Continuity of Care – General Consultation (Discussion Page) – Closed
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Hello, and thanks for inviting comment on this draft policy.
My concern relates to the transition of care policy, and in particular that of referrals. There are many problems with referrals, and this new policy is a chance to truly make meaningful change.
The draft states “referring physicians must make referrals in writing and must take reasonable steps to confirm that the referral is within the scope of practice of the physician to whom they intend to refer”
This needs a lot more clarification. I specifically suggest:
1) referral must be legible
2) referral must contain enough information for the accepting physician to triage the case priority
3) referrals of an urgent nature should be made via direct communication in addition to writing, according to the judgement of the referring physician
Some referrals I get say “nose problems”, which is inadequate to make a judgement call, especially if the “nose problem” ends up unexpectedly being a tumor.
This new policy should have wording in place to ensure that the referring doctor is aware of their professional responsibility to provide the specialist with necessary information.
Looking forward to your comments.
Dear Team,
I have just had a chance to review the proposed policy and would like to strongly support the following :
210 Communicating with Patients
211 Referring physicians must communicate the estimated or actual appointment date and time to
212 the patient unless the consultant physician has indicated that they have already done so or
213 intend to do so.
This is in regard recent local policy implemented by a clinic in my region.
The statement below could be countered with the same sentiment “ due to high volume of admin tasks , our staff will not contact your patient ……” in a tit for tat response that leaves the patient abandoned.
With no rules to the road we will see bad behaviour and the patient will not have an accountable health professional managing their care.
I would like the CPSO to clearly define the responsibility of referring and consulting physicians with respect to communicating with patients.
I feel the draft policy, as is, does this and I support it.
While I also appreciate CPSO’s attempt to more clearly define responsibility of communicating appointment times, I disagree with there approach and your statements.
I would be interested to hear your rationale on why you feel that the responsibility of booking appointments for your clinic should be done by another clinics office administration (and the resources it takes for booking the appointment be paid out of another physician’s overhead costs).
If a consultant agrees to accept a consultation, and all the patients demographics/contact information were included in the referral, it is a waste of time (physician,staff) and resources (ie fax machine toner, paper, electricity) for the appointment time be faxed back to the primary care provider’s office advising them to notify the patient.
I think that these policies are overreaching and draconian. As a reasonable person, we as patients must accept some degree of responsibility for our care. Asking our doctors to be available 24/7 is ludicrous. What if they need a vacation? A small town doctor may not be able to find a replacement, should he then never be able to take time off? This will only serve to force doctors out of small towns. And as for having my doctor hold my hand to make sure I get a test done…. He has better things to do. If he tells me to get a test done after we talk about why I came to visit him, I sure am getting that test done. If I don’t, that’s on me and only me.
Finally we hear from someone who is logical in their thinking!
Why is this policy even drafted? is it politically motivated?
The expectations from this policy may be difficult to attain or enforce.
There are costs involved in after hour coverage, both human and financial. Also it seems there is more and more push to take pressure away duties from hospitals and ERs and put it on the back of individual physicians.
Once regulations become more burdensome and unrealistic, there will be less and less MDs willing to take on responsibilities. I vote against this policy all together
Hello,
I am interested if the policy will address a new behaviour I am encountering in my community specialty practice.
Essentially the previous workflow for the referral process has been to have a referral received for an issue.
We then agree to provide an appointment and send back an appointment time and date and specific information to prepare the patient for the visit. The primary care physician’s office ( the referring physician ) is responsible to contact the patient with this information.
The change in behaviour I am witnessing is a refusal by clinics to contact the patient with these details. They essentially have identified this is an administrative task and refuse to do it.
While I comprehend the concepts, I struggle to believe the interest of the patient is taking priority.
As a busy specialist office I feel the onus on communication with the patient stays with the referring physician until the patient physically shows up in consult in the office. Up to that time the duty of care resides with the physician who has billed for the care provided. I fail to see how the duty transfers to the specialist before they have seen the patient or been able to bill for the visit.
I am interested to hear if the College has recommendations on this point. Where does the duty lie?
I think it’s unproductive to imply that the interest of the patient would be any better served by the family doctor doing this task, or to say that being a “busy specialist” has anything to do with it – we’re all busy, and we all have an interest in the patient. Neither does who has billed for seeing the patient have anything to do with it – the fee we are paid (specialist and family physician) is already underpayment for our services.
You’ve hit the nail on the head that this is an administrative task. It would be just as simple to mail the information to the patient as to fax it to the referring physician, but would be more costly. The real problem is that neither the specialist’s office nor the family doctor’s office have enough time or resources to devote to this, so each of us hope the other will deal with it.
Family Doctors book their own appointments with patients they are intending to see.
Consultants should book their own appointments with patients they are intending to see.
I see no reason that the consultants office cannot contact the patient with the appointment date & time, provide instructions, rebook, give directions to office, order tests that they want prior to consultation.
Fee for referring a patient = $0
Fee to see patient in consultation: >$0
I think family doctors are just as busy as specialists: it is your office booking the appointment so it makes sense to contact the patient directly. Otherwise, there are extra layers of work created. We refer the patient, wait to hear back from the specialist’s office and then contact the patient. Wouldn’t it be just as easy for a specialist’s office who is booking the consult for their own practice to let the patient know the time as to fax it back to us?? Afterall, the specialist’s office is the one booking the appt for their office to see – it is their practice and business! We book patients for their appointments with us – it’s reasonable that other offices do the same.
Offices should book their own appointments! If you’re booking a patient in to bill for them, then book directly with the patient. It’s not fair to dump everything on family doctors – we’re expected to refer, follow the referral and make sure it’s given in a timely manner, inform the patient, then bug the specialist’s office for the referral note back – if I refer a patient to an office, I would expect that office to inform the patient of the appointment time.
Are you joking? This is why family doctors are fed up with specialists! I am sending you a patient and it is YOU who gets to bill for them! Included with my $30 visit fee is NOT 20 min of admin time doing the following: 1) faxing the initial referral 2) fielding 3 phone calls from the patient, “what is going on with my referral? I haven’t heard and it has been X days/weeks/months” 3) receiving the appointment FINALLY from the specialist 4) calling the patient (sometimes multiple times) until they answer the phone 5) explaining to them when their specialist appointment is 6) reminding them of the reason for their visit because that problem was so long ago they have forgotten about it 7) spelling out the doctor’s name, address, and giving driving directions
answering questions about what kind of doctor is this, what will he do, where did he train, etc. 9) hearing them say they can’t go that day for X/Y/Z reason, please change it 10) begin again at step one !!!!!!!!!
I am a family physician working in rural Ontario. I am very much concerned about the requirement to have a voicemail available both during and after office hours for patients to leave messages on. My concern is that if a patient leaves a message stating they are having chest pain that evening, suffers a major heart attack overnight, and I don’t get to that message until next morning, am I held liable for the poor outcome of the patient? Reverse that to the daytime – I can’t check messages until the end of the day and they call in the morning – am I liable as well since I’m in the office?
We have trialed a nursing voicemail where patients can leave messages for our nurse, and I would say 75 percent of the messages are completely inappropriate. I have patients who call back a number of times in a row once the voicemail cuts them off at the time limit, talking about their chronic pain condition which I had just seen them for earlier in the week and nothing has changed. I have family members (who are not my patients) of my cognitively competent elderly patients demanding things on the voicemail when the patients themselves do not want these things done. My nurse easily spent half an hour a day listening to these voicemails. We have since gotten rid of the machine as it is not a good use of her time. I do not think a voicemail machine will be a good use of my time and can open up a lot of legal difficulties for physicians.
I, too, am a family physician with a large rural practice in an underserved area. I already see patients 5 full days per week, and do an average of 3 hours of paperwork every night, and another 8-16 hours of paperwork, chart reviews, research and phone calls to patients every weekend. I am already stretched too thin and nearing burnout. I rarely see my own children.
Now you want patients to be able to reach me 24/7? Now I have to let patients leave voicemails 24/7 and I have to respond in a timely fashion?
I agree with the writer above that allowing patients to leave a voicemail about their chest pain, for example, creates a huge liability, and more importantly, a risk to patient safety. What if they leave that message on a Friday night, and they do not go to emerge when their chest pain gets worse because they are waiting for me to call them back?
If patients could leave voicemails 24/7, I would have to hire another support person (and I already employ 5 people — imagine my overhead) just to listen to all the voicemails, review them with me, and then call people back. I would have less time to actually see patients, and no one wants that.
