Advocating for a centralized referral system

Many Ontario patients are waiting weeks or even months to see a specialist. In this third episode of a three-part series, physicians explain how a centralized referral system could help alleviate anxiety and uncertainty around wait times, based on the Ontario Medical Association's Prescription for Ontario: Doctors’ Solutions for Immediate Action advocacy document. Listen in as we hear from Dr. David Urbach, head of the Department of Surgery at Women's College Hospital in Toronto; Dr. Danielle Martin, a family physician in Toronto and chair of the Department of Family and Community Medicine at the University of Toronto; and Dr. Mohamed Alarakhia, a family physician in Waterloo and CEO of the non-profit eHealth Centre of Excellence.

Transcript

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Georgia Balogiannis: In this podcast, the Ontario Medical Association looks at current issues of interest in healthcare. Spotlight on Health gives you all the straight talk. We're Ontario's doctors and your health matters to us. I'm Georgia Balogiannis for the Ontario Medical Association. 

Ontario patients can wait weeks or even months to see a specialist. This third of a three-part series looks at the OMA's recent advocacy document for change, titled Prescription for Ontario: Doctors’ Solutions For Immediate Action. Physicians discuss the anxiety and uncertainty around wait times and a centralised referral system that may alleviate those issues. 

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Georgia Balogiannis: Dr. David Urbach is head of the Department of Surgery at Women's College Hospital in Toronto.

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Dr. David Urbach: I'm head of a department of surgery at a hospital. I do research, health services research, looking at issues around wait times and access for surgical procedures. So, I have a research interest as well as a leadership responsibility to improve things. So, I've seen this problem from many different perspectives. I know what can be achieved if we work towards more coordinated models of care. I've seen the problems and I've also seen the solutions, so I'll give you an example of just something that works really well in healthcare and that is something called the Ontario Bariatric Network. It's a coordinated model for the provision of weight loss surgery. 

All referrals for a patient who's having insured weight loss surgery in the province goes to a single central portal, and from there the referral is assessed. It's parcelled out to a regional centre, and then within those hospitals, they're further distributed relatively evenly among all the clinical providers — that's surgeons, but also physicians who are not surgeons, and allied health professionals, so dietitians, social workers, other professional clinical roles. And what that serves to do is that you have a system where there is not huge variation in wait times from centre to centre or from surgeon to surgeon — it's highly predictable and it's highly uniform. 

The waits right now are not all that long. A lot of that is because of the supply of services and the demand for services. And when I say supply, I'm talking about availability of operating rooms, doctors, nurses, anaesthetists, surgeons. That's our capacity to be able to do procedures. The demand are the patients who are hoping to have procedures. 

The more efficiently we can link those together, the better a system will function, the more uniform access will be and wait times will be among the entire population. Now why did that happen in obesity surgery and why did that not happen in the other things that I do like hernia surgery or gallbladder surgery? Most other things that we do in healthcare are really legacy types of activities that just evolved to the current situation without a lot of guidance.

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Dr. Urbach: Everywhere else you go and you have to wait in line somewhere. People would be shocked and angry and frustrated if they just had to choose a line and there was a lack of predictability of how long they were going to wait in that line, and there was a possibility that that could be three times as long as the line next to them. So for example, when you used to arrive at Pearson Airport in Toronto and go to customs, you had to choose a customs line and there's never ending frustrations because it always seems like the other lines are moving faster. 

But when you walk into a bank, when you walk into a Tim Horton's, when you walk into just about anywhere, these days you don't have to choose a line, you just join a common queue. It's the most efficient way to get people to the endpoint as efficiently, as quickly, as possible in a system that's fair for everybody. That's one of the reasons why these models are so important for us as a profession because not only do they address the needs of the population, but I believe they're critical for us to have a work experience for specialists and physicians that is supportive, that's sustainable, that diminishes a lot of the stresses that come from managing an independent practise with resource constraints that we're all trying to deal with. 

