Waiting for referrals to improve

What can we do about wait lists? What can we do to improve the state of the referral process in Canada? For Dr. Mohamed Alarakhia these questions have been the driving concern of his life work.

Since 2011, Dr. Alarakhia has been the managing director of the eHealth Centre of Excellence in Kitchener, Ont. The centre has offered primary care providers support with the adoption and meaningful use of several digital health tools but now, working alongside the Ontario Ministry of Health and Ontario Health, Dr. Alarakhia’s group has partnered with the eConsult Centre of Excellence to lead a new provincial eServices Program. The goal is to expand the adoption of eReferral and eConsult tools across Ontario to support patient-focused care and streamline the experience for clinicians and patients.

He spoke with us about the bottlenecks in our current system, why fax is still the predominant method of communication, and his vision for a perfect referral process.

Q: How would you describe the current state of the referral process in Canada?

It hasn’t really changed. The 2004 Health Accord identified wait times as a problem in Canada that we needed to do something about, and 16 years later we’re still having challenges. Unfortunately due to COVID-19 many procedures have been put on hold—rightfully so—and we’re just starting to ramp up, but that means even longer wait times.

The referral process is essentially a fax-fest. Information goes from provider-to-receiver asynchronously as they try to fill in gaps and eventually a patient is contacted by phone and seen. There are pockets of success we can learn from, as well as from other jurisdictions where they have modernized the process to make it easier for everyone. But we have a long way to go.

Q: Regulatory authorities in Canada—the colleges of physicians and surgeons—have added practices to the standard of care. Last fall, the CPSO specified who is responsible for contacting the patient in certain situations. Are the colleges going too far, getting it right, or should they be doing less?

Yeah, it’s interesting. We talk about the regulatory changes without talking about the enablers of any change. We ask “Who needs to contact the patient?” when we’ve made contacting the patient extremely difficult. You need to find the patient and call them. The patient needs to be aware that someone’s calling them and be available. Sometimes doctors are calling from blocked numbers, particularly with COVID-19 because they’re out of the office. We’ve made it really challenging to do these things. In a world where we’re making these processes easier, I think the changes made (by the colleges)—the ones that I’m aware of, at least—would have been the right ones.

Some changes made on both ends of the referral process have improved it. For example, you need to indicate urgency, you need to complete the information that you send over. Then the patient needs to be contacted in a timely way. But we have to look at how to enable patients to get the best information about their referral. How do you facilitate communication between clinics? How do you facilitate communication with the patient?

Q: Is that the great bottleneck?

Yeah. There isn’t transparency in the system just because of the way we’ve set it up. Faxes seem to go into the ether. You don’t know if it’s gone to an inappropriate place. It takes time for someone to say “I can’t help you with this.” Then it goes back to the sending provider, and they send the patient somewhere else. And you’ve wasted all that time. Or people will get an MRI for knee arthritis when they don’t actually need that. So they waited for the MRI, they’ve got the MRI and it’s not useful to the orthopedic surgeon to make a decision about surgery.

A patient enters one of many different and unorganized queues. Some are going to be longer, some are going to be shorter. But we can’t optimize it. We don’t have a streamlined process to get patients to the right place at the right time.

Q: People outside of healthcare are stunned when they find out how much fax is used in medicine but many clinicians still see a lot of value in the fax. What’s your take?

I actually did my master’s thesis on the referral and, as part of it, looked at the fax machine versus electronic referral. I will say, the fax has set the bar despite it’s tremendous challenges. It works 99% of the time. It gets the clinician sort-of the information needed in a way that fits in with the rest of their clinic workflow.

So clinicians are hard-pressed to give up the fax if the replacement isn’t as good or better. (But) I think we need to remember a few things: Patients don’t have fax machines, so they’re never part of that loop with the clinicians. And, as we’ve seen with COVID-19, people are not always able to get into their offices. The fax doesn’t integrate nicely with other information systems.

But if you’re going to “axe the fax” you need an alternative, not only for the referral part—that integrates the patient demographic and history—but also for other parts: the hospital discharge reports, the prescriptions, the reports for exceptional access programs. Everything comes in the same way. So I think clinicians are concerned and say, “Well, you’re going to digitize one part of it, but what about the rest?”

