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!

Come on in… The water’s fine!

Since we started encouraging pooled referrals, we’ve never looked back. If you’ve been following our Clinical Practice Redesign work, you know that we consider the pooled referral to be our default condition, that is, anyone referred to our group is automatically scheduled for the earliest appointment available with any urologist. (Caveats: If the problem requires subspecialty expertise, we look after triaging to the appropriate urologist. If the patient already has a relationship with one of our physicians, we try to maintain continuity of care by scheduling the appointment with the same physician. Most importantly, the patient or referring physician can specify which urologist they prefer, and we will schedule the appointment with that doc. The wait may be longer in that case.)

I like the analogy of an ice-cube tray to illustrate the advantages of a pooled referral system. When you pour water (referred patients/demand) into one compartment of an ice-cube tray (specialists/capacity), the water automatically spills over into the other compartments until they are all filled. The result will be even and efficient distribution of water. Unless overall demand exceeds the tray’s total capacity, all the water will be accommodated. Overflowing water represents excess wait times.

The alternate model is to cut up the tray into separate ice-cube compartments, and then fill the compartments individually. Not only does that require more effort (you have to move the water jug from one compartment to the next), but also there is more risk of overflow. In this model, if individual compartment capacity is exceeded, water will spill. Some compartments may be underfilled. This model is inefficient because the compartments don’t work as a system.

One day soon, you’ll be thanking me for providing this sweet analogy, because I think pooled referrals are soon going to be a topic of conversation in Saskatchewan. And, when someone mentions them at a party, you’ll be knocking socks off with the ice-cube tray story. You’re welcome.

Why the interest in pooled referrals? Because of the Saskatchewan Surgical Initiative! SSI says that by 2014, no one in Saskatchewan will wait more than 3 months for surgery. That’s bold. But, other health systems have achieved it. The methods they used are well-known, and applicable to Saskatchewan. One of the most powerful methods is pooled referrals. (Still don’t believe me? Check the 2-pager highlighting the SSI plan.)

So how will SSI get us from here to there? First, we need to know what “here” and “there” are.

“Here”

Our current state is the 2nd ice-cube tray model (see above). Most specialists are “organized” in solo or small-group practices. Even when they are physically congregated as a larger group, the individual members of that group still behave as solo practitioners as far as distribution of referrals is concerned. Often, large specialty groups are just a device to share office expenses and on-call duties. Not that there’s anything wrong with that.

Most Saskatchewan specialists have plenty of work to do, so there’s very little perceived incentive to share a common pool of referrals. They may even be worried that they will be “giving away work” if they participate in a pooled referral scheme.

GPs often have established referral patterns based on their experience with a certain specialist, and their judgment of that surgeon’s expertise. Or, they may be golf buddies. GPs who are new to the province, and are practicing in solo, rural practices, may not have developed a personal relationship with many specialists, and may be uncertain as to which one will best serve their patient’s needs effectively and promptly. There are recent efforts to make referral-to-consultation wait times available to GPs via a website, but the information is self-reported by specialists. Participation by specialists is not mandatory, nor is the information audited or verifiable.

Patients are even more in the dark. They rely on their GP’s advice, or talk to friends and family who may have been referred to a certain specialist. They have virtually no information on individual wait times. They may not receive confirmation of the appointment for several weeks.

The system is working great for us specialists, because we always have plenty of work, and it’s delivered straight to our front door. Everyone else… not so good.

“There”

The “ideal” state I’ve most often heard described goes something like this:

GPs submit referrals through a centralized online system. Artificial intelligence (AI) software asks for key clinical information to ascertain which specialty would deal with the patient’s condition. The system tracks all available specialists’ wait times and subspecialty interests. The patient is then assigned to the appropriate specialist with the shortest wait time, and receives the appointment date before leaving the GP’s office.

Whoa. Ease up on the 1984, Jackboots! This system would be maximally efficient, but very restrictive. There would be little choice given to patients, even though they would be assured of the shortest wait time possible.

If we imagine a system guided by patient-centredness, we may sacrifice some efficiency, yet improve overall satisfaction. Keep the centralized online system with AI. When GP and patient jointly submit clinical information, have the AI suggest alternatives to specialist referral (alternate provider, care pathways, patient education resources). If a specialist referral is appropriate, the system gives the patient all the information he/she needs to make a choice. Some patients may still prefer that their GP choose a specialist. Others may want to know wait time information, subspecialty interests, results of patient satisfaction surveys, and even condition- or procedure-specific outcome data. The choice remains up to the fully-informed patient.

Because concern over long wait times tends to trump all other considerations, we generally ignore the other factors that affect patient choice of a consultant. (During a famine, one overlooks a little mold on a loaf of bread.) Once wait times are better managed, and therefore shorter, patients will behave more like well-informed consumers. The balance will shift from a seller’s market (favoring specialists) to a buyer’s market (more choice for users). Patients will start to consider geographic convenience, surgeon experience and outcomes, other patient’s satisfaction with that specialist, in addition to the wait time.