The number of people who call during our regular clinic hours and “just want to talk with the doctor for 2 minutes” is already overwhelming, and of course it is never just two minutes. My assistants do a great job of triaging patients’ concerns, determining who needs an appointment when, providing a sympathetic ear to the socially isolated, and politely deflecting unreasonable demands. No voicemail can replace that thoughtful dynamic.
Push me further, CPSO, and there will be another 2400 patients without a family doctor.
Please re-consider putting the onus of notifying a patient about a specialist appointment on the referring family physician. Family physicians have enough responsibilities downloaded on them. In addition, it is redundant to have the family physician notify the patient of the appointment and the specialist also notify them of any information pertinent to their appointment,
Thanks for your consideration.
To whom it may concern,
I am a Family Doctor based in Ottawa.
I am very disappointed that the College is recommending that the referring doctor (mainly family doctors) be responsible for notifying the patient regarding appointment time and date with the consultant. This puts a huge extra load on our staff and creates more opportunity for lost information – a prime example is when the patient cannot make that appointment and then they are playing phone tag between us and the specialist. More no shows happen with frustration on all sides. It is also very redundant to ask this when the specialist office still has to contact patient with details of appointment prep! This kind of redundancy will only lead to more falling through the cracks. The specialists’ staff should absolutely be responsible for conveying instructions for the appointment but it only makes sense to pass along the date and time at same time.
Additonally this is another big burden off unpaid work being shuffled to Family Doctors. Our work is primarily office based with a very high overhead as it is. This cost that comes out of our income is critical to the infrastructure of primary care in Ontario. It is unfair to load the consultant secretarial work onto us and our staff. It’s no wonder more family docs are burning out and leaving general office practice for focused and hospital based practices.
Thank-you.
I don’t believe that asking the referring physician to inform the patient of their specialist appointment is not very patient centred in addition to being a tremendous administrative burden to already overburdened family doctor’s offices. How does it make sense to ask the referring doctor’s office to explain where the specialist office is, where to park, how to prepare for the appt when it is not their office? They are not equipped to answer any patient questions about the appointment and if the time provided to the patient does not work, they are unable to reschedule and then have to act as an intermediary
Totally agree-as a specialist, I prefer to deal directly with the patient to book an appt. Leaving it to the referring doctor is a recipe for NO SHOWS and telephone tag. Ironically, when I refer a patient as a specialist to another specialist, my referral letter indicates in BOLD 36 POINT TYPE that the patient should be contacted directly with the appt. details. Unfortunately, virtually no one follows my direct instructions on this point.
Is the intent of the policy for the referring physician to inform the patient of specialist appointment to create even more administrative burden on family doctors and drive more family doctors out of practice? Shouldn’t all doctors be responsible for booking their own appointments and how is it patient centred to give a patient an appointment time with no opportunity to say that it is inconvenient (without having to call a second office and the inconvenience that entails)?
Hello,
Feedback re: communication of specialist apts. I’m appalled, frankly, that this requires feedback. As a family MD, we area happy to continue being responsible for the patient until a consultant can see them. We are simply asking that specialists call patients directly to book these appointments. Rescheduling cannot be undertaken via family med clinics, and the consulting clinic needs to advise the patient of instructions. Asking a family medicine MOA to relay information is an abuse of our human resources, This should not even be considered as an option. Specialists can book their own appointments with patients, just as I do. I am happy to be responsible for the patient until they are seen. I am not happy to coddle specialists or do their administrative work.
I do not remember in médical school the lecture on “How Family Doctors need to be the secretary for Specialists”
I call it downloading of responsibilities. Family Doctors are already burdened with high overhead costs. While thèse costs are the same for specialists in private clinics, many spécialists incur NO overhead costs when they work in outpatient clinics in hospitals.The fairness of this baffles me.
Furthermore, there is no financial compensation for thèse tasks for the Referring Physician while the spécialist Physician gets the entire fee.
We have had specialists tell us we must explain their $200 no show fee to the patient.
The correct procédure in my view is:
The Referring MD sends all the required information to the specialist.
The specialist contacts the patient with ALL the details and explains his/her policies.
The specialist sends communication to the Referring Physician that he/she has received the consult request and, either will contact the patient or notifies us of the date of the consult.
The specialist arranges any further testing( if needed) directly with the patient. Again, we should not be seen as the clerks/secretaries for specialists.Everybody is just as busy.
The specialist sends an appropriate legible consultation report in a timely manner. We often have to run after thèse and this puts the patient at risk.
Finally one last point and this may be politically incorrect. I have heard that the CPSO is run by mostly spécialists. We can only hope this has not created a bias and that they will make fair decisions.
So while the government keeps lowering and destabilizing the fees for physician services, the CPSO ups the standards expected for those services.
The atmosphere of practicing medicine in this province is made so unstable by ever changing remuneration and policies.
What other profession do you know of where the compensation keeps getting less while the standard keeps getting put up? all with the threat that if you don’t comply, you’ll get punished by never working again and having your name shamed on the internet for years to come even after you leave the profession.
really?
you want to impose all these new duties on physicians who are expected to do them free of charge?
Response in PDF format.
Well written, thank you.
I second this! I fully support your well articulated argument.
I could not agree more! Thank you for outlining so clearly the problems with the proposal for the referring physician to be responsible for notifying patients of an upcoming appointment, and the inconsistency with other policies.
It is so draconian and counterproductive for the CPSO to put the entire responsibility of communication upon doctors. It is perhaps politically convenient for the College to do so to keep its status, but very counterproductive for physicians most of whom have already lost faith in the College as a fair regulator.
Having worked in addiction medicine for 10 year, I could tell you less than 3/4 of the patient keep a valid phone number or address.
We often have no way of getting hold of them.
An adult patient needs to take some responsibility for their life and health. This politically charged mantra that patients are all victims and their troubles are all someone else’s fault is not healthy and does not help health outcomes in the end.
In your policy you need to put patients are responsible for maintaining a way their doctor can communicate with them.
I cannot believe how unrealistic and draconian this draft policy is, especially in regards to how much responsibility it downloads onto physicians who are already stretched thin. Patients are one half of the physician-patient relationship and should therefore be equally accountable for their own health-care related decisions and actions. Blaming and burdening physicians when patients are unwilling to share this responsibility will not ultimately improve their health outcomes.
Please also respect physicians as human beings who do not have access to unlimited financial and administrative resources, and who cannot work 24/7 even when trying their best. No such unrealistic expectations are placed on any other professionals.
This policy, if implemented as is, will drive physicians elsewhere or cause increased burnout. That would be ultimately counterproductive to patient interest and well-being.
Please think really hard and do the right thing for the future sustainability of healthcare in this province. Don’t be short-sighted and play ‘politically correct/popular’ at the expense of physician and patient well being.
I could not have said it better myself. The policy is insulting, over-reaching and reeks of being drafted by those who have never worked a day in front line care. If implemented as is I cannot see myself staying in the province and if I leave I will be sure to inform every patient of exactly why I left and who (CPSO) they can blame.
Thank you for the opportunity to comment and for implementing an extended consultation period. I have a small number of comments.
The requirement for a written referral in the transitions of care document should not apply to the Emergency Department or any inpatient hospital setting, where consultations are uniformly requested by direct telephone communication with the consultant or a trainee on the consultant’s team. The requirement for a subsequent written referral will not accomplish anything other than to reliably waste the referring physician’s time. (For example if I am resuscitating a patient in the Emergency Department, should I fax a referral to the ICU or should I attend to the patient?)
In the ‘Continuity of Care’ document, the section on availability by telephone is not relevant to many hospital-based physician who do not have offices, e.g. those that work in Emergency Departments, intensive care units, operating rooms (anesthesiologists and surgeons who primarily provide after-hours emergency coverage), or inpatient wards. Such persons are directly and immediately available by mobile phone or by pager in their time on duty, with no expectation of availability after transfer of care.
I suggest that throughout these documents that the term ‘emergency room’ be replace with the commonly accepted term ‘Emergency Department’.
Talk about opening a hornets nest. Voicemail for instance. As a doctor has already mentioned pts leave all sorts of stuff on voicemail that is a total waste of time. If the expectation is if they leave it on voicemail we are expected to act upon it it will become a major time sink. Many family doctor offices feel like they are under siege when the phones are answered. That’s why they do stuff like only answer phones between 10-12 and 2-4 for instance. If there is a dispute about if a voicemail was dealt with how will that happen? Will docs be expected to archive their voicemails? How about this. Fix the doctor shortage and the practice environment such that doctors are competing for patients. Then those that provide good service get the patients. It has already been acknowledged that the CPSO is a major contributer to physician stress. Many docs I know won’t take on new patients because if they turn out to be unreasonable you cannot fire them without worrying about a complaint to the CPSO. And then we wonder why patients cannot get family doctors.
