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!

"Medical Justice" makes no sense on so many levels

Hi, I'm Dr. Visvanathan.  Please come into my office.  Before I provide you with high-quality, compassionate care, I'd like you to sign this agreement that you won't bad-mouth me publicly.

According to the American company, Medical Justice, this is how all my patient visits should start.

This story is a jaw-dropper.   Medical Justice markets itself as protector of physicians' reputations.  The problem, they say, is that anyone can anonymously blacken a physician's reputation via the internet, particularly on doctor rating sites (such as RateMDs).  The physician has limited recourse.  Medical Justice's solution is to have all a physician's patients sign an agreement that allows the physician to remove from the internet any unwanted comments the patient may post.

Doctor rating sites - and their use and misuse - aren't a new story.  Back when (now defunct) Plain Brown Wrapper was the international sensation everyone was talking about, I posted about an experiment I tried using RateMD, one of the doctor rating services.  Rather than try to shut down patient comments, I left a message on my rating page inviting comments, but challenging people to leave constructively critical comments.

My post on the site said: "Hi, it's Kishore Visvanathan here.  Thanks for leaving a comment on RateMD.  I'd like to use your comments as a way to improve the service I give.  If you have any concerns about the care I provided to you, please make a constructive comment about how I can improve."

Actually, I'm paraphrasing, because when I visited the site for the first time in a long time (prompted by writing this post), I found that my invitation for constructive criticism had been removed.  Interesting...  I wonder if they are concerned that doctors might subvert the original purpose of RateMDs, and actually turn it into a way that doctors and patients could have a dialogue about improving quality?

Other doctors have different approaches to RateMDs.  As do some medical students.

I digress.

If Medical Justice wants docs to worry about anonymous comment posting, how will "asking" patients to sign their agreement help.  Anonymous posting is... difficult to track.  I presume they're willing to make the effort to force website managers to cough up the names of the offending posters.

Most importantly, if a doctor is so worried about his/her reputation, why not earn that reputation through consistent efforts to improve service?  Sure, there will always be people who have an unhappy experience and want to gripe publicly about it.  I doubt that they would be thwarted by the Medical Justice gag agreement.

Medical Justice's legal circling-the-wagons drives a wedge between physician and patient.  We should invite feedback from our patients.  Some comments may be personal and painful to hear.  Those are the ones to pay close attention to.

50ish man, loves long walks on the beach, and Quality Improvement

Last week, someone asked me what was new and exciting in urology.

I dread that question.

Usually, I have to rack my brain for some new technique or piece of equipment that will wow the person.  Surgical lasers are a good bet, but new technology isn't as riveting to civilians as it is to surgeons.

But this time, I blurted out "Doing things better in the OR".  And I realized that I really am excited about quality improvement - even more so than getting a new laser.  And the best part was that he was excited to hear about quality improvement as well.

We talked about the surgical checklist and about the ways the Saskatchewan Surgical Initiative  aims to improve care.  He was genuinely interested.  I think it was because he could see the impact QI could have on him and his family and friends.  While a new surgical technique or instrument may help a limited number of people, system changes affect everyone.

Before this conversation, I avoided talking about QI in healthcare because, frankly, it sounds a little nerdy.  Now, I think it may turn into my go-to ice-breaker.

Don't hide your passion!

Multitasking in the OR? We're fooling ourselves!

I was in the middle of a case in the OR on Friday when a conversation caught my ear.  Apple’s iPad 2 was being released that day, and the anaesthetist and his resident were excitedly talking about it.  I’m coveting an iPad 2, so I’ve also been looking forward to its arrival.

But, as much as I would have loved to share the excitement with them, I was a wet blanket.

“Hey, guys.  No iPad talk in here”, I said, semi-jokingly.

Without an objection, they stopped their conversation.  A little later, the anaethetist asked (semi-jokingly) why he couldn’t mention “that thing we can’t talk about.”

I explained that I was so interested in the iPad gossip that I thought it would likely distract me from a tricky part of the procedure that I had been starting at the time.  After the case was finished, we compared notes on how we each planned to acquire the new toy.