We have the technology—and I can speak for Ontario today—that exists to digitize each and every one of these processes. It is just about the collective will. You need to understand what clinicians need, what patients need, and put together a case for change. It has to be like the “Quadruple Aim”: improve the patient experience, improve the provider experience, support the population (by decreasing wait times) and provide value for money.

Q: And you’re working on that at the eHealth Centre of Excellence?

When we digitized our work, we made sure we built in these different components. We capture patient experience metrics about the referral process. We’ve had over 5,000 patients share their experience. Providers are also able to share their experience and guide the development of the technology. There have been hundreds of features that have been added because of this feedback.

We’ve built decision support into the system that says, “Hey, do you really want to order that MRI? Do you know you don’t need that MRI to refer to an orthopedic surgeon?” And we’ve reduced referrals for unnecessary MRIs by 12%, which will actually save the province about $11 million. Not only does that take people out of the queue who don’t need the service, but that money can go towards decreasing the waitlist for MRIs. Plus wait times are published in real time online. We’ve reduced orthopedic referrals by 52 days.

The eHealth Centre of Excellence was responsible for what’s now a provincial initiative called eServices, which is expanding in Ontario. It’s looking to incorporate all these different perspectives, digitize the referral process, and do so in a way that makes sense for patients and providers. So we at the eHealth Centre of Excellence have partnered with another centre of excellence in the province, the Ontario eConsult Centre of Excellence, to look at how eConsult and eReferral work together.

Q: Can you remind me: What’s the difference between eReferral and eConsult?

An eConsult is where one provider asks another for advice. So I have a patient with a mole, I take a picture and I send it to another provider asking: “Is this worrisome? Should I remove it?” That other provider just gives you the advice back: “Yes. I think it’s worrisome. You should do this type of excision and send it off.” Or I have a question for an endocrinologist about a blood value that was off. “This is the medication they’re on, should I make any changes?” And they give an answer back. We’ve seen tremendous uptake in Ontario and the pandemic has certainly increased the use of that.

An eReferral is when you transfer care to another provider. You might imagine they’re part of the same continuum. When I’m asking for specialist advice, in some cases they may say, “Well, I actually need to see this patient.” That eConsult turns into an eReferral. In the other case where you send an eReferral, they might say, “I can actually give you some advice so the patient doesn’t have to come to see me. Try this first and then let me know.”

Q: OK, and how do eConsult and eReferral work effectively together?

That’s the task that we’re at in Ontario: how to combine these things. If I’m sending a referral and I get a consult back, what does that mean for the provider who’s sending it? What does that mean for the patient who was expecting to see another provider?

We’ve just started to integrate certain features into the EMR on both ends—for the sending provider and the receiving provider. So if I send a referral to a cardiologist, instead of seeing the patient they say, “I can give you some advice on that” and it becomes an eConsult and is integrated in the EMR. That may happen in about 20%-30% of cases now.

Q: Isn’t the personal connection—among doctors, as well as between doctors and patients—more important in referrals than anything a centralized electronic referral system can provide?

The personal connection is important. I think if there are two doctors who trust each other, we still need to facilitate the referral and the ability both for patients and providers to make choices. So patients may say: “Hey, this person did my left knee. I want this person to do my right knee,” rather than being automatically directed to the surgeon with the shortest queue. So I think that that is still an important thing to facilitate. But it’s within the broader context of “I might really like this person, but their wait is 10 months and this other person is two months.” Also geography: “Oh, this person, I can get an MRI and it’s 45 minutes away, but the wait isn’t as long as an MRI that’s 10 minutes away.” So once you know that, you have a conversation about it.

Plus people change practices. The other day I got a new practice announcement for a specialist. You don’t remember those things all the time, right? There needs to be a place where you can access that information. Previously, a lot more clinicians, you bumped into the person in the hospital, you got chats in the corridor, it doesn’t happen as much anymore—

The doctors’ lounge is gone.

Yes, that’s right. So can we create a virtual lounge? A virtual way for people to connect, but also bring in other information. “What’s the wait time?”, “What are their sub-specialties?” There’s time wasted when you send someone a referral and the response is, “Oh, I don’t do hands. This person does hands. I do shoulders.” So how do you facilitate full awareness of what is available, what other people do, etc.? Things like: “Does the provider do virtual visits as well?”