Having just reviewed the draft polices and done the on-line survey, I wanted to convey my concerns to you directly.
Regarding the Availability and Managing Tests Policies:
I believe that the draft recommendations for after hour and vacation test and care requirements are substantially over burdening and frankly insurmountable in some circumstances. I am referring to solo primary care docs not in a call group at present who live in a small community with established patterns of after hours care such as a walk-in clinic or ER department.
My other concern is the lack of mention of a patient’s responsibility to comply with an ordered investigation. Should a doc be entirely responsible to ensure and/or document compliance? I don’t think so. For tests done and reported, I do agree with a higher level of expectation.
These policies seem to excessively down load responsibility onto docs. I would suggest a more balanced approach,
Thanks
Without addressing any of the merits (or lack thereof) of these policies, I’d like to point out that the section regarding availability by phone states that “physicians must have … a voicemail that allows messages to be left outside of operating hours”. This makes no allowance for those of us who use a “live person” answering service. Surely you can’t mean that voicemail is the only acceptable option after-hours.
This policy is ridiculous.
Patient has to take at least some minimal responsibility, why their health is entirely physicians responsibility?
Almost anything coming from the CPSO lately is lacking common sense. While we are getting paid less and less CPSO expecting from us more. Two thumbs down to these policies and the whole institution of CPSO!
Think Specialist doctors need to be more forceful in denying continuing appointments to patients that no longer need their care and could be followed by a family physician. Would free up appointments for patients on waiting lists to see a specialist.
As another poster mentioned. I work in addiction medicine. Most of the patients in an addiction or methadone clinic don’t keep a constant address, or phone number. At any one time, we are not able to get hold of 75% of them. They get new phone numbers faster than they get haircuts.
Even worse, they generally do not do medical tests ordered by a physician. We have only a 20% compliance rate with blood tests.
I think in your policy, you have to allow for patients’ responsibility. Most patients, even addicted ones, are not our children. Patients are independent autonomous persons who are able to make their own decisions. With autonomy, also comes responsibility.
What you are unloading to us with this policy, is almost like parental duties for patients.
I 100 percent agree. I also work in the addiction field and it is a miracle if anyone follows through with recommendations and bloodwork regardless of how many times I remind them. Plus they often don’t have a valid phone numbers intact info. To say I am now responsible for ensuring they get their tests done is absurd. What happened to patient responsibility? You wonder why every physician I know wishes they never went into medicine. Patients are responsible for following through on tests and it is ridiculous to hold the doctor responsible for the patient’s lack of action.
Availability and Coverage of Care
In the Wasaga Beach area there are not a lot of options for specialist care and Toronto is too far away especially for seniors. Also, extended health coverage for seniors would be appropriate given seniors are in the age bracket where falls and other medical events are more common. Even middle income seniors cannot afford physiotherapy, dental, and other services that are not covered. We are suffering and no-one is listening.
These are 2 areas in the draft policy that I do not agree with:
Informing patients of appointment time & date – this should be the administrative task of the consultant physician NOT the referring physician. Family Physicians are responsible for booking their own office appointments, so then why is there a different expectation for a consulting physician? The usual response to a non-emergent/urgent notification of an appointment date & time is either ” that day & time do not work and I need to reschedule” or ” can you give me directions to their office”. Family Physicians should not be expected to provide administrative support for consultants.
After-hours care & messages: Family Physicians in capitated models did provide an on-call service through Telehealth as part of their negotiated agreement. Physicians could provide support to the telehealth nurse and/or the patient directly. This was a remunerated service that was unilaterally cut by the ON government to save money. It is reprehensible that the CPSO would now mandate this service while we are in binding arbitration with the government. This is a service that should be negotiated with the government including appropriate payment!
The Liberal government learnt that they can impose not just fee cuts, but also that they can extract free services from physicians by using the College as their henchman.
The College would do ‘anything’ to keep its “self-regulation” status? Who wouldn’t want to be self-regulated? which means no oversight of the College’s finances and books. No wonder CPSO is in top 100 employers of the GTA. Self-regulation keeps the gravy train coming.
24/7 coverage is not something that is reasonable or that most of us signed up for. We are promoting balance and healthy relationships with careers to our clients but doing the opposite for ourselves. I also feel we are stepping back in time from allowing our clients to take a healthy amount of responsibility for their health. Why should we be parenting them. Here is our advice and recommendations do what you want with it.
Every few months, CPSO comes out with another one of these bright policies. At what point, can you say you got enough policies and you can put it to rest for maybe a few years?
The great majority of other jurisdictions don’t have anything nearly close to this ever-increasing top-down draconian way of regulation.
The recent judge’s report was quite telling. The CPSO is referring more more physicians to disciplinary per capita than other provincial colleges and taking much longer with its investigations too.
You keep increasing our fees on the basis of more policy making and more and deeper investigations which you are creating more than the norm yourselves. It’s like circular logic. You create more investigation and more policies and justify your higher fees based on that!
We get it. For us physicians in Ontario, working and dealing with the College is like walking in a field of landmines. Any patient can now email a complaint to you which you love, because it increases work and hence justifies another fee hike.
We get it! We have already heeded the message and are searching other jurisdictions that are not so anti-physician and not so unpredictable always coming up with new ways to make our lives hell. We are also not investing and putting any money into our practices.
“Being Available by Telephone: Physicians must have an office telephone that is answered
7 and/or a voicemail that allows messages to be left during operating hours and a voicemail
8 that allows messages to be left outside of operating hours.”
Voicemail? You’ve got to be kidding.
Is that secure? Do we need these recorded? What is the expected response time to a voice mail? Can we bill OHIP for work responding to voice mail?
The patient face-to-face relationship is following by the wayside and we are slowly becoming customer service representatives.
Interesting the Province will fund Telehealth phone advisory service to the tune of 30 million per year, but refused to pay physicians for telephone advice. Meanwhile due to patient demand 3rd party telephone advisory services are billing patient direct for “Mobile app encounters” and those services are exploding across Ontario and beyond. While the lack of funding is not the CPSO’s fault, they need to hold back on this policy until they understand the impact upon overworked, over burdened physicians that cannot possibly provide the coverage expected by the CPSO everyday, every hour. WE will see medical legal Armageddon if this policy goes in place, complaints will sky-rocket due to increased demands by patients and need for ease of access of care, and physicians will be bound by lack of funding for their time to provide this care and increased admin time upon their offices. The only good thing will be the increase opportunity for 3rd party work for experts for the CMPA…there will be no shortage of work in the complaints dept. !
I have two concerns
1. Referring doctors are responsible for contacting the patient with the date and time of the appointment.
I am a specialist with a high volume of patients. I prefer to contact the patients myself (my secretary) because I don’t like no-shows and we have a email/text/mail/phone system based on patient preference in place that has decreased the rate of no-shows. I don’t like relying on someone else (another busy family MD) to ensure that I don’t have any no-shows.
2. Having a voicemail that accepts messages 24-7. I prefer not to have patients leave voicemails. If it is an emergency they should go to the ER. If it is urgent they can access a walk-in clinic. Otherwise, they can contact my receptionist who will triage my calls for me. Leaving messages is both dangerous and inefficient.
Office manager of family practice and walk -in. Would like to be kept informed of challenges or changes that impact the practice.
Please include in the policy a statement to the effect that physicians’ answering machine messages need not begin with “If you are having a life-threatening emergency, please hang up and dial 911.” These messages are useless and just waste everybody’s time.
With respect to 24 hour coverage, this is not feasible. I like the idea someone suggested re having physician support of telehealth, but this needs to be worked out with the Ontario government. The policy as it is can not be seriously considered with the financial and resource drought we are currently in.
The requirement to ensure lab results are carried out is paternalistic. I understand results need to be reviewed and all efforts are made to do so, but to ensure patients carry out tests is impossible. Even confirming appointments, most people do not answer and many do not have voicemail. How on earth could we track down each patient who didn’t complete potentially important tests? Every test potentially could show a life threatening condition and patients have to bear some responsibility to at least perform the test. I ask that you strongly consider rescinding this policy before it comes into effect.
I can see the merit in trying to improve care in Ontario, but putting this burden on physicians will not results in any improvement in patient care. Truly there needs to be more communication and resources provided by the government to coordinate this, as all this does is chase physicians from the province, and possibly from clinical medicine. Thank you for the time and opportunity to comment.
Hello,
I am writing today to provide my feedback on the Continuity of Care Draft Policy.
In general, I agree that the CPSO does have a role to play to ensure that physicians are meeting the standards of continuity for their patients, to ensure that appropriate follow-up occurs, and to practice good communication with other providers.