My request to change the topic of conversation had been slightly tongue-in-cheek, but I had noticed I became slightly distracted when they dropped the i-bomb.  I don’t insist that the OR theatre be silent during all my cases, but there are times when it is appropriate, in order to let the team focus on critical activities.

As I thought about that situation, which was somewhat light-hearted, I recalled another recent situation in which the OR team’s attention may have wandered from the prime task: patient care.

We were transferring an anaesthetized patient from the operating table back to a stretcher at the end of the surgery.  At this stage, patients are usually still unconscious and completely reliant on us to safely move them.  The anaesthetist is in charge of this patient movement as they control the patient’s head, neck and airway.  Once everyone is ready, the anaesthetist will signal “On 3”, and then count to 3.  The team will move slide the patient from the table to the stretcher.

It seems simple, and usually is, but involves a coordinated effort to make sure the patient is safe and also that any attached tubes and IVs don’t get dislodged.  There was a conversation going on between some of us and not all the staff heard the anaesthetist’s countdown.  The patient was moved safely, but it wasn’t the usual smooth transfer we’re used to.

No harm was done, but as I commented to 2 medical students who were observing in the room, I thought it could have gone better if we were all concentrating on the important task.  Also, I told them that I should have addressed it with the OR team right at the time but, frankly, wasn’t sure how to raise the concern without offending anyone or seeming overly picky.  (I hasten to admit that I have been guilty of participating in distracting side conversations also.)

Most non-medical conversations in the OR are positive – they promote a good team relationship, and often relieve tension during a long or difficult procedure.  None of us maliciously distract our teammates in the OR, but it’s easy to fall into a habit of chatting during critical times.  We may not even identify them as critical times because they are routine to us (e.g. patient transfers, induction of anaesthetic). 

I would like to think of critical times in the OR in the same way as critical times in aviation.  (Note: this is total fantasy on my part, as I have no aviation experience!  If any readers have such experience, or know someone who does, please leave a comment to correct any misconceptions I have.)  I’m sure that in the cockpit during takeoff, landing and turbulence, the conversation is sparse and professional.  But, while at cruising altitude, the pilots likely swap a yarn or two.

What’s the difference between the two situations?  The difference is culture – the mutual understanding and unspoken agreement of how we behave at work.  The pilots likely have it drummed into them from the start of their career about the importance of attentiveness during critical maneuvers.  They would have to agree on what those maneuvers were.  They likely also have some shorthand way of telling each other that something critical, yet unexpected, is happening.  The fact that there are only 2 of them in the cockpit, likely reduces the complexity of communication. 

I’m not sure that we all agree on what points during surgery are critical for everyone’s attention.  But, we’ve made a start with checklists.

We’ve taken a page from aviation safety with our surgical safety checklist.  Prior to every case in the OR, the surgeon, anaesthetist and nurse review a list of items important for the safe and efficient care of the patient.  It’s lead by the surgeon, who has the responsibility to make sure that the other team members are participating.  Sometimes, the anaesthetist may be in the middle of starting an IV, or giving a medication, or checking the patient’s chart and will give me a wave saying, “Go ahead, I’m listening”.  At the risk of offending my colleague, I usually decline to start and invite them to finish the important task at hand before we complete the checklist.  One anaesthetist told me “Go ahead with the checklist. I can multitask.”  Really?  (Here’s a brief AORN Journal commentary on “multitasking” in the OR.)

A stumbling block in the OR is communication (surprise!).  And, as the surgeon leads the team, a big part of the responsibility for open and appropriate communication lies with me.  If I’ve allowed myself to get stressed, I tend to speak sharply.  I get annoyed when the flow of preparations doesn’t go the way I envision it (as if the team should be reading my mind!).  I don’t always speak up in situations where I think team members should be avoiding distractions.  And, I don’t invite feedback on how my own behaviour affects the rest of the team.

If you have any suggestions on how to get these important conversations going safely and productively, please leave a comment.  When we’ve let it slide for so long, it seems so hard to get started.  But, for our patients’ sake, I would like to try.

Improving the FP-specialist referral process

Last week, I attended a joint conference of the Canadian Medical Association’s specialty and family practice (FP) representatives. This was the second year of the joint meeting and the theme was the same: How to improve the referral process between specialists and FPs.

The main task was to identify problems with the current system. There was no shortage of suggestions/complaints.

