The Web Offers Hope to Fix the Wait-time Crisis
DOCTORS TEND to be a confident bunch. Take the experienced family physician in Nanaimo, B.C., who said he didn't see why his patients would need to use the province's new website that reveals detailed information on wait times for surgery. He already knew all about the backlogs - if a patient needed, say, a hip replacement, it didn't matter much which specialist got the referral. "The bottlenecks are at the hospitals, so they all have months-long waits," he said. But since he'd been asked, he clicked his way to the B.C. site's table for his corner of Vancouver Island. It turned out that of five nearby orthopaedic surgeons, the busiest had 82 patients in his queue, with a 96-week median wait. But the least busy specialist, a relative newcomer to the region, had just six patients waiting for artificial hips, and the median wait to go under his knife was 23 weeks. The surprised GP admitted that his patients just might want to know about the big difference.
Or consider another veteran family doctor, this one in Sault Ste. Marie, Ont., who couldn't imagine he'd have much use for the pioneering wait-times site maintained by the Cardiac Care Network of Ontario. If his patients need angioplasty, for instance, he sends them to a Sudbury HOSPITAL, where he knows the procedure is done reasonably promptly. Why shop around? But, again, since the question had come up, the doctor googled the network and found the site. In a matter of minutes he was looking at a table that shows the median wait for angioplasty in Sudbury is 13 days, while the wait at a suburban Toronto hospital, about four hours' drive further away, is just two days. Worth keeping in mind - especially if you take into account a recent survey conducted by the network that found one in five Ontario heart patients is willing to consider travelling far from home to get quicker care.
Hearing these stories sets off Dr. Alan Hudson, the neurosurgeon who heads the Ontario government's strategy for shrinking wait times. "That's classic! They don't know what they don't know," he says. "And these are probably very good docs. You can see how hard it is to change things." Most physicians routinely refer patients to the specialists they know best, Hudson says, which means the workloads of in-demand surgeons often reflect mainly their web of contacts with other doctors. But the physicians' personal networks have a powerful new rival: the INTERNET. Across Canada, websites are exposing the previously closed-off world of wait times to the scrutiny of anyone who knows how to manoeuvre a mouse. Hudson, not a man given to understatement, describes the idea behind these sites this way: "What we're trying to do is change the whole system of health care delivery."
In the political debate over what to do about long waits for health care, the focus is usually on front-line medical resources. Train more doctors and nurses, keep operating rooms open longer hours, add more hospital beds - these are the solutions that get the most attention. This fall, Ottawa and the provinces are also preoccupied with setting the benchmarks they've promised by Dec. 31 for how long Canadians should wait before receiving certain surgeries and scans. Officials admit it is doubtful they will lay out a full range of benchmarks by that key deadline. Often lost in the swirl of discussion on priorities, though, is the Net-delivered information that some see as the most democratic force for change.
This flood of new data is meant to tell patients what they need to know to take greater control of their own care. Being able to pinpoint where waits are shortest is expected to encourage them to move around more inside their provinces. And if the wait-tracking sites evolve to let easy comparisons be made among provinces, some doctors predict growing pressure from patients who want to travel to another province for treatment. As the rise of Internet wait-times disclosure shifts power to patients, it's also bound to keep the pressure on politicians and hospital administrators. "What the public is going to see initially is that the wait times are coming down," Hudson says. "If they ever start to go back up again, all hell is going to break loose."
The revolution hasn't arrived overnight. Ontario's cardiac network was born out of the late-1980s uproar over patients dying while waiting for heart surgery. Its website now tracks more than 75,000 procedures a year, showing, for instance, that from May to July this year, 67 per cent of emergency and urgent heart surgeries were done within the recommended wait of no longer than 14 days at Kingston General Hospital, compared with 93 per cent done within that two-week period at Toronto's University Health Network. Partly inspired by the Ontario cardiac care experiment, Saskatchewan launched a site in 2003 that details a wide range of surgical wait times, organized by specialty and region. Alberta's site arrived that same year, and has been beefed up since. Last month, B.C. unveiled a slick version of the concept, with a home page that features a picture of an articulated wooden artist's dummy, like the one on those TV ads for the pain reliever Robaxaset. Click on the label beside the body part that needs work, and the site opens to lists of surgeons who can do the job and their recent waiting times.