That being said, I do have concerns about the following specific policy proposals:
1) Availability and Coverage – Being available by telephone. I believe this section has more to do with office management than it does with patient care. I believe the CPSO is in place to ensure that physicians practice safely and wisely, not to ensure that we are everything to everyone at all times. I do not believe it is helpful to have a voicemail system in an office setting where phones are often ringing all throughout the day. It is not feasible to be checking messages while also answering the phone. We do not have expectations for people to be able to leave messages with government offices or telecommunications providers, and I do not think it is reasonable to expect this from physicians. Moreover, offering an after-hours voicemail to patients who may leave detailed messages about urgent issues will raise liability concerns if these issues are not addressed immediately, and the nebulous question of reasonableness of response time will haunt us. In general, if a after-hours message clearly states the usual office hours and the appropriate time to call back, I think that is sufficient, albeit not the most convenient, for patient care.
2) Availability and Coverage – Facilitating Access to Appointments. I think the example references on lines 64 and 65 should be removed – they are too specific to be included in a Policy this broad.
3) Managing Tests. Although it would seem obvious that any physician ordering a test is responsible for the follow-up investigation or treatment of abnormal tests, it is often the case that a Consultant physician will discover an unanticipated/incidental abnormality in the course of clinical investigation and refer the issue back to the Referring physician for management. I believe the policy should include advice to the contrary.
4) Walk-in Clinics – Coordinating with Other Health-Care Providers. I suggest that a timeline for provision of a report to the primary care provider be included in the document.
Thank you for your consideration. Please do not hesitate to contact me with any questions or concerns
Regarding the continuity of care proposal;
-If it is desirable and manageable (which it is not) to have doctors available 24/7, then this should be funded adequately and doctors compensated generously for yet another encroachment on our personal freedoms. No more uncompensated work.
-Managing tests and following results is only realistic if all providers have access to a provincial registry of test results for all patients in Ontario. Failing that, this is likely impossible. Many hospitals and some lab companies do not provide readily accessible digital results eg Joseph Brant Hospital. This must be mandated and implemented before you thrust new responsibilities onto physicians. The government should be responsible for the creation and maintenance of this system but has been negligent in not providing this. Furthermore along this line it must be mandatory that all labs results must use the exact same names for tests so that physician EMR’s can adequately track the results over time.
-It is completely unreasonable to put the onus of verifying whether or not a patient has done an ordered test. Patients are wont to be non-compliant with test requisitions or get adverse health advice from pseudo medical ‘providers’ about testing. The physician cannot and must not be expected to police the compliance of patients. Patient responsibility is essential.
-The demand for contextual information on the test requisition is unreasonable in that it exposes confidential information about the patient that the patients may not want to be shared with lab tech staff. We have physicians to determine what testing is appropriate. If the objective is to provide information about the reason for ordering certain tests, then the government should provide a secure requisition that can be entered into the system by the providers EMR.
- I agree that walk-in clinics should make a reasonable effort to send a report to the primary provider, but in order to do this there must be a provincial register of all physicians including their contact information, fax number, e-mail address, or street address. This must be mandatory on the government to maintain and update.
-Demanding that patients who choose to not have a family physician, be covered comprehensively by a walk-in clinic is unreasonable. Many physicians who work in walk-in clinics do so to avoid the stress and responsibility of being a primary care provider and are often semi-retired. Imposing these responsibilities may compromise availability of physicians for this work.
-Walk-in clinics are often run by and for FHG and FHO groups to provide coverage for their patients. These groups need specific compensation for maintaining this service or they will likely withdraw service when Walk-ins are mandated to provide reports and follow up. I suggest a fee for using a walk-in clinic instead of a primary care provider.
-If a walk-in clinic Dr works to the closing time of the clinic, they should receive a per diem to maintain access for critical reports until the next Dr, starts the next day. No more uncompensated work.
These policies of requiring WIC to provide referrals for patients if needed or request even if the patient has a primary care provider will create a medical legal nightmare in Ontario. I work a FHG, after hours clinic and in addition provide coverage for a WIC in underserviced area in an Ontario urban center. While providing referral to patients orphaned, makes sense and helps patients in need of care, forcing referrals on WIC engaged with patients that have a Primary care provider, will only fragment primary care even further in Ontario. Within my community some specialists will NOT accept referral from WIC due to the confusion over MRP and follow up care.While I agree WIC cannot be relieved of duty of care, follow up on tests ordered and standard of care issues for quality, we do NOT want to further encourage patients seeking care outside of their primary care. What about patient first mandates with MOHLTC, is not the purpose of this mandate to IMPROVE patient care and care closer to home, patients need to be streamed to the BEST source of care, ie THEIR Primary Care, NOT more episodic encounters that are convenient. If the province funded primary care to allow GPS to bill for telephone advice or Telemed encounters, we would not have these issues as much with patients seeking care at WIC because they cannot get off work or the GP is “not available(which often translates to “not available when the patient wants them”)”
As I CMPA expert I would implore the CPSO to reconsider this policy. Forcing referral upon WIC will be disastrous to say the least. The CPSO is already inundated with Complaints and I guarantee these policies will increase the complaints committee workload ten-fold. A WIC cannot provide the quality of information needed to make a good referral, as they often do not have access to the patients chart (Primary care provider). Otherwise WIC will no doubt be forced to post “Referrals to specialists for elective care cannot be provided by this clinic.” and/or “This clinic cannot provide elective care to patients that already have a primary care provider.”
I have serious concerns about the aspects of policy where new adminstrative burden has been put on practicing physicians. These measures should be suggested only after resources have been provided to establish voicemails or after hour coverage. Shifting the responsibility entirely on physicians for getting the tests done is outrageous. If patient decides not to get test done, isn’t it invasion of their privacy to keep on bugging them. Physician resources are limited and it is responsibllity of entire community to utilize this precious resource appropriately. This undue administrative burden will be counter productive for patients health as it will lead to physician burn out , physicians retiring early, leaving province and ultimately discouraging future intend to be physicians to consider other career options. I urge college to make reasonable choices which are sustainable. Physicians want best health for their patients but if they are dissatisfied it will reflect in their work as physicians are humans too.
Thanks for getting input from us.
I think I will forward this input to the College if Physicians and Surgeons as well-known for the College too is seeking input
I have practiced for almost 40 years in Toronto -with almost 10years working in walk in Clinics.
Let me say clearly that I believe Family Practice as has been practiced traditionally is in demise. Family Physicians are feeling overwhelmed and seem to be struggling to have acquire minimum work load.
The brunt of the load of Family practjce is seems to be falling more and more, on the walk in clinic doctors like myself!
I could write a book on this subject!
I will keep it brief- forgive me for any spelling errors for I am typing on my cell phone.
So these are the kind of comments I hear from the poor,vulnerable patients who seem to be desperate to have a good Family Physician.
1.My doctor cannot give me an appointment even though I am suffering, until after 3 weeks!
I was told to go to a walk in clinic- or ER by the Secretary.
I ddid not want to wait in the ER.
So I came to this walk in clinic
2.My doctor suddenly closed the practice- and I was never informed.
3 My doctor has retired and I have been looking for 3 years to find some other doctors to take me as a patient
4 I have moved into the city and no doctor is taking new patients.
So then I often have the challenge of,
A. Trying to form a doctir- patient relationship at short notice-while trying to juggle to give priority to the most pressing problem for which the patient has come.
I can see desperation and feel empathy when I am being asked to deal with other pending chronic pending problems at the same time, because the Family Physician or the system has not had time to deal with them!
2 I have struggle to a semblance of Famy practice care- ordering tests, arranging follow ups with the Famy Physician, the specialist, the ER and often with myself.
This is when I get a distinct feeling and fear of being trapped as a regular Family doctor- a role which I FEEL TOO IMPOTENT TO ADOPT-AND WHICH I FEAR THE COLLEGE IS GOING TO THRUST UPON walk in doctors like myself!
I have much more to day-to-day this will suffice for now.
As a Family Physician who also does Walk-in Medicine, I am extremely concerned with the continued burdens placed on the physician and taking away any responsibility of the patient. When a patient is seen in the walk-in clinic it should be his/her responsibility to relay information to his/her own family doctor. When a test is ordered it should be the patient’s responsibility to ensure they follow up for the results.
Physicians have enough things to do already and should not be forced to continually baby patients. This is not what we were trained to do. This is not Medicine.
As a Walk-in physician, I should be appreciated as I along with others that staff walk-ins keep people out of the ER on a daily basis. We reduce the huge burden on local ERs. Instead of this appreciation, we will now be responsible for ensuring that records get the to the PCP? When and how will this be done? How many hours will this take? Who will pay me for these hours?
