  My son was disgusted with me.

This led to a discussion about which method would get more cars through the construction zone more quickly: Option 1 - everyone merging into the left lane as soon as they saw the “Right Lane Closed Ahead” sign, or Option 2 - some drivers continuing in the right lane until it was barricaded, and then merging.  We couldn’t figure out the answer, but my son told me it didn’t really matter.  What mattered to him was how fast we got through, so he could get to soccer on time. 


I can see how he would come to that conclusion.  Getting to his game on time was the only benchmark he had.  In fact, maneuvering through the construction-zone traffic had become a game unto itself, and our goal was to get through in the shortest time possible.  Setting that goal lead to our (fantasized) tactic of blocking other drivers who wished to merge into our lane.  That tactic would get us through the line a little quicker, but at the expense of the other driver.

What if the game were played differently?  If there were evidence that Option 2 is actually more efficient, traffic engineers may want to promote it.  They could post signs asking drivers to continue in the right lane until the last moment, and then encourage courteous merging.  But, even if this option is more efficient for the driving collective, individual drivers will still “win” if they are selfish and refuse to allow anyone to merge in front of them.

Maybe we need a different way of keeping score, and a scoreboard to let drivers know how the game is going.  The engineers could set up an electronic sign that indicated how many cars per minute (CPM) are passing through the construction zone.  Perhaps every time a driver exhibited the desired merging behaviour, a happy face would flash and the CPM number would increase.  If someone blocked a merge, the opposite would happen.  I’m not sure what the most effective sign/scoreboard would be, but whatever it was, it should give this message: We’re all in this together!

Last week, I spoke with a friend who works in a chronic disease management program.  Her program had been trying to secure funding for an initiative that would engage patients in their own care, with the intent of reducing disease progression and hospital admission.  She was frustrated because the acute-care department that managed patients in hospital had received funding for a high-tech intervention that would benefit a few patients with severe disease, yet her program had been unable to obtain a fraction of that amount to promote an intervention that would keep many more people from being hospitalized in the first place.

This will be a familiar story to clinicians who see behaviour in another department affecting their own department (e.g. surgeons griping about medical specialists’ discharge patterns – see this recent post), yet feel powerless to influence that behaviour because it’s happening “outside their silo”.  Everyone is playing the game for themselves, sometimes to the detriment of the system/patient.

Healthcare organizations often use “dashboards” to show key performance indicators at various levels, e.g. mortality rates over the entire organization, consultation wait times at the department level, or complication rates for individual surgeons.  The trick is to make all these dashboard/scoreboards relevant for what really matters: the patient’s experience. 

It’s the patient’s experience that cuts across all of healthcare’s self-imposed boundaries, yet our current scorekeeping emphasizes those boundaries.  Budgets are assigned according to categories created for provider convenience – medicine vs. surgery, inpatient vs. outpatient, acute care vs. prevention.  I think that most providers, if in a conflict over behaviour or budget, would let a colleague “merge” ahead of them, if they could see that it would be better for the collective effort. 

The challenge, then, is to set up dashboards/scorecards that emphasize (and reward!) that collective effort, rather than individual success.   We're all in this together!

P.S.  If you want the answer to the “Late Merge” question that my son and I couldn’t figure out, take a look at this interesting explanation by a Minnesota traffic engineer.