From the specialists:

Inadequate information in the referral letter (e.g. no medical history or list of medications)

No clear clinical question to be answered by the specialist

Tests results not included in the referral letter

Illegible writing

Inappropriate referral (to the wrong specialist)

No indication as the urgency of the problem

Referral initiated too late in the course of the patient’s illness

Treatment recommendations or requests for further testing not carried out (“I don’t think anyone read the consultation letter I sent back.”)

FP not willing to manage chronic conditions, even with specific recommendations in my consultation letter

And just so specialists don’t get too smug, the FPs shot back with:

Don’t know if the specialist has received my referral letter

Not clear if the specialist will contact the patient with an appointment, or whether I should do it

Don’t know how long the wait times are

Don’t know what tests the specialist wants done ahead of time

Delay in receiving consultation report

Clinical question not answered in consultation report

Not clear who is responsible for providing ongoing care for chronic conditions

Don’t know what each specialist’s sub-specialty interests are

Some comments that came up during general discussion were interesting:

Calling the process a “referral” implies the necessity of a face-to-face visit between specialist and patient. We should consider the process a “consultation” which suggests an exchange of information between FP and specialist. This could be accomplished by phone, email or hallway conversation.

Funding mechanisms (such as fee-for-visit) limit solutions. Several practitioners who worked under alternate funding programs talked about using telehealth, phone calls and email to great advantage. This is (financially) unattractive for fee-for-visit specialists, unless their jurisdiction has fee codes covering these options.

Some of the solutions aimed to improve the content and quality of the referral letter using standardized templates and checklists. Our clinic’s microhematuria algorithm is an example of this with its request for specific testing to be completed before the urologic consultation.

I’m most encouraged by efforts that go beyond just the fine-tuning of the current process. Some people are trying to make referrals more appropriate, or even render them unnecessary.

For example, the Saskatchewan Surgical Initiative’s back pain pathway trains FPs on how to better distinguish surgical and nonsurgical candidates. Patients who are unlikely to benefit from surgery can be immediately directed to the appropriate treatment (physiotherapy, exercise) rather than languishing on a surgeon’s wait list, only to be eventually given the same advice.

A clinic in Northwest Territories is looking at common reasons for specialist referral, and then targeting FP professional development around those topics. Increased FP expertise and confidence for treating common “specialty” conditions will reduce specialist referral rates and allow patients more prompt treatment.

The patient referral process is the key interface between FPs and specialists, and as with many of the “hand-offs” in healthcare, it’s fraught with problems. After attending this conference, the two biggest problems I see are these:

There’s no feedback system to educate either FPs or specialists as to the quality of their contribution to the referral process. In the current system, a FP can send me a referral letter with inadequate clinical information, yet will get a complete consultation report in return. From his/her point of view, the referral letter got exactly the intended result, so why should they change their behaviour? As one of my partners is fond of saying, “What you permit, you promote”! Of course, it works both ways; if I don’t answer the FPs clinical question or help the patient with their problem, I will only know about it if the patient is referred back to me for further assessment. Neither of us can improve unless we’re shown – in an objective and constructive way – where we need to improve. I know that peer feedback would be a strong incentive for me to provide a better service.

An even deeper problem is lack of patient involvement in improving the referral process. The FP/specialist conference clearly focused on perceived physician needs. As healthcare workers, we often flatter ourselves that we can represent our patients’ interests in these matters. My experience in working with patient representatives on similar groups is that they bring a perspective that we lack. As such, I recognize that I can’t predict what a patient would add to the discussion. But, I’ll take a stab at it anyway:

No clear clinical question? I’ll tell you the question, because I’m the one with the problem.

Not enough medical history on the referral? Let me fill that out for you.

I’m being referred for pain in my knee. You “don’t do knees”? Well, then you better make that crystal clear right away, because I don’t want to wait 9 months to hear it.

I drove 4 hours and stayed in a hotel overnight to have a 10-minute discussion with you. Why couldn’t we do that over the phone? Because you get paid more if I turn up in person!? If I knew that ahead of time, I would have made the phone call, paid you the difference and still come out ahead.

Maybe next year we can get some input from the people who are truly affected by a dysfunctional referral process.