The CPSO continually strives to make itself relevant by conjuring up more red tape so the staff at the CPSO can ensure that they all have secure jobs for the future. Under the guise of better medical care, the College continues to put burdens on the physicians without any recourse.
Between the CPSO and the MOH, we physicians have no one to turn to.
We are constantly bombarded with threats from the CPSO whilst the MOH continues to limit our payments.
So very true: the present ER wait time in Ontario is ~7 hours (vs 7 minutes in the US), & this reckless policy will probably double it, as the security valve of WICs will be effectively paralyzed.
Hello and thanks for reading my feedback!
The policy goals are laudable but the implementation is disastrous.
The best solution is to use technology, implemented once, for the whole province, by the MOH. The CPSO should back off and allow other bodies such as the OMA and MOH to solve this issue. The current OHIP database contains most of the necessary information and the little bit of extra information that is needed to make a workable system can be provided by the doctors, willingly, after a few negotiations that include payment for administrative work. Sadly, provincial e-health initiatives have become notorious for failure and cost-overruns. Yet, this remains the best logical solution. It’s not a CPSO problem to solve.
The policies as proposed will result in a net harm to patients as physicians respond by changing the focus of their practices to avoid the most onerous requirements. Expect a shift in MD services toward care that is not ‘medically necessary’. The remuneration is outside of OHIP, so it pays better. The acuity is less, so the 24/7 provisions don’t apply and referrals are often not needed. Almost every specialty, including family practice, has an opportunity to provide this type of care (cosmetics, lumps & bumps, travel medicine etc). While this re-scoping may be a lifeline for the doctor, it further threatens an already stressed and dilapidated system of “medically necessary” care. We need to make mainstream medicine appealing and rewarding. This policy does neither.
Coordination with other health care providers
Physicians practising in walk in clinic cannot provide information back to the original family doctors all the time. This is a draconian step and there are multiple limitations and reasons for this.
Walk in clinics have limited time. Available time is short and they cannot track and ensure labs and other things can be sent without additional resources spent per patient. Even then there cannot be any way to confirm that information has reached the primary health care provider
There is not central system of knowing who the real family doctor is. Patients dont know the names( or exact names) of the doctors and often those doctors are not their family doctors any more
Record of encounter cannot be shared without additional consent and can lead to issues with family doctors knowing things patient never wanted them to know due to multiple situation like stigma, LGBTQ issues,
Providing record of encounter to all patients in walk in clinic should be paid in advance by the system, MOH, doctor or broader system
Absolutely right: this mandatory reporting is a huge attack on patient’s rights of Autonomy & Privacy.
My other concern is regarding Availablity of doctors 24 hours a day and 7 days a week
Most walk in clinics open for short hours, often doctor is a locum and sometimes flying out of province.
this should be at the doctors discretion to make judgement about the time line to respond.
Physician work in multiples places and do community work as outpatients.
this availability requirement cannot be put in place, is not practical and will doctors even more burdened
Providing comprehensive care to the patients
Walk in clinics cannot provide comprehensive family care to the patients. This simply defies the purpose and utility of Walk in clinics.
Its similar to saying that FD in ER should provide comprehensive care to the patient
College cannot expect to merge episodic care and continuous care under the hands of walk in clinics as there is clear limitation to patients history and patients test results and patients expectations as expressed in previous encounters
How can college expect a walk in doctor to provide comprehensive care
as he is not willing to do comprehensive care
There is not enough time for providing comprehensive care
Patient assessment vary depending upon which disease they present with it.
Physicians dont get paid in walk in clinic for providing comprehensive care
There is no support available from MOH to doctors providing regular care in walk in clinics
My concers is regarding Walk in clinic comprehensive care
There is no reason that CPSO Should enforce availability of doctors in the absence of one doctor in the clinic.
Walk in clinic change their hours based on the availability of the doctors.
How can they ensure a doctor is available in the absence if the owner is not a doctor and they cannot find a doctor
Exactly: this Policy statement is totally out of touch with reality, I just wonder was there any medical doctor among the originators of it?
my concern is regarding Availability and coverage for continuity of care
Telephone access is not possible for all doctors and voicemails.
Telephone policy is strange, as doctors office cannot be run as call centers
There are not enough resources to put more staff
Its shifts the blame on the doctors and their staff and will make sharing responsibility harder for the physicians
Patients requests for any medical advice should be with an appointment and physicians cannot be available for telephone on a daily basis
Absolutely right: ” doctors office cannot be run as call centers”
Hi
I have read the proposed policy on continuity of care and recognize the importance of this initiative.
I would like to know if any thought was given to the difference between inpatient and outpatient consults. I completely understand and support that a report from an outpatient consultation should be sent to both the referring physician and the primary care physician who will have an interest if not a hand in how the issue in question is to be managed. However the situation with inpatients may be different. Unfortunately hospital admission seems to generate a large number of consultations – some for acute issues which may not be of interest to the primary care physician. As an anesthesiologist/intensivist in a very specialized quaternary care hospital I am often asked to see in patients in consultation to assess their ability to survive high risk cardiac surgery or a prolonged ICU stay. I am not sure if those consultations are of any real value to the primary care physician. I can foresee primary care doctors being buried under a deluge of consults and wonder if there is any way to separate out those of real value to them.
Thank you.
I agree that mandating the referring physician contact patients with specialist appointments, while specialists’ offices are expected to relay any visit PREP, is totally redundant and very often creates unnecessary back and forth to reschedule appointments, etc. My office (family practice) books our own appointments and specialists’ offices should do the same. Cut the middle man. More efficient.
With respect to having a system to track tests being completed, I think this puts too much responsibility on the physician and next to no accountability on the patient. It would be a huge administrative burden to track every lab req or xray req that is handed to a patient as they exit my office. Again, at what point does patient accountability come in?
I do like the note about having walk in clinics notify the primary provider when one of their patients has been seen. Even if we didn’t get a full note, something as simple as “your patient was seen on this date for X issue” would be helpful. It’s difficult for family docs to steer patients away from unnecessary walk-in visits if our only indication is an outside use report and we’re left guessing where the patient was seen and for what reason.
Finally, requiring 24/7 community coverage, without any anticipated remuneration seems outlandish. I fully agree with trying to reduce ER visits but isn’t this part of why an ER exists? Small town rural docs without large call groups will be put at a huge disadvantage if this part of the policy is implemented, and they’re the ones already struggling with fewer resources as it is.
Thank you for allowing me to give my feedback.I acknowledge the role of cpso in ensuring best care to the public. I would also like to politely remind public that doctors in ontario mostly provide best possible care within constraints of our public health system. The physician patient relationship has been built on trust and it is paramount for public to have faith in their doctors and these policies in my opinion create a sense of mistrust even though intentions are correct.
I have read the draft policy carefully and this is my first time responding.
I dont think any one will doubt the fact that healthy and happy employees provide best customer service possible and doctors are no different. In the current day and age a lot of administrative unfunded responsibilities have been showered on practicing physicians which is creating dissatisfaction.
This policy though with right intent makes lives of hard working devoted physicians even tougher as they are not backed by much needed support by the MOHLTC.
Let me share with you a specialist view -
Availability and coverage – Specialists have hospital responsibilities sometimes for 2 weeks in a row. They are taking care of the most sick patients. Typically when the office is closed, patients usually presume they are on vacation well infact they are working hard. While at work at hospital- it is not feasible to regularly answer office calls or renew prescriptions or see patients in private offices. Many of the time specialists are in solo practice meaning they dont have any after hour or vacation coverage. I know of specialists including myself who dont take more than 2 weeks off in entire year and that too to meet MOC requirements. Unless there is a support structure from MOHLTC to achieve these requirements from CPSO, I anticipate that specialists would likely close community offices and shift to hospital based practice or vice versa resulting in further lengthening of wait times.
2) Managing tests- I agree that tests should be communicated back to patients and critical results should be dealt right away. In case of critical results – communicating it to physician achieves usually nothing as there is little it can be done in private office. Usually these patients need to be seen in ER or Urgent care centres of hospitals right away. My suggestion would be to have a system in place where labs contact patients directly and ask them to go to UCC or ER right away saving time and getting patients help in a timely fashion. When labs call physicians they dont have necessary contextual information without looking at medical records to guide them.
secondly, we should have accountability of patients as well. Would a physician time be better spent taking care of patients who are interested in their health and outcomes can be improved versus chasing non compliant patients. This requirement in my mind will result in increasing wait times for specialists as they are spending their clinical time which can be used to see new consults in reminding patients to do tests.
