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!

Cloud-computing and electronic medical records: We're missing the boat

When we finally get our electronic medical record (EMR) in Saskatoon Health Region, will it already be out-of-date?

Last Friday's Globe and Mail business section was buzzing with news about "cloud computing".  Apple's recent announcement of iCloud - while not the first cloud-based storage service - might, according to one analyst, do to that market what the iPod did previously to the MP3 player market.  iCloud will let you store data on remote servers and access it from anywhere you have internet access.  That means remote access to music, photos, video and documents.

How about your medical records?  Not so much.

Another article about cloud-computing focused on EMRs.   Bottom line: We're struggling.

Several years ago, in a blog far, far away, I pouted about the lack of a functional, province-wide EMR.  Since then, I have achieved on-line access to all x-rays done in Saskatchewan hospitals, except Regina.  Lab results ordered by one of our urologists, or copied to one of us, are sent electronically to our office EMR.  I usually get results on my inpatients even before the hospital ward receives them.  It also saves our staff the nuisance of manually assigning results to patient files.  I can also access patient pharmacy records, that is, if I can remember password #37.

There has been progress, but it's slow and local.  I have access to test results that I've ordered or another physician has thought to copy me on.  Otherwise, if I want x-ray reports, lab results and, most importantly, patients' medical history from another physician's office, I have to retrieve the information manually.  This usually involves me writing a letter, or my staff phoning a referring doctor's office.  It sometimes requires a follow-up request.  Then, if the information isn't forthcoming, we give up and repeat the test.

It's a frustrating waste of time and money.

An EMR that lived in the cloud would give me access (with appropriate permission) to all of a patient's records.  What's the roadblock?  According to the Globe and Mail piece: interoperability and security/privacy.

But, banks seem to have cracked this problem, and they deal with pretty important information.  Different industry, you say?  Well, Toronto's Sunnybrook has already put the power of an EMR into patients' hands with MyChart.

I hope that an EMR will arrive in Saskatoon Health Region in the near future.  But, if the data lives on local servers and isn't remotely available (to the patient, and any caregiver around the world who may be providing health services to them) then I fear our patients and staff will be saddled with an EMR that is DOA.

Solution to dumping unwanted medical records: drop-off boxes

Saskatchewan made the national news!

Not good.  Abandoned medical records found in a dumpster.  Privacy Commissioner "astonished".

This has happened before, and predictably, the Commissioner and blog commentators trot out the applicable penalties and want to find someone to blame.

This is definitely an breach of patients' privacy and completely unprofessional.  But, maybe we should look beyond finger-pointing and try to find a solution to this recurring problem.  For whatever reason, the custodian of these records decided to move them from the original doctor's office.  Perhaps the doctor moved or retired.  Maybe they were culling out-of-date charts.  Regardless of what journey the charts took from the file room to the dumpster, they were unwanted.  And, we already have models for managing valuable, sensitive, yet unwanted items whose current owners cannot manage for various reasons, including inadequate resources.

Baby drop-off programs.

No questions asked.  Leave the baby and we'll look after her.  No blame, no penalty.

Unsecured medical records will continue to be a problem because of physician retirement, relocation (particularly a problem in Saskatchewan!) or lack of filing space in medical offices.  It is clearly the professional responsibility of physicians to securely store, then appropriately dispose of patient records.

But, for a variety of reasons, some docs are not going to fulfill their responsibilities.  So the question is, do we want to try to force them to do it (good luck with that if the doc is retired or deceased), or do we want a mechanism to secure and dispose of orphaned records?

How about this: Set up locked drop boxes around the province.  Use hospitals/medical centres, as doctors know where they are and have access to them.  The Privacy Commissioner would have to decide whether records would be automatically shredded or whether someone would have to screen them first.

Yes, the doctor is ethically responsible to provide storage.  Yes, the doctor is obliged to pay for secure shredding and disposal.  The vast majority of docs do so and will continue to do so.  But, for the rare few whose circumstances may lead them to ditch records and run, wouldn't it be worthwhile to provide a secure alternative?

P.S. Electronic medical records, anyone?

A generic referral template is a better idea than specialty-specific templates

A lot of people have been thinking about how to improve the GP-specialist consultation process.  It's going on at the national level.  It's going on at the local level.  And, as part of the Saskatchewan Surgical Initiative, there's interest provincially.

Recently, I had a conversation with someone about what would be the best first step on a provincial level.  Should we develop a general referral template that the referring doc could use for any specialty, or is it better to make specific referral forms that address the information needs of each specialty?

