The Fixing Health Care series presents 10 common problems faced by patients in Canada, along with 10 solutions that the authors argue can be achieved within our existing publicly funded health system. While the ‘problem’ scenarios in the series are fictional, the authors offer these examples to echo the patient experiences they have encountered through their work in health care and social services.
The Problem: Wait times to see a specialist were bad before COVID and are worse now
Meera has suffered from headaches since she was a child. Sometimes, the frequency is as high as one a day. Recently, the headaches have been getting worse and she has trouble getting out of bed.
Meera saw her family doctor, who referred her to a neurologist headache specialist. After three months, she had heard nothing, and the headaches were getting worse. She checked back in with her family doctor, who said that a fax had been sent to the neurologist; he showed her a copy of it in her chart. The doctor said it can take a long time to see a specialist, and that she should go home and wait.
Three months later, still waiting to see a specialist, Meera had a headache so terrible she had to go to the emergency room. After a long wait, the doctor told her she had a migraine, and that she should definitely see a neurologist. Meera was so upset, she called the neurologist’s office herself, only to be told they hadn’t received a fax about her case. She called her family doctor and was told by reception that the office had a record of the fax on file, but that they would resend it to the neurologist anyway.
Six months after that – about a year after the first fax – Meera finally saw the neurologist. She confirmed the headaches were migraines and started her on some pills that have improved the situation.
Meera was still frustrated though – she had to wait a year to see the specialist, first because of a lost fax, and then a long wait list. What if she had had a brain tumour? And why are we still using fax machines, anyway?
The Fix: Canada must increase the use of digital referrals by doctors.
Stories about lengthy wait times for specialist health care appointments are pervasive in Canadian culture. Among 11 high-income countries, the Commonwealth Fund (an internationally recognized health care research foundation) ranked Canada’s health care system in 10th place in 2021 (ahead of only the United States), in part because of this very problem. In 2016, the foundation estimated that 56 per cent of Canadians were waiting more than a month to see a specialist, while the international average was 36 per cent.
Addressing this problem has proved to be quite difficult, however, in part because we have little-to-no current or complete big-picture data about how long Canadians are waiting to see health care specialists. At present, only patients who get surgery have their wait times monitored on a routine basis to assess our health care system. In other instances, we only have piecemeal information. For example, a 2018 analysis published in Healthcare Policy found a median wait time of 96 days to see a neurologist, 98 days to see an allergist and 112 days to see a dermatologist in Ontario, while a national study published in the journal Canadian Family Physician in 2020 assessed 2,060 specialist referrals made from 2014 to 2016 by primary-care doctors in seven provinces and one territory, and found a median wait time of 78 days. A comprehensive, national assessment of specialist wait times remains elusive.
Notwithstanding the lack of reliable data, there are two digital solutions that could improve backlogs in the specialist referral process and make access to care more reliable and cost-effective.
E-referrals and e-consultations allow patient information to be sent securely and directly to specialists using a variety of secure digital applications, without the need for handwritten doctors’ notes or faxes. Currently, there is no real incentive or legislative requirement for physicians and specialists to implement e-referral services or alter their fax-based systems. This needs to change.
In an e-consultation scenario, a family doctor sends a patient’s information, along with specific questions about potential testing and treatment, to a specialist. After reviewing this information, the specialist either provides advice directly to the family doctor or determines that an in-person appointment is needed. E-consultation tends to be very timely – in the case of the Ontario eConsult Program, the average response time is 48 hours.
If the patient requires a traditional face-to-face consultation, e-referral provides faster access by automatically sending the patient consultation request to the appropriate specialist who has the shortest waiting list (although patients do still have the option to request a specific specialist). This central, single-entry “triage” system reduces wait times and eliminates the need for paper and fax-based documents. In a 2020 study of orthopedic referrals in Ontario, e-referrals shortened the time a patient had to wait to see a specialist by a mean time of 21 days compared with patients referred via fax, who had to wait longer.
E-referral and e-consult systems not only make care faster and better, but they can also help us to better understand wait times, and the health system as a whole, by increasing our collection of digital data. Governments and ministries can gain valuable insight from the data provided by e-referral and e-consultation requests, allowing administrators to properly plan for health human resources where they’re needed most and eliminate bottlenecks.
The digital referral process also has the potential to be more cost-effective. One study of the impact of digital referrals in 2021 showed that MRI orders made by e-referral for knee investigations were 13 times more likely to be appropriate and necessary than faxed referrals. Unlike the faxes, the e-referrals enabled the use of an algorithm to determine whether an MRI was appropriate based on clinical guidelines. The study offers an exciting prospect – a reduction in unnecessary and expensive MRI testing could save provinces millions of dollars each year.
E-referral and e-consult have both started rolling out in several provinces, but the implementation of the technology has been slow across Canada, despite evidence that patients appreciate and support the use of these digital tools because they can track the status of their e-referrals through online portals.
Motivating primary-care providers and specialists to implement e-referral and e-consultation could be very straightforward. The first step would be for governments to mandate that any electronic medical record used in the province must interact seamlessly with e-referral and e-consultation systems. The second step would be to negotiate a deadline for when all physician consults must be requested by e-referral, or the specialist’s pay for the consultation will be discounted. After all, as our patient in the story recounted above, “Who uses faxes today, anyway?”
About the authors:
Dr. Robert Bell is professor emeritus in the Department of Surgery at the University of Toronto, former deputy minister of health for Ontario and former CEO of the University Health Network. Anne Golden is past president of the United Way of Greater Toronto and the Conference Board of Canada. Paul Alofs is former CEO of the Princess Margaret Cancer Foundation. Lionel Robins is past chair of the Princess Margaret Cancer Foundation, and a board member for the United Jewish Appeal Federation and the Betel Senior Centre.
More from the Fixing Health Care series:
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