Transitions in care – Like I mentioned before specialists work at hospitals and triaging referrals and giving appointments in 2weeks may not be feasible in 14 days. 4 weeks may be a reasonable time frame.
I would have liked to comment on some other aspects but since patients are here for 8 am appointment I need to go to attend them.
Thanks for listening.
I think 24/7 availability is unreasonable. Doctors have personal lives to attend to . Also chasing the patients to do a test is unreasonable .
If the CPSO really wants to improve patient care ,it should look at lobbying the MOHLTC for a patient’s bill of rights which would include a provision that “no patient in this province should be kept on a stretcher in a hallway of a hospital for more than 2 hours”. Regarding voice mail, you are assuming that the patient’s call is directly related to the problem that I am treating the patient for:e.g.I prescribe glaucoma drops and the patient calls me up because his eyes are burning.I return his call from the meeting I am attending in Vancouver but the patient doesn’t have voice mail, so now we play phone-tag. The concerned daughter in Toronto gets my voice mail and now leaves a message which I return while sitting in the Winnipeg terminal waiting for my connecting flight.Finally the eldest son calls me from San Francisco and wants an explanation.” Well, it could be a reaction to the drops, or an acute glaucoma or a uveitis or an eye infection.It is also not wise to be diagnosing over the phone. So I tell you what: call your sister in Toronto and ask her to call your dad in Peterborough and have him come in the office tomorrow at 9:15.I should be landing about one hour earlier.”What a conference this was!”
Great example
These are draconian and far over-reaching policies. Asking doctors to keep their voicemail on all night/weekend long and then respond to every single message the day after is ridiculous. I don’t know of any other profession, either in this province or elsewhere in Canada (or the world for that matter), that has a similar requirement. This isn’t continuity of care – it’s about adding bureaucracy to the everyday lives of Ontario’s physicians at the expense of waiting rooms filled with Ontarians who truly need timely care. The CPSO expects doctors to fill in reams of paperwork, respond to hours of voicemail, provide after-hours care each and every day of the week, and maintain a smiling, empathetic demeanour as they are literally regulated to death in every corner of this province. Poorly-conceived policies of this sort are part of the reason doctors are burning out and have suicide rates above the general population.
And as for walk-in clinics: I visit my local walk-in clinic because I DON’T want to see my regular family physician for my STD checks. Please do not force my walk-in doctor to send faxes for my visits, and it doesn’t make any sense at all to have them send a fax to the family physician for every single common cold, stomach flu, eye infection that they see. This is a waste of time and resources.
Very succinct & valuable summary: the Policy is inhumane & dangerous for our fragile Health Care system, it MUST be re-done, unless we are looking for a catastrophe!
from CMA :….
The previously cited guidelines developed by the CPSNS 3, the standard of practice by the CPSA4 and the guide to enhancing referrals and consultations between physicians developed by the CFPC and the Royal College5 also have recommendations for consulting specialist responses to referral requests (including information requirements and timelines). These resources can be used as a starting point for establishing referral communication standards in both directions and with patients. As an important example, the guidelines for both provincial colleges specifically indicate that the consulting specialist is responsible for arranging appointments with the patient and notifying the referring physician of the date(s).
best policies from NS and Alberta…..specialists are responsible to take care of appointment….
so simple, so obvious….
I am really disappointed with these new policies
How can they expect physicians to be available 24/7?
This is ridiculous . Already we are overburdened with so much . Patient also need to be responsible for their own health care. I am totally against this policy
Hi my concern is about the 24/7 coverage for test results ( labs) , doctors in solo practice can’t be available 365 days / year, 24/7 , some system has to be in place to protect the patient and the doctor equally,
Sent from my iPhone
I am a FHO physician in a suburban community and my comments pertain to this type of setting. As such, I have to provide coverage for my patients from 9am-8pm. In areas where FHO’s are abundant i.e. not under serviced, I believe WI clinics should not be open during these hours. This would encourage patients to seek care with their own family physician who may order tests and then are responsible for any follow up/continuity of care. I have far too many patients who reflexly go to a WI clinic and make an appointment to see me the following day. Despite educating patients to call our office first, these WI visits continue to occur. The WI physicians would then be encouraged to open a practice, decreasing physician shortage, and provide continuity of care.
Outside of these hours, the best care for patients would be to have an urgent care facility in close proximity to an Emergency department. Patients could be triaged appropriately to either facility or advised to their their family doctor in an appropriate time frame.
Ultimately, the Ontario government is our employer. As such they should should provide better governance as to where and how their employees practice. We don’t need more WI clinics, we need more physicians willing to provide long term care.
The ordering physician is ultimately responsible for any test ordered. Their place of practice has to ensure correct contact information is available to provide any necessary follow up. WI clinics should provide legible communication to a patient’s family doctor for each visit to increase the continuity of care and not repeat unnecessary tests.
Our medical system needs some drastic changes in order for it to survive and continue to provide quality care.
Thank you.
We have to be careful with the approach of “prohibition” rather than “encouragement & motivation”.
Besides, there is no free access to the comprehensive care/capitation models for ALL interested primary care practitioners.
Also, with this regulation, there must be some mechanism precluding the patients going to ERs for non-life-threatening matters, which most probably will surge in case WICs became unavailable.
Dear Sir/s
This policy is too hard on physicians , being available on telephone voicemail is impractical , we have to do our clinical work too, patient expectations are too high to be addressed over the phone , please reconsider this aspect .Not every physician has the luxury of having a secretarial support, even in a tertiary care hospital set up .
Strongly agree
This policy plans to hold a physician accountable whether a patient follows through with a medical test which is a treatment plan.
To hold a physician accountable for the actions of an autonomous free-willing third party is not something that could stand up in Divisional court. The policy is legally flawed. I can’t believe CPSO’s army of inhouse lawyers could not weed this out before putting this up for public comment.
Hello, I am a family physician in North York.
Regarding Communication with Patients lines 211 to 218.
Thank you for lines 214 to 218. I agree that it would be most efficient for specialists to forward descriptive information to the patient.
However, I disagree with lines 211 to 213:
This policy puts the responsibility of notification of specialist’s appointments directly onto the shoulders of family physicians. It looks like the policy is attempting to achieve a compromise regarding office workload.
The way I personally see it though, is that patient safety should not be compromised. Delegating to another doctor about an appointment set by a different doctor is not safe for the patient nor is this efficient. Family physicians make their own appointments with patients. Specialists could do likewise. I can see that if the specialist’s office is having trouble contacting the patient and needs to enlist our help, my office would be more than happy to help with those calls as we are not at liberty to release alternate patient contact numbers without permission. Also, the patient might miss the appointment if the family physician’s office did not receive the notification to notify the patient. On several occasions we have not received information that their offices have stated to patients that they had forwarded to us.
I understand that everyone’s office is busy. Family physicians will share with the workload in any way we can in the best interest of the patient. We should continue to work together to draft policies that do not compromise patient safety.
Thank you.
I am commenting on the “Availability and Coverage” Section. Lines 108-111 are unrealistic and contrary to lines 29-31. They could only be written by someone living in an urban ivory tower who is totally out of touch with the reality of rural practice and life in general.
Unless the CPSO is willing to provide and coordinate a pool of locum physicians that can be available immediately, the expectation is ludicrous.
How can one plan on an unexpected illness? How can one get a locum in an expedited fashion? When it is next to impossible to get a locum for a rural underserviced area with incentives and a great deal of lead time, how will you get one to volunteer for an emergency situation where hard work will be the only reward. Further the CPSO position that rural areas require demonstrated skill sets not found in urban areas only narrows this pool of potential candidates.
The concept that a CPSO enforced restriction is the responsibility of the individual physician to remedy is likewise unreasonable in any situation. If the CPSO takes the perogative to remove a physician from seeing patients, it is the CPSO’s responsibility to ensure those patients’ needs are met. If the physician has demonstrated a deficiency in practice that requires removal from practice, it follows their judgement in finding a replacement may be equally flawed. Further, under the suggested policy, the suspended physician might be twice punished if unable to find someone to cover the practice? That would be double jeopardy.
This brings about the contrary nature of this policy to physician well being. Requiring physicians who are already incapacitated for reasons of sudden health issues or discipline, to have the added burden of finding a replacement for fear of discipline (and all policies carry that threat as part of the mandate to enforce them) is hardly conducive to physician health. Policies should not add to the stress and suffering of illness, but alleviate them. It is lovely for the CPSO to suggest that all physicians have contingency plans in place, but common sense notes most people, including health care professionals, rarely plan on illness and therefore do not plan for them. Further, one only has to look at the difficulties the OMA locum program has in obtaining coverage for well planned absences, to see how unrealistic short term coverage is likely to be obtained.