An informal telephone survey

Other than face-to-face discussion, what is the most effective way for me to communicate with my patients? Most frequently, I use the phone, but will occasionally send patients a letter, particularly if I’m reporting test results and recommending followup. I’ve dabbled with email, but found the “secure messaging system” available to me somewhat cumbersome.

Recently, I gathered data on how I was using phone calls to reach or respond to patients. Before I share the results and some interpretations, here’s how I collected the information.

From December 16, 2010 to January 14, 2011 (excluding my holiday week of December 20-24), I recorded data on all calls with patients and family members. I used the database program, Bento, on my iPhone. Bento makes it quick and simple to set up a basic data collection template (“library” in Bento-speak). Setting up a user-friendly template requires some forethought so as to make data collection simple. You can create a new library either directly on the iPhone, or on your computer and then sync the library between computer and iPhone.

The computer-version of Bento lets you search and sort the database, or export the information to a spreadsheet.

I prefer to limit the number of choices in each data field so that I can use pull-down lists and checkboxes. If all the information can be entered/confirmed with one touch on the screen, it speeds data entry and makes for consistent responses. I was interested in a snapshot rather than a lot of detail.

I used these categories:

Date – touch on date selects today’s date as default.

Duration of call (minutes) – I used the screen keyboard to enter the number. I could also have used a pull-down list of numbers from 1 to 20.

Reason for call – Pull-down list included:

Patient initiated – results (e.g. calling for lab reports)

Patient initiated – postop problem (e.g. concerned about infection after surgery)

Patient initiated – other question

Physician initiated – results (e.g. biopsy reports)

Physician initiated – followup (e.g. recovery after surgery)

Physician initiated – other

Time of call – one touch to record the current time

Local/Out-of-town

Call unsuccessful/busy/not in

Comments (always handy to have a “miscellaneous” column in a database!)

If you spend your whole work-day in front of your computer, you could just set up this database in Excel. Because I travel between several sites at several hospitals, in addition to my office, I’m much more likely to consistently record information on a single device, and my iPhone is always at hand.

Results

Time period: 3 weeks

Number of calls: 39

Total call time: 179 minutes

Average time per call: 4.6 minutes (range 1-12 minutes)

Average call time per week: 59.7 minutes

Unsuccessful calls: 4 (10.3%) – (1,1,2 and 2 minutes respectively for these calls)

Average time per call (excluding unsuccessful calls): 4.9 minutes

Frequency distribution of successful call duration (chart below):

Local calls: 17 (43.6%)

Physician initiated: 16 (41%)

Time of day calls made (chart below):

Interpretation

My impression was that I made fewer calls than usual during the measurement period, likely because it was over the holidays. Less surgery is done during that time, so there would be fewer calls about post-op concerns. Also, it may be that patients were traveling, or busy with holiday visitors and so less likely to have time to call to discuss non-urgent concerns.

Concerns discussed in shorter calls (5 minutes or less) could probably be dealt with via email. These calls tend to be straightforward, single-question discussions. However, longer discussions are not conducive to email as there is a lot of back-and-forth with more involved discussion. Trying to conduct these discussions through email is probably not effective.

Three calls were quite lengthy (1 of 11 minutes and 2 of 12 minutes). Most of the time, I could anticipate that a call would be lengthy and so tried to make the call when I had adequate time for the discussion. However, this sometimes means that I would postpone making the call until I was going to be free for a longer period. I return many calls in the short breaks between OR cases or between seeing patients in the office. These short breaks aren’t adequate to discuss, say, a biopsy report showing cancer and the testing and treatment that will follow. These would be circumstances where scheduling time for a call (or office visit if convenient for the patient) would be helpful in reducing unsuccessful calls, and also making sure patients receive the information in a timely fashion.

In the study period, I spent about an hour per week speaking with patients on the phone. As I mentioned above, I think this was less than usual. This is one heck of a good deal for the patients’ insurance plan (AKA Sask Health) as I do not receive reimbursement for this work.