Nova Scotia jumped in just last week with its take on the concept. Provincial officials boasted that they are leading the country in terms of detailed information about access to diagnostic imaging, such as MRI and ultrasound scans. The Nova Scotia system also tracks how long it takes for a patient to see a cancer specialist after being referred by a regular doctor, along with details on the wait times for some surgeries. After two years planning the site, officials said they hope it inspires patients and their physicians to consider moving around the province for care.
While Nova Scotia is the smallest province to try putting wait times on the Web, giant Ontario is about to get into the game. Hudson said that later this month the province will unveil an Internet system that will bring together a massive amount of patient data from some 70 hospitals. It will offer easy-to-access information on the so-called Big Five list of priorities set by the Prime Minister and the premiers last fall - cutting wait times for cardiac and cancer surgeries, eye operations and joint replacements, along with diagnostic imaging. Patients who use the new Ontario site will be able, among other things, to select a health problem from a menu, type in a postal code, and see a list of the five closest hospitals that provide the needed procedure and the length of their wait times. The challenge is to take patient information from what Hudson calls "152 IT cottage industries" at hospitals and clinics and consolidate it on one information technology system.
Doctors may have to be more open with patients who know much more about the state of the waits. "We're in the early days of a new mentality," says Dr. Eric Cohen, a Toronto cardiologist and the Cardiac Care Network's medical officer. "There has to be a higher level of disclosure to patients about what wait times are, what acceptable wait times are, and what some of the options are if those acceptable wait times can't be met." According to Cohen, not only should doctors tell patients how quickly they need treatment, they should also be explicit about the level of risk they face - something that's not always happening now. "It's certainly our suspicion that many patients are not aware of how their physician would classify their level of urgency," he says. "We believe there could be more communication between the referring physician, the hospital or physician that's providing the invasive procedure, and the patient, about their estimated level of urgency and their recommended wait time."
One problem with the wait-time sites is that it's hard to make neat comparisons among them. Alberta and B.C. let patients find out the wait times of surgeons by name, while Saskatchewan, Ontario and Nova Scotia provide information only down to the level of the hospital or district. And there are key philosophical differences in the approach to stating how quickly surgery and other procedures should happen. Ontario's cardiac network, for instance, has its precise recommended wait times for a range of heart cases, but the Saskatchewan Surgical Care Network lays out just three targets for all types of care - within 24 hours for the top priority cases, three to six weeks for those rated as urgent, and a sweeping "more than six weeks" for elective ones. Saskatchewan Health Minister John Nilson says that's better than any other province. "Right now we are the only province that has our indicators, our benchmarks, our targets, out there," he says. "As each of us work with this, we'll end up with common benchmarks across the country."
But how will that move to common standards happen? In the September 2004 health accord they signed with Prime Minister Paul Martin, the premiers promised to "establish comparable indicators of access to health care professionals, diagnostic and treatment procedures, with a report to their citizens to be developed by all jurisdictions by Dec. 31, 2005." Critics say that while provinces are separately making progress, it's hard to see much sign of coordination. "Every province is doing work," says Dr. Ruth Collins-Nakai, an Edmonton pediatric cardiologist and the Canadian Medical Association's president. "But there's no national or interprovincial progress. We don't have common indicators to be able to compare from province to province." The case for moving many more patients between provinces for faster care - a reform Collins-Nakai says is key to managing wait times - would be easier to make if straightforward comparisons could be made among provincial wait lists.
While critics point out the shortcomings of what's being put on the new sites so far, enthusiasts are looking ahead to much more information coming online in the future. "The wait times are just the beginning," Hudson says. "What will eventually happen is that you'll know the infection rates for each hospital, you'll know the readmission rates for each hospital, you'll know the outcome rates for each hospital. Wait time is only one dial on the dashboard - you need the whole dashboard." If he's right, patients who have felt like mere passengers in the health care system might soon be turning into drivers.
HOW TO BE AN INFORMED PATIENT
B.C.: www.healthservices.gov.bc.ca (click on Surgical Wait Times)
Alberta: www.health.gov.ab.ca (click on Initiatives and then Wait List Registry)
Saskatchewan: www.sasksurgery.ca (click on Wait Time Information)
Ontario: www.ccn.on.ca (click on waiting lists question)
Nova Scotia: www.gov.ns.ca/health (click on Wait Times)
See also HEALTH POLICY.
Maclean's October 17, 2005