I can not see this unrealistic expectation being forwarded by any other professional body. Why is the CPSO trying again to make Ontario an unattractive place to practice medicine. Why is the CPSO continuing to create policies that will ensure rural Ontarions will have even more limited access to physician care. Why is the CPSO practicing Orwellian double speak when it comes to physician wellness? This part of the policy is just wrong and needs to be deleted in its entirety unless the CPSO will take the lead role in ensuring access to a willing and capable pool of locums for these unplanned or emergent coverage situations.
Very valid & important points, e.g. “If the CPSO takes the prerogative to remove a physician from seeing patients, it is the CPSO’s responsibility to ensure those patients’ needs are met” – this must be one of the key considerations with this and many other CPSO policies.
I totally disagree with this policy. This policy is totally unneeded and without merit.
CPSO has become the most draconian medical regulatory body in N. America and likely the world. Self-regulation is a concept that now applies only to CPSO itself and not the profession. Sure a few people on the council are elected, but their election is irrelevant. Most physicians blindly vote for candidates they don’t know anything about. After candidates are voted in, they have to go along with the “regime” which is perpetuated by the career people at CPSO, who are not elected and work there permanently.
CPSO is the number cause of physician burnout and despair in Ontario. Constantly coming up with new unneeded policies that no other jurisdiction is even talking about is not just a waste of our membership fees, but plain and simple tyranny. Since these consultations are useless and the policy gets passed anyways, I am contacting my MPP and encouraged other physicians to do so. Legislature to generally limit CPSO’s self-serving powers is where our little physicians’ fight now belongs. We sure have a better chance with this new gov than the last one. It’s us vs. the CPSO.
Response in PDF format
I agree that consultant’s office has made a appointment for patient to be seen . This information shall be directly communicated to patient when where and if missed or any change ?? . I don’t think this even needs any discussion simple straight information from point A to point B. Copy of this info shall be sent to referring doctor as well.
Likely nothing new to add, but the most concerning areas I found were:
1) “critical” test results – the few remaining private labs centralized their processes and take a long time to provide results. Patients going to these labs are generally assumed to be medically stable. Getting paged at midnight for a result that was drawn 12 hours or more ago seem nothing more than the lab legally covering the tail at the expense of my sleep. I am almost never going to wake the patient up at that time to give them the result or tell them to go to emergency. If it can wait 12 hours it could wait another 7-8 hours. You are forcing us to backstop the labs’ inefficiencies. Critical result handling should at least have an acceptable turn around time for lab tests. I do not send urgent tests to these private labs therefore (use local hospital lab with 1-2 hour result time).
2)Mandatory voicemail for patients – though convenient it will create a lot of extra work for our offices (meaning extra costs). Response time unlikely to be prompt as phones themselves very busy in morning. There will be occasional urgent messages left inappropriately, difficulty contacting some patients back (as already occurs), etc. This would be a clunky, time consuming mess to provide on top of our already busy pace, and I suspect it will be unpaid work.
Some parts of the policies I agreed with (like appointment estimates within 14 days- even a month would be an improvement). Other parts beyond the above also were concerning.
I am at the stage of my practice where I could stop if things became too onerous. That would orphan some or all of my patients (if I get a replacement, they often look after fewer patients than the oldster they replaced from my community’s experience, and the Ministry only allows 1:1 replacement with FHO’s). I think I do a pretty good job, and frequent, unsolicited feedback from many of my patients echoes this. I’m not convinced much in this policy will help/make me do a better job, and there are concerns that increased workload will be incentive to scale back or stop practice. Time will tell.
Thank you for soliciting feedback.
Completely agree with these points
As a subspecialist who’s spouse is a family physician, I often receive referrals lacking essential information, and my spouse often doesn’t receive reports from specialists she’s referred patients to. The transitions in care document provides clearer direction for information that should be provided in referrals to specialists, and the requirements of specialists to provide a written report back to the referring physician, as well as what this report should obtain. I strongly support providing clear expectations for these processes. Failures at either end negatively impact patient care, and increase waste in the health care system.
The summary article in Member’s Dialogue “strongly advises” physicians to “capitalize on advances in technology that can facilitate continuity of care.” There’s an advocacy piece here that is difficult for individual physicians to follow, but that the College – as a large, provincial organization – can and should move forwards with. When health information began to be computerized in the early 1990’s, there was an incredible opportunity to implement a province-wide, if not nation-wide health care system, gated only by circle of care. For reasons unknown to me, this opportunity was lost.
A perfect example, as a pediatric respirologist, are consults for “recurrent pneumonia.” It’s essential that I see the chest X-rays the child’s had – to see how big the pneumonias were, whether they were all in the same location, or whether the abnormalities on the X-rays were actually something else. Having a child see me for “recurrent pneumonia” without the X-rays is like consulting with your mechanic that your car “makes a funny sound when turning left,” but without bringing the car. We ask the referring physician to arrange to have the X-rays copied onto a CD to be brought to the appointment with the child, and we ask the parents the same, but having children show up without the X-rays is common. When this happens, the parents often ask “well, the X-rays are in the system, aren’t they?” When the family does arrive with the X-rays, I can tell you that I can get X-rays from 5 referrals on 5 CD’s, all using different medical imaging software, all of which works differently, and some of which may not work on our hospital computers.
I don’t know whether “this horse can be brought back into the barn.” Continuity of care would be immensely improved if physician’s office notes, hospital notes, lab testing, and imaging were uniformly accessible within the provincial health care system. There are scattered steps in this direction in the province – for example, my spouse can access some lab results obtained in the community through her office (though I can’t, in my hospital), and I can see medical imaging from a limited number of provincial sites and records from one other children’s hospital – but there certainly isn’t anything consistent. Ontario has innumerable non-commercial and commercially-developed software being used to house medical data. I urge the CPSO, as part of this process, to strongly advocate for inter-operability and inter-accessibility – within circle of care and confidentiality boundaries – of electronic health software within the province of Ontario (if not nationwide).
Respectfully submitted.
Dear Cpso,
I must commend the cpso for doing such a good job on clearly outlining issues regarding continuity of care . I feel that all the recommendations are reasonable and simply state what we all should be doing as doctors to provide safe and timely care to patients.
Thank you.
HI,
One aspect of continuity of care that may be overlooked is about patients under the care of specialist IMGs, who practice in a subspecialty under a restricted licence, but are unable to proceed to independent practice due to the inability to pass the Primary Specialty examination of the Royal College. The Royal College has a pathway for these experienced foreign-trained doctors to be certified in the subspecialty by passing a relevant subspecialty examination and to be then conferred with an “Associate” certification. However, the CPSO does not recognize this Associate certification, and is insistent on the physician passing the Primary Specialty examination. In many instances, the IMG may not have practiced in the Primary Specialty for years, having devoted all clinical practice to the subspecialty. Since the only option of the IMG physician is to cease practice once the time limit on passing the Primary Specialty examination expires, and thus affecting the care of hundreds of patients, it is only logical and prudent that the CPSO recognize that an Associate status granted by the Royal College (by examination), should be eligible for independent practice, thus minimizing the break in continuity of patient care.
Hi . I’m writing from espanola Ontario, I’ve been trying to gather my ultrasound pictures my dr won’t give me access to them . I’ve been really frustrated with her as she no longer seems to care about patients . I had an mri done on July 3rd to check for brain tumor , was informed my results would be in within 3 days . I gave her benefit of doubt wait a week still no calm so I called on July 17 cause she still had not called with my results for head mri . Turns out she didn’t open my test until I called the office . Then once she read the results she got her secretary to call me to say over the phone I have a brain tumour. So unprofessional of my dr to do that. Then ask her for a follow up to see what my next steps are and she said she doesn’t want to follow up with me . This is a serious matter . She knows that as long as this tumor is on my pituitary gland that my husband and I can not continue to try to concieve . This tumour is causing my to have infertility issues and it can be fixed. My dr should have requested a follow up for this matter. If she continues to push me aside I will have to take the law and start a file against her. A brain tumour is a serious problem.
I can & would like to comment from 2 viewpoints, as I do both, the Family practice (FHG) & and a WIC/Urgent care coverage.
The MAIN overall CONCERN is, the Policy makes a VERY DANGEROUSE & unrealistic expectation of “all physicians who order tests” in general (& the WIC physicians in particular) to be available 24/7 for critical results management.