If I'm a surgeon who does not have as much access to operating room time in hospitals or other facilities as I need for the number of patients that I have waiting, then I'm stuck. I can internalise that stress. I've got patients who I've seen who I've made a commitment to because we've scheduled them to have surgery, they've put their trust in me, and I can't provide surgery in time. That's very stressful for the physician as well as for the patient. If there's other surgeons who have more capacity, there's no easy way to flow those patients to the right place where they'll get treated easier. I believe it's not great to work entirely independently without integration with colleagues. 

There's nothing like co-managing patients and sharing our processes and pathways, assisting other surgeons, that allows you to really standardise and increase the reliability of care rather than having types of variations where surgeons have all sorts of different approaches. The more we can coordinate — and sometimes that just involves sharing a common referral intake or it may involve co-management of patients — then practise evolves towards a consistent level of care. The logistics aren't nearly as complicated as a lot of people think. Especially if you think of starting this on a smaller scale. 

A lot of it is fear of adopting new models about how that would work. “It's not what I'm used to. I've built this incredibly successful career as a surgeon. I've got a great reputation. I don't want to risk any of that.” These are the things no doubt that people are thinking of when it comes to adopting these new models of care. Changing behaviour, changing culture is very difficult. Often as physician leaders, what we can do is try and be persuasive and try and emphasise the benefits and support people and do small demonstration projects. 

We have a health system that's very stressed and very challenged, and there's a lot of public mistrust right now that the health system is actually capable of providing their needs. This is something that worries me. The model that we have can be improved, but it should not be thrown out and recreated in a different entity that's going to introduce all sorts of different problems. 

Unless we actually do something to change the system in a meaningful way, we are at risk of losing public confidence and once we've lost public confidence in the capacity of this health system to address the needs of average people, more and more government will look at out-of-hospital ways to deliver surgical services, looking at a new for-profit delivery sector to provide significant surgical procedures that a lot of us believe should properly be done in hospitals.

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Georgia Balogiannis: Dr. Danielle Martin is a family physician and chair of the Department of Family and Community Medicine at the University of Toronto

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Dr. Danielle Martin: For family doctors in the province of Ontario. Referrals are one of the biggest pain points in our practise. We have no way of knowing really reliably how long wait times are for a given issuer or specialty, nor do we really have a reliable way of knowing who is offering comparable services within our neighbourhood or region or the neighbourhood or region where our patients reside. And so we spend a lot of time in family medicine spinning our wheels, trying to figure out how to access the right specialist who deals with this issue and has a reasonable wait time for a specific problem. 

It's a source of immense frustration to family physicians as we know it is for our specialist colleagues. This is not about anybody not doing a good job. It's about a system that is not set up rationally. The system as it exists is totally opaque. There's no transparency of information. We don't know who sees what kinds of problems. We don't know how long their wait time is for any given kind of issue. We don't know what information they need in order to be able to properly process or triage a referral, and therefore we can't communicate that effectively back to our patients. 

Managing of expectations is a big part of our function in primary care. Not being able to answer those very basic questions isn't just frustrating for us. It's frustrating for our patients and it undermines our patients’ faith in us and in the healthcare system.

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Dr. Martin: Most of our patients, most of the time, do not need to see or want necessarily to see a particular specialist. They are very happy to see any competent, decent, good physician or surgeon who manages this problem. I mean, if you can get someplace within 20 minutes as a patient, why would it make any difference to you who you're seeing? But we need some help putting that infrastructure in place so that we can help our patients to arrive at the right place at the right time with the right information. 

In my own hospital, the gastroenterologists pool all the referrals, and so you can check a box on the referral that says, “I want a specific person” for whatever reason or “I want next available appointment”. Small-scale examples like that are happening all over the place. In that example, we're talking about three to five people who are pooling. I mean, imagine how much more efficient and effective it would be if it were a hundred people. How delighted would I be to get a response in 48 to 72 hours from a qualified specialist giving me the answer to that question and pulling that patient out of the queue for an in-person consultation? 