My first thought was that specialty-specific forms would be best.  They would give more useful information to allow the receiving specialist to anticipate the patient's need for special testing or procedures.  They would also allow inclusion of a management algorithm (suggested by each specialty group) to help the referring physician complete the initial steps in diagnosis and therapy.

I still think a specialty-specific form would be ideal, but on further consideration, it's not the best first step.

With respect and gratitude to all my colleagues who make the effort to write a complete referral letter, I receive many inadequate referral letters.  At our office, our staff spends a lot of time calling back to referring docs' clinics to ask for lab and xray results, and details of the patient's condition.  The really annoying thing is that the results we need are actually available, but the referring doc didn't think to send them along.  This slows down the assessment process as I can't give a final opinion without these results.   Also, we may schedule more testing, only to find out that it has already been completed.  

From conversations with specialist colleagues locally and nationally, I know that this is a universal problem.  As such, I think that all specialists (and patients!) could benefit from a generic referral form that prompts referring docs to give the basic information needed in a referral letter:

Reason for referral/clinical question to be answered

History of present problem including treatments tried and the outcome

Past medical history

Medications

Allergies

Test results (lab and xray)

Other information could include urgency of the consultation, any special conditions of note (physical or mental limitations).

Perhaps a specialty-specific form would be developed later, although it would take exponentially more work to create.  Getting each specialty group to agree about the minutia on such a form would take a long time.   Also, in the absence of an electronic storage system, GPs would likely find it cumbersome to file myriad specialty-specific forms.  I'm not sure that the marginal utility of developing a specific form would warrant the effort.

However, given the above-griped-about scarcity of information on many referral letters, all specialists would get at least some benefit out of a global, generic referral template.  

I suggest starting with a basic form, including the information noted above.  The form should be clearly marked "DRAFT #X.  EXPIRY DATE: XXX".  This would prevent having multiple (confusing) iterations of the form drifting around a doctor's office.  

There would be a mechanism for feedback from both the GP and specialist.  Perhaps it would be tear-off section, or a second page that could be faxed back to the developers.

Start small - perhaps with two or three GPs.  Getting feedback from them would be simple, as they are small group, chosen by the developers.  Blank forms could be sent out to specialists for comment, or the GPs could complete some forms with simulated patients so as to solicit reviews from specific specialists.

Run short PDSA cycles - two weeks at most.  Collect feedback on which content is most useful, and also what design makes the form easy to complete (for the GP) and read (for the specialist).  Make it clear that this is not meant to be an all-encompassing form.  The project will get bogged down if everyone gets to add their "pet peeve" to the mix.  The developers need to be ruthless about this.  

After each cycle, expand the GP user group.  I think we would have a pretty useful (not perfect!) form within 3 months.  

I wouldn't blame any family docs who might be reading this for getting cheesed off at my impertinence and stopping several paragraphs back.  But, if you're still with me, let me say that I think this should be a two-way street.  Half of the consultation process is the information contained in the referral letter.  The other half is the information the specialist provides in a consultation report.  Specialists are not squeaky clean here.  GPs point out they often wait a long time to receive reports.  Their clinical question may not be answered.  The consultation letter may be difficult to read as it may be several pages long, with any requests for further testing or recommendations for management buried inside the text.  There may be no indication as to whether the GP is expected to provide ongoing care, or whether the specialist will do it. 

Specialists can do better too. 

There should be a similar template to help specialists provide good quality consultation reports that will help the GP manage the patient's care.  We could run parallel PDSA's to address this side of the equation.

We could have a generic referral form and consultation report template ready within 6 months.  The biggest barrier would be too much fine-tuning.

Perfect is the enemy of good.

A mother's voice speaks loudly and clearly for EMR and PFCC

"Anonymous" left a powerful comment on a recent post "Leaders: Clear the path and your team will do their best work". As she tells the story of taking her daughter for treatment of a chronic condition, you can feel her frustration at a system that can't move a simple piece of information from one provider to another within 36 hours.

Implementing an EMR might move providers closer to patient and family-centred care, but it would certainly help patients/families overcome resistance to PFCC. A PFCC-aligned EMR would be accessible to the patient. (How could it not be?! We own our medical history!) With the same access to information as any caregiver, patients/families can choose the role they play in their own care. If you want the old "You're the doctor" approach, you can have it. If you want all your test results - explained in plain language (see this Wired magazine article for a suggestion on how this can be done) - you can have them. (Without needing to lug around a "medical binder".)