The trip from here to there

How do we make our way through the wilderness to reach this utopia of patient-centredness? First, we could talk to people who’ve already made the journey.

While many specialists consider pooled referrals to be a radical change, they are actually more familiar with the concept than they may realize. Some specialties already use a pooled referral model. Radiology is a prime example. When I order an xray, I accept that the test will be interpreted by the radiologist on duty that day. Because of subspecialty interests, some work may be streamed toward a specific radiologist. I have the option to have the xray films reviewed by another radiologist if I choose.

In order to be confident in the pooled radiology system, I have to be satisfied that the quality of work is consistent among all the radiologists. This is a tricky subject to raise if we’re considering implementing a pooled referral system, yet it’s critical that we address it. All specialists are not created equal. Differences in knowledge, skills and attitude all affect performance. How will a pooled system function if some of the participants don’t perform to a common standard? This is an important consideration for patients using the pooled system, but also for the specialists in the pool.

An objection sometimes voiced by specialists, regarding pooled referrals, is that they don’t want to work with Dr. X because they don’t respect his/her abilities. (Note: This is rarely stated at the meeting, and sometimes requires administration of a few drinks after the meeting. In vino, veritas.) Whether this objection is based on actual clinical shortcomings, or just personality conflicts, it’s still important to acknowledge it as a barrier to implementing pooled referrals.

Next, we need to think of a way to get everyone into the car, i.e. incentives. For patients, we should offer something beyond just the shortest wait time possible. The referral system should direct the patient toward appropriate care (which may not be referral to a specialist) within a reasonable time frame, with the provider of their choice.

For GPs, our system should reduce their paperwork burden, and increase job satisfaction. An electronic referral system that lists all specialists’ interests and wait times, as well as the information specialists want to accompany the referral request, would simplify the GPs job. If the electronic referral system also included expert information on how to manage common clinical problems before considering referral, GPs could provide more service to their patients in their own practice.

Incentives for specialists are a little trickier. We already have plenty of work to do. We are, for the most part, well paid. We value our autonomy, i.e. I choose my own practice group.

Honestly, I don’t know how to motivate specialists to participate in a province-wide, pooled referral system. And that’s why I think we should let patients and GPs drive this initiative. They are the ones with the most to gain.

First steps

Start by collecting reliable information that patients and GPs want. Of course, we first need to ask them what they want, but I have a few suggestions. Collect information from all surgeons regarding their specialty and subspecialty. Develop a method to measure and verify wait times from referral to consultation. Post all this information on an open-access website. Publicize the website. Eventually, the site could include patient satisfaction survey results, and outcome data.

Next, implement an electronic referral system. Other provinces have a headstart on these systems, so we should beg, borrow or steal. Or offer to collaborate. Pay a premium to GPs and specialists who use this system, but make sure the system is useful and user-friendly enough that they want to use it even without being paid extra.

Finally, don’t try to push specialists into a pooled referral system. Instead, set clear and realistic expectations for wait times and offer specific incentives to achieve those goals. Provide support and training for specialists who wish to implement changes (including, but not limited to, pooled referrals) in their practices. Acknowledge and address real barriers (personal and professional) to adopting pooled referrals. Do not expect busy clinicians to implement these changes on their own. Praise – publicly and frequently - the practices that achieve the goals.

Establish a new level of expectation in Saskatchewan: Patients are entitled to the information necessary to make a decision about which specialist they wish to see.

Turn up the heat until everyone wants to jump into the pool.

Heaven

I’ve been to wait line heaven... it’s a Wal-Mart.

I studiously avoid shopping at Wal-Mart. I know it’s a popular spot, and that’s the problem – the more people who shop there, the longer the wait at the checkout. And I hate wait lines.

But, last month, while looking for a piece of summer camp equipment for my son, I paid my first visit to our local Wal-Mart outlet. They had the item in stock, so I prepared to brave the wait for the till. I headed for the express checkout line. There were over a dozen people in the first line. I looked around for a shorter line. But, there was only one queue for multiple cashiers. Now, that’s odd for a department store.

Whether by tradition, or based on hard statistical analysis and marketing research, various businesses manage wait lines differently; for example, grocery store lines vs. bank lines. At the bank, you form a single queue, at the front of which you look for the next available teller. At the grocery store (and most department stores), you size up individual lines, trying to judge who has the most groceries, which teller is the chattiest, and who will be paying with loose pennies dredged up from the bottom of their purse. Then, while standing in line, you kick yourself for not picking another line that seems to be zipping along. Queue-er’s remorse.

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.