I’ve also been struck by the occasional patient’s comment that they are very pleased to be able to reach me by phone, as they didn’t think they could call directly to speak with “the doctor”. I know that many family practices insist that patients set up appointments to discuss concerns. If they didn’t have this rule, those family doctors could spend most of their day on the phone, gratis. But, if patients have been acclimatized to the idea that they can’t reach their doctor to ask questions, maybe some of them don’t even bother to make a call in the first place. If the problem were urgent, I suspect they would seek out help. But, for less-urgent problems, the questions may be going unasked. Perhaps I’m missing opportunities to provide better service/answer questions by not giving the level of accessibility that email would afford.

Canadian Patient Safety Week - Welcoming our second-degree guests

Canadian Patient Safety Week is next week, but its theme – Ask.Listen.Talk - was on my mind a lot this week. And it made me think about a party we held last New Year’s Day.

We invited several friends over for brunch. At the last minute, one family called and said they wouldn’t be able to come. Weather conditions had prevented their visiting relatives from returning home, and they didn’t want to leave them alone. Of course, they were welcome to come to the party, so we set a few extra places at the table.

If you’ve ever been a “second-degree guest”, that is, accompanying someone who was invited by the host, you know it can be awkward. You may not know the host. You would rather suffer in silence rather than put the host out by asking for something. You don’t feel comfortable.

We recognized that our second-degree guests felt that way. All the other guests had been in our home previously and knew their way around. They felt comfortable with helping themselves to cutlery or serving themselves drinks. They made themselves at home, and we invited our new friends to do the same.

But that wasn’t enough.

If I’m visiting someone’s home for the first time, and am told to make myself at home, I won’t. Because I don’t know what “making myself at home” means in that home. Can I poke through the fridge looking for leftovers? Can I flick on the TV and watch the game? I don’t know what their micro-culture accepts, and so I will err on the side of sitting quietly on the couch.

Recognizing that our second-degree guests felt the same way, we did what any host would do, and made sure to pay extra attention to their needs. Would you like another drink? What do your kids like to eat? Like any host would, we wanted them to feel welcome and comfortable.

CPSW’s theme - “Ask.Listen.Talk.” - suggests that communication between patients/families and caregivers, and among caregivers, improves patient safety. No argument from me. But I think we need to consider how we implement Ask.Listen.Talk. in our practices.

Patients and their families are like second-degree guests visiting the healthcare system. Everything from our facilities to the language we use is unfamiliar and intimidating to them. While healthcare workers bustle about around them, visitors worry that even a wrong turn in a hallway may take them into an unauthorized area. They feel awkward.

And then, next week, we want them to “Ask.Listen.Talk.” Maybe we’ll put up some posters, or hand out a brochure. That will be the equivalent of saying “Make yourself at home!” Patients/families won’t know what is acceptable in the healthcare culture. Is it OK to ask the doctor whether or not she washed her hands before examining my mother? Will she be upset with me for asking? I don’t take a red pill at home, but I’m sure it’s OK here at the hospital, because the nurse must have checked it before she gave it to me. She looks too busy for me to bother her.

It’s nowhere near enough just to publicize our belief that communication improves patient safety. We need to actively seek out patient and family comments and participation, like we would for second-degree guests in our home. And when those comments arrive, we need to receive them positively and consistently. A sour look in response to a voiced concern speaks much more loudly than an Ask.Listen.Talk pamphlet on a bedside table.

Last week, I spent some time with a medical student, and we observed what we considered to be a breach of a patient’s dignity. We talked about it after we left that care area, and I asked him how he would address that with the caregiver responsible. He laughed. I laughed too. We both realized that I was being absurd. It would be a rare medical student who would comment on a breach of patient privacy, dignity or safety. At best, they would be ignored. At worse, they would be excoriated for their impertinence. How dare you…

He felt – undoubtedly correctly – that the caregiver would not accept such a comment from someone who was without standing in their culture. But we did explore possible approaches. I thought that he would need to test out – role-play – some options with like-minded colleagues before “going live”. Perhaps the old just-trying-to-be-helpful gambit: Would you like me to pull the curtain around the patient’s bed while you examine him?

I used a similar approach with our second-degree brunch guests. I wanted my 10-year-old son to find out if our guests needed anything, but I realized that giving him that vague instruction would be useless. It wasn’t that he didn’t want to help, or that he is unfriendly. It’s just that it was a new situation for him, and he felt uncomfortable. He needed some coaching and a specific script.