Anonymous, you speak clearly and passionately on your daughter's behalf. Your points are respectful. You don't lay blame. I can rant endlessly about the benefits of EMR, in person and on this blog, but I won't have nearly the impact that you can have. Oddly, even though power in healthcare usually rests with providers, in this case, it's the opposite. You, Anonymous, have the power to advocate for EMR. You can make the point that patient care will improve. You can tell your family's story about how your daughter's care is impeded by the lack of EMR.

Talk to the decision-makers who can make EMR happen in Saskatchewan. Tell your story to your MLA. Write to the Minister of Health and the Premier. Ask to have 5 minutes at the start of your regional health authority's board meeting to explain what an impact the lack of an EMR is having on your daughter's care. The comment you wrote is already a powerful letter-to-the-editor for your local paper. Speak to your daughter's patient support group about how EMR could make all of their lives easier.

EMR = PFCC. Spread the word, Anonymous.

Leaders: Clear the path and your team will do their best work

Something a healthcare senior leader said recently gave me pause for thought.

As part of a group discussion around healthcare improvement, the perennial topic of electronic medical records (EMR) came up. While everyone at the meeting agreed that EMR would be hugely beneficial to patient care, X opined that technology couldn’t change attitudes.

Here’s the context: The group had already agreed that the primary driver behind healthcare improvement should be the philosophy of patient and family-centred care (PFCC). X’s point was that having EMR would be great, but it wouldn’t convert anyone from being provider-centred to patient-centred.

I spent the next few minutes of the meeting on a thought tangent.

X’s assumption was that providers are fixed in a self-centred existence. They have to be “re-educated” and convinced to embrace PFCC. EMR and other technology don’t influence behaviour.

But, what if there’s a different explanation? Let’s assume that every nurse, doctor, clerk and housekeeper would get tremendous satisfaction from applying PFCC principles in their daily work. They may not be familiar with the formalities of PFCC, but they understand what it means to be kind and caring. Further, assume that all newly-hired providers come to their first day of work with the desire to do their best to serve their patients. What happens after that?

We beat the PFCC out of them! We put obstacles in their path, fail to reward (or even punish) sincere efforts to put patients first. We make it easier to be self-centred than patient-centred.

Here’s an EMR-related example from my practice: A man is referred to me with pain in his side, possibly related to a kidney stone. I recommend a CT scan to locate the kidney stone. He tells me that he already had a CT scan done at his local hospital. The referral letter didn’t indicate that a CT had been done, so I didn’t have the opportunity to look at it prior to this visit. I try to access the CT films using the online x-ray viewing system, but as is frequently the case when we try to do this from our office, the system is not working. I tell the man that I will check his CT the next day when I’m at the hospital and can use that system. He leaves without a definite diagnosis or treatment plan.

Another common example is the “missing” lab test. When a patient has already had a certain blood test performed, but the attending physician doesn’t have access to it (e.g. it’s a weekend and the family doctor’s office is closed), it’s just “easier” to poke the patient with another needle and repeat the test. The physician ordering the repeat test isn’t deliberately cruel; if the results were easily available (EMR!), it wouldn’t be necessary to stick the patient again, and it wouldn’t be done.

My conclusion was that X should think about healthcare providers’ behaviour differently. Rather than presuming the worst, X should assume that providers naturally want to provide PFCC, and that “the system” impedes them. If we assume the best, then our approach would change from one of trying to educate providers in PFCC, to one of trying to remove the barriers that prevent them from fulfilling their natural inclinations.

Here’s what this means for a leader: If your staff isn’t delivering PFCC, it’s not because they don’t want to. It’s because you have not created an environment that lets them do their best work.

Clear the path. Unleash the potential.

Listening to my FP colleagues - Part 2

Last month, I heard from family practitioners (FP) from across Canada about what they thought was lacking in the FP-specialist referral process. Last week, I had another opportunity to learn what’s on the minds of my FP colleagues.

As part of the Sask Surgical Initiative (SkSI), care pathways are being created for conditions like back pain or hip problems. I’m participating in developing a prostate cancer pathway. Our working group has mapped out the current state in the province, that is what path men currently follow when diagnosed and treated for prostate cancer. Now we want to explore changes that could make the journey quicker, smoother and more effective, or as SkSI puts it “Sooner, safer, smarter”.