The centralization of intakes is another thing—does something go to a central spot and then get referred out? Now, I think there’s a misconception that this eliminates patient choice. It doesn’t. Orthopedics has central intakes for most of Ontario but it allows for patient choice in terms of geography and surgeon. For people who just want the fastest surgery or assessment, it facilitates that. So we’ve actually done this as eReferral now; it goes to one spot. The patient is sent to an assessment centre to see an advanced practice physiotherapist and he or she is assessed. Then it is sent to the orthopedic surgeon, if they need surgery, they’re booked in for surgery. All of that is digitized. So you have full awareness as the patient: “Oh, I’m going here. This is the next step.” The primary care provider, whoever referred you, has the same understanding of where you are in that trajectory. So they can help you along that pathway. Gone are the days where (the process is a) black box and you’ll hear in eight months.

(This system) allows us to monitor for the bottlenecks. You can take the queue and refine it further based on patient needs because it’s digitized and manage it remotely versus on 20 fax machines in 20 different places. It’s really hard to switch and during the pandemic, the switch becomes harder. What if there’s an outbreak somewhere? What happens to all those patients? Do they stay in that queue until that outbreak is clear? Or can they move through, ethically, between organizations and specialists to a different queue?

Q: Why did you get into referrals as an area to focus on?

I’ve always been interested in digital health and referrals are a wicked problem, meaning there are many different factors that are part of it and we’ve been struggling with it for a long time. Still, there are jurisdictions that have made the declarations like, “We’re only doing eReferral after x date.” To me, the solutions are there, we have the ability to solve this problem, but it needs a collective effort.

It seemed like an area that, although difficult, there was lots of opportunity and potential. Electronic referral, done right, is 30% more efficient on the sending end and 50% to 90% more efficient on the receiving end and—

Q: Wait—you know that from surveys you’ve done?

Yeah. We’ve surveyed clinicians and conducted time studies. Even the processing time at central intake is reduced by 35 days when you do something electronically. After you’ve done that sort of assessment, then you think, “Well, that’s time that can be freed up to do other things; things that can support the referral process in a different way or support patients in a different way.” There’s untapped potential.

We’ve seen it in other jurisdictions—in the U.K., in parts of the U.S., like in San Francisco—where they’ve benefited from the same approach. So why not here? And why not now? We have long wait lists because of COVID-19. It’s actually a great time to say: “We want to move forward on this.”

Q: Put your science fiction hat on: What could the referral process look like?

I would love for patients to have a personal health record where they could go and see the services that best fit them for the ailments they have. Like when you go on Amazon it tells you you’re going to buy this next. Patients would be able, for example, to put their knee osteoarthritis on a pain scale and it would say, “Your arthritis seems worse. Have you tried this physiotherapy? Have you tried these exercises?” or “You have an option to get an injection” or “You would probably benefit from a referral. You should connect with your provider.”

And then on the provider end, they have similar decision support. So we’ve done 130,000 eReferrals already. You’ve got a ton of data to sort. It would be great if clinicians were presented with the optimal path for this patient that minimizes wait time, increases their wellbeing and decreases pain. For example, for the osteoarthritis patient, they would usually get an injection first then, if it doesn’t work, go to see the orthopedic surgeon. But maybe the provider could get a prompt that says, “Patients like this benefit from bracing and so, hey, there’s a place that prints 3D printed braces that are customized for that patient.”

It’d be an intelligent system that routes patients to the right spot at the right time with full awareness of what they need. Say they need cognitive behavioural therapies, for example something that can be delivered by an AI chatbot. So they’re referred and the provider is going to watch their progress. If they need things to be accelerated or escalated to the next step, that’s going to happen.

There’s going to be more self-management built in. Patients can book services themselves if they’re available in the community. And as their primary care provider, I would understand what services they’re accessing and understand what’s available so that if we need to take the next step, we could take the next step. It would be more coordinated so that they wouldn’t be seeing three different doctors who don’t know that they’re seeing the other person and maybe giving some conflicting advice.

We’re introducing other tools into our armamentarium because we can’t actually sustain things with our current system. We’ve talked a lot about challenges, but there is also lots of opportunity. The vision I painted doesn’t have to be that far away.

This item originally appeared in the September issue of the Medical Post magazine.