“Ask them ‘May I get you something to drink?’”, I suggested.

“’May I get you something to drink?’”, he repeated.

And off he went.

Coaching and scripting to encourage dialogue around patient safety will help us demonstrate to patients and families that we are serious about engaging them as active participants in safe care.

The day after my student and I had discussed impediments to his commenting on the breach of dignity, he joined me in the operating room. As I introduced him to the personnel in the room, the anaesthetist said this to him: If you see anything going on in here that you think is unsafe, please speak up. We value your eyes on what we’re doing.

That was a big step in the right direction.

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!

Show me the money

The latest Saskatchewan Medical Association “President’s Letter” had some encouraging tidbits in it. The SMA and Government are negotiating physicians’ fee-for-service agreement. Usually the focus is on the percent increase in global funding to physicians, but this time the newsletter mentions some initiatives the Ministry of Health is proposing around Quality and Access. “Clinical Practice Redesign” and “Dedicated Quality Improvement Work” are noted as areas for targeted funding. They’re both laudable, if as-yet undefined, goals.

But, I’m most interested in the suggestion that funding may be given for “Physician contacts with patients via telephone and email”. I think this has great potential for improving patient access and satisfaction.

I’ve heard from many patients that they have trouble reaching their family physician (or specialist) over the phone. They may have a quick question that could be handled over the phone, but instead are required by “office policy” to make an appointment to see the doctor in person. Last month, my wife was quite annoyed at being subjected to this approach when she wanted to find out the results (normal, as it turned out) of my son’s xrays. She drove across town, and waited to be seen, all to receive 30 seconds worth of information. That’s not good value.

We shouldn’t be surprised that doctors require patients to come in for a “face-to face”. (See a previous post about this: “Awkward”) There’s no value (i.e. fee code) assigned to alternate ways of communicating with patients. I spend between 30 and 60 minutes daily returning phone calls and emails, as well as writing patients letters about results or follow-up. That’s an unpaid hour of work. I’m sure that lawyers and accountants would shake their heads at that.

Even though I plan to continue to communicate with my patients like this, whether I get paid for it or not, I can envision ways that I might change my practice if this alternate communication gets its own fee code. At present, I see phone calls as “extras” that I fit in between “real” (i.e. billable) visits. If I were to be paid for phone calls, I might schedule blocks of time to make them. I could get calls done during regular hours rather than after the end of the scheduled workday. Also, my staff could tell my patients when they should expect a call. That would be more convenient for patients, and would likely reduce the amount of phone tag frustration. I don’t like it when the cable guy says he’ll be around “sometime between 9 and 5 on Wednesday”, and I’m sure patients don’t like to hear a similar message about when the doctor will return their call.

Tight Spot

A couple of summers ago, my family visited Scenic Caves near Collingwood, Ontario. As we hiked through the caves, we came to a cleft in the rock called “Fat Man’s Misery”. It’s a narrow gap in the rock that only slim people can squeeze through. The alternative route is to backtrack and take a slightly longer path.

My younger sons – then aged 8 and 10 – were amused at the thought of someone getting stuck in this crevasse. They thought it would be easy to pass through, and before I could stop them, they both did so. That left me with a problem.

A turn in the middle of the crevasse made it impossible for me to see the other end. I could see the passage narrowing as it turned. It looked like I would fit through the visible part, but I had no way of knowing whether it narrowed even further around the corner. Also, the passage was irregular and I would only be able to fit through facing one way. If there were any other rocky protrusions around the corner, I might get stuck in an awkward position.

Do You Recall

At the IHI Clinical Practice Redesign Summit in Vancouver, Advanced Access guru Catherine Tantau suggested that the gold-standard for specialist wait times is 1 week.
When wait times are that short, practices start reaping the benefits such as less wasted administrative effort, fewer no-shows and greater flexibility in physician schedules.

One week? It boggles the mind!

In early 2008, we were on our way with our 3rd NAA down to 30 days from our starting point of 70 days. Then, one partner switched to half-time work. Our 3rd NAA crept up a little until July 2008 when 2 more partners switched to half-time. Since then, our 3rd NAA has gradually climbed back to its original level. Aaaaaargh!