 And so there's all kinds of exciting possibilities that we could get to if we could all just agree to build this infrastructure first. But it requires investment and thought and time. Culture change is equally, if not more, important. We need to figure out what it would take for such a system to be considered acceptable to all family doctors, to all specialists, and to the public, and that's going to involve championing and giving examples of success of these models by Ontario's doctors. 

I do think that from within the profession, we need to move away from the notion of a specialist referral as a personal introduction and instead move towards the notion of a pool of specialists as a shared resource to the people of Ontario. 

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 Dr. Martin: It's an important issue because it matters to our patients. It's also an important issue because it is driving burnout. What family physicians experience as quote, unquote paperwork or administrative work that has no added clinical value to our patients is increasing exponentially in the daily work that we do. And a big part of that non-value-added documentation and administrative burden is about trying to figure out referrals. A good number of these patients have been referred to more than one place for their issue out of desperation, trying to find somebody who can take them and see them.

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Georgia Balogiannis: Dr. Mohamed Alarakhia is a family physician in Waterloo and CEO of the nonprofit eHealth Centre for Excellence.

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Dr. Mohamed Alarakhia: Patients are suffering on waiting lists, and it's not acceptable in our system for that to continue to get worse. As a clinician, it's a black box in terms of when I send a referral I'm not really sure all the steps that are happening with that referral. 

I've had rejected referrals where referrals go in and they come back either people are too busy, which I understand, or they don't see that patient with that condition anymore, and so then I have to find out another place for that patient to go. I've heard from many of my colleagues in terms of what they experience and through the work that I've done have talked with a lot of specialists about this process and it really is, I think, equally frustrating on the end of specialists in terms of getting the information they need to make a triage decision about a referral. 

Surgical referrals are not spread out equitably. We know female surgeons don't get the referrals that they need. They're not compensated as well as they should be. Our system is not designed to be equitable in terms of distribution of referrals.

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Dr. Alarakhia: So in terms of how we started looking at more of a centralised intake type of program and organising referrals, it really came from a group of clinicians meeting together and talking about the frustrations that they had in terms of supporting their patients. In some areas we were doing better in terms of improving access and starting to organise some processes, but in many areas we weren't. And so we were able to set up a diabetes central intake that had those resources that looked at that referral and were able to get it to the right person. 

We put in technology where clinicians could launch this right from the electronic medical record. They were able to launch the form. It was always the most current form. It pulled the patient's information, the physician's information, right into that form, and then all you needed to do was fill out the reason for referral because the other information is there and then you send it off. That's received by the central intake and they're able to look at that and then determine where it goes based on if there's a patient preference or you want the shortest wait time. It allows the central hub to really take that referral and truly get it to the person with the shortest wait time. 

That has yielded tremendous benefits in terms of patients getting the right therapy and those that need surgery moving on to surgery. One other thing that is important when you digitise a process is that you can include something like decision support within a system. So for example, if I have a patient who has knee pain and they likely have osteoarthritis, they don't need an MRI for their knee, and so if I refer them with electronic referral system today for an MRI it will actually tell me that they don't need an MRI for their knee. They need an X-ray instead. 

And so by implementing decision support within the electronic system we were able to reduce MRIs by 12%. That will save the government $13 million a year and, importantly, reduce the number of people who are actually in that queue for an MRI so that those people who actually need an MRI will be able to get one. By implementing this process, we've reduced wait times for orthopaedic surgery by 54 days, for cataracts by 53 days. By streamlining the process for MRIs, including also decision support, we've reduced the wait times for MRIs by 31 days. And so we're having tangible differences in terms of decreasing wait times and making it easier for clinicians.

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Dr. Alarakhia: Anywhere in Ontario, a physician should be able to refer a patient into a central hub. We have the building blocks for this, but really I think we need a strong push to make this available across the province. It really needs to be a co-design with clinicians. I do think the field is ready for this now, and I think if we empower the clinical leaders to actually move forward, I think we'll be able to do that.

Georgia Balogiannis: This podcast is brought to you by the Ontario Medical Association and is edited and produced by Jodi Crawford Productions. To learn more about the Ontario Medical Association, please visit oma.org.

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