An important part of the working group’s next step is broad representation of interested parties, and FPs play a central role in the process. They do the initial testing that raises suspicion that a man may have prostate cancer. They make the referral to a specialist. They provide education, support and ongoing care as a man has treatment. They are often responsible for long-term follow-up after the man’s treatment.

We need the perspective of an FP on our working group, so I met with the executive council of Saskatchewan’s section of family practice to ask for their help in recruiting one of their members. While supportive of the prostate cancer pathway, they made a couple of pointed comments.

Make our work simpler. Many well-intentioned groups are developing guidelines, checklists, templates and standardized forms to help manage specific conditions. While each of these efforts makes sense in the context of that condition, when FPs are bombarded by dozens of documents, it’s bewildering. Without consistent design, the learning curve starts anew when completing each form.

Perhaps the end users of these documents (in this case, FPs) should insist that any new forms adhere to a common template. If a template is too restrictive, then a set of design principles such as font size, page layout and completion instructions could be used. As one of the FPs pointed out, “Poorly designed forms may only take me an extra 30 seconds to fill out, but that adds up over the course of a day.”

Ultimately, an electronic medical record would solve these problems by “imposing” a style template and virtually filing all documents in one location.

Compensate us appropriately. There were strong feelings about this one. Because of their central role in patient care, FPs are asked to participate on a multitude of committees, boards, and working groups. This work often happens outside of regular work hours and so interferes with family life. When the meetings occur during regular work hours, fee-for-service FPs are often asked to sacrifice practice income.

One of the FPs pointed out that when committees didn’t pay him for his attendance, they undervalued his time. He had been asked to sit for hours through deliberations that didn’t involve him, just so he could participate in discussion of a single relevant issue. He felt that if he were being reimbursed at the same hourly rate he could earn working in his office, the committee would be more careful to schedule the meetings so he was present only when truly necessary.

Others pointed out that most administrators sitting on health-related committees are salaried employees, and so don’t pay any financial penalty for the time they spend at meetings.

I’ve been relatively insulated from the financial burden imposed by participating in administrative work. The pooled revenue-sharing nature of our urology practice means that our group can support one or more individuals taking on non-clinical work that we see as important for advancing patient care. However, if I were a solo, fee-for-service practitioner, taking a day away from my practice could end up costing over $1000 in lost income, with overhead expenses continuing to mount in my absence.

The executive committee indicated they would support our effort to recruit FP representatives for our prostate cancer pathway initiative if our recruiting message included the offer of a stipend. To be fair, I think that stipend should be offered to all non-salaried participants, including specialists and community representatives.

That puts the ball squarely back into the government/SkSI’s court. What other consultants provide their expertise for free?

P.S. I received a stipend for attending the CMA meeting last month...

Spoonful of Sugar

I got a big dose of my own medicine last week. And it was bitter.

We've been waiting for our new electronic medical record (EMR) system for several years. We implemented our old EMR over 4 years ago, and I posted previously about some of the benefits. Unfortunately, the EMR program was "orphaned" about 2 years ago when the software company was bought by another company. It changed hands again, this time acquired by one of the companies applying for approval by the Saskatchewan Medical Association (SMA).

While software vendor approval has been drawn-out, it's an important process that helps ensure that vendors will be committed to and capable of providing service in the long-term, as well as expanding the capability of their EMR software to include connectivity with laboratories and between physician offices. We are fortunate that the company that owns our old EMR has received SMA approval, as they have all the necessary codes and knowledge to transfer records between the two systems. As far as we can tell, the transfer of patient information went smoothly. But that was the easy part...

Goats and Apples

OK, one last post about our recall rates/internal demand. I’ve been fixated on this topic for many recent posts, and it’s probably time to move on… after I show you this chart:

Looking good!

In July, 6 out of the 8 docs who were working had patient recall rates in the single digits, and the clinic average recall rate was 6.8%. That’s the first time we’ve had a clinic average in the single digits. We need to maintain these gains, and I think we’ll be helped by a change coming to our office this fall.

Mea Culpa

Did you ever have the experience of having an idea that was vivid and compelling when you saw it in your mind’s eye, only to have it fall flat when you gave it voice? Maybe, when you tried to express yourself, you were tired. Or in a rush. Or not quite as clever as you thought you were. That’s what happened with my last post, Wasted. (Heavy on the 3rd excuse.)

After the post went up, someone emailed me another meeting invitation, with the comment I see you like to have plenty of notice for these invitations! A similar remark about how upset I seemed, received a few days later, along with some of the comments on the blog, made me realize I need to clarify my intentions about that posting.