I do not see any feasible way for the physicians in a solo practice or smaller groups to be available 24/7, even in the present large capitations groups, there are hours of availability & coverage: even for these groups, this new requirement must be NEGOTIATED & the additional compensation provided to cover this additional work-load/responsibility.
WICs in particular are limited by the availability of MDs, many of them are senior & semi-retired practitioners, who e.g. can be ill or absent on e.g. week-ends: the critical results must be owned by the lab, who has to contact the patient/ER/ambulance in case the GP is not available (the lab determining a critical result calls the ordering MD, & if the latter is not available, calls the patient to report to the ER ASAP).
As a Family practitioner, I prefer to see my patients in the office for more significant matters: Periodic Exams, review of complex/chronic med conditions, DM-follow-up etc. It’s a more complex, expensive model, requiring preliminary booking of & patient’s compliance with appointments, with office nurse & more auxiliary personnel involved.
I don’t mind & keep it clear for my patients, that they can go to a WIC in case of minor/trivial issues – cold, UTI, injuries, refill of regular medications, especially if it’s urgent or happens on week-end/holidays.
These visits usually do not require any account/paper trail to my office, except for occasional copying on investigations (usually limited to simple X-rays or blood works, which labs routinely copy to Fam doctor).
I do not need to have another extra 10 pages a day to my regular pile of in-comings, describing sniffles, paper cuts or poison ivey exposure. Moreover, I would say that even the ER reports we receive – the whole bunch of 10-pages of loosely arranged notes/general tests are usually unnecessary; in rare cases when I do need something from ER-visit, my secretary contacts them directly & requests e.g. the U/S or CT-report: these are exceptions, not the rule.
“I do not need to have another extra 10 pages a day to my regular pile of in-comings, describing sniffles, paper cuts or poison ivey exposure. ”
Especially when most of it would be illegible, disorganized, incomplete and hard to follow.
(par-2) as I just wrote in my prior 1st part, I am providing comments from two viewpoints, as I do both, the Family practice (FHG) & and a WIC/Urgent care coverage.
And as a WIC/Urgent Care MD, I’d like to emphasize, there is a clear distinction between WIC, ER & Comprehensive Family care/practice. WIC cannot & should not be perceived or expected to perform at the level of neither ER, nor Family Practice.
It operates more like a med relief/security valve for relatively simple but urgent matters, so the Fam practice resources should be better utilized for comprehensive care. WICs are especially helpful for after hours, week-ends coverage of the periods of seasonal outbreaks.
WICs cannot (& there is no need!) to provide the Record of every encounter to the patients’ primary care provider: it’s increasing the unnecessary paper turnover & the time of the WICs encounter without providing Fam Doc’s with any valuable information: this data transfer will cause the delay & might potentially cost a life/complications to the next patients in line, or increase the pressure on ER-departments due to decreased WICs capacity, as WICs is basically the last resort to keep patients from dying in the streets/ER-waiting rooms, especially during the respiratory epidemics.
There is a concept that WIC will gradually disappear as the Comprehensive models will take over & provide the required coverage/availability. Any attempt to disrupt the WICs services prior to that would unavoidably bring a surge in ER-visits, to critically increase the back-log & potentially cause the collapse of the system: simply put, the patients will start dying in ER-waiting rooms or on their ways there from potentially well-treatable diseases.
Some patient accountability should be written in. Some judgement must be allowed if we are realistic about costs to system. IF A MODEL is thought to be ideal it should be control TRIAL tested rather than assumed for decades especially if costly to run.
For patients with intellectual issues of course more specific follow up is always needed and helpers are always involved .
We tell many patients to return for results and at that time set up future testing. In situations where healthy patients have routine tests we now tell them to phone in and confirm we received the tests and that we were not trying to reach them for review. Sometimes reaching patients is an issue. Afternoons suggested for patients to call us when the phone is less busy with booking of new appointments. When tests are expected to need management we book return appointments before leaving or as soon as the test date is known we suggest booking . In cases where I am less confident about the patient taking booking initiative I make a paper note or note in he appointment calendar to check up on their status. For usually reliable patients I tell them to book imaging or do labs and don’t mark them down. ( should not have to baby sit competent patients) I know EMR can be set up to memo all interactions but that can be very time consuming to enter every action and trace every action and take away from emphasis on actual direct care time. I know doctors manage large amounts of old and new information themselves where non DOC staff of three would be needed to replace that. Some standard check and balance guides should exist but allowance for severity of illness ( or possible severity) and patient capability should be flexible. System checks also could be recommended outside the realm of the office – eg. PAP taken in by Lab having tracer for report going out- also billing code for PAP from doctor could have same Tracer for report code and could have flag attached to abnormal report by pathology to see if visit codes show up- and: or could have auto- memo to offices to confirm the patient came in- I know memo already goes to the patient now in Ontario.
Another issue is that if multiple and repeated calls to patient and multiple messages to reach them through multiple channels . There should be some rules allowing offices to leave information at the reception to alert staff to give a message if the patient happens to call in for any reason outside of our request to call them . Many change numbers after we have just updated info ( which we do at every sign in to the office) and they do not think to tell us. Somewhere our obligation has to become the patients – especially when we have told them to plan to call us back.
With respect to specilIst referrals we always track in EMR and in paper book and recheck to make sure messages return. Urgent cases are marked with green highlight. We also label letter to specialist as urgent or not. We phone if deemed needed and fax and or phone ER depending on preference but always fax eventually with full CPP and written record of our concerns . Many patients plan to book to see us after specialists visits so we don’t chase them when we know they have already promised to do this and we know the special will also advise follow up with us. That would be tedious to have to track in triplicate.
For continuity of prevention care we do run our own EMR programs against lists sent from the Ministry. Letters from ministry to patients now do help with this.
As usual, arrogance and disengagement from an institution that charges members dues that are outrageous ,and then puts unrealistic , pie in the sky , utopian demands upon those in the trenches who are trying to keep people out of ER departments, improve their patient’s well being , help students who are away from home cope, and thrive at university/college, while being pulled in multi-directions, by multi-managers,with little back up from those that should and could assist, namely specialty groups, colleges, associations. Instead of trying to “stay out of the Toronto Star” , and be overly politically correct, it would be helpful if your money was put to proper use ,and instead of fear mongering, assist, aid and encourage standards, efficiency and morale. Your actions are causing many MDs to retire prematurely ,and others to consider moving. The Ontario government needs to be made aware of this travesty of the state of physician morale in Ontario.We are being outlawed by this “college”. Too many foolish rules. family doctors and specialists can communicate between themselves, and work out a reasonable system for themselves. The Province’s doctors don’t need “the omniscient know-it-all” bureaucrat-types to dictate minutia to you!Already, everyone dumps on the family doctors, including the “college”. If this keeps up,perhaps a class action law suit might be in order?I’m losing my doctor currently, thanks to The CPSO!
Are the CPSO and their staff liable for the health of physicians who they demand so much of? One would think that these hardships brought upon the physicians of Ontario, the stress that they must endure vis a vis the CPSO dictating outrageous practice demands upon autonomous professionals who practice their craft at high standards with dignity and respect , would be a cause for action by the practicing doctors of Ontario? I know that many of the public are very upset over the way that the Wynn government, and the CPSO have been and continue to treat our doctors! For political correct points, no less!
One more item I recalled . With respect to pronouncements – usually we have ourselves on the hook 24/7 as family docs with backup for vacation. The problem can be unexpected sudden death when we are out of town. On call docs may have some info available but that may vary when we have not been able to prep them ahead. Often a Coroner will call for information after gathering family input or input from EMS and make a best diagnosis. Then family docs can get he call to look after the paper work because the Coroner on call ” had plans for the night” . This even occurs when a call comes from a territory 30 miles out of town in that Coroners area . Continuity could be an issue here since information went through three sources before coming to the family DOC or on-call doctor. Our input can be helpful but should not put as as the final signature?? To put into perspective think of what is protocol for patients who do not have a doctor and of who signs the paper work .
There is a push for fast paper work ( perhaps over accuracy?) so for weekends family DOC input could perhaps be worth waiting for even if just verified by phone or fax if they have returned from distant travel ? On this note I have tried to chase down a patients status where death was expected and had a funeral home call me 4 days later asking if I would do a form at that time. Is there a true protocol with all these varied approaches and various situations and patients with or without a regular physician. I prefer to worry more about continuity of care in the living but this issue still involves continuity of information so should be addressed
Continuity of Care Committee
[email protected]
I have recently experienced a situation which should be considered in your policy development regarding the patient’s right to maintain their doctor/patient relationship as part of Continuity of Care.
The situation involves a clinic where I had worked with the Founder over the past 27 years. Accordingly, I had a large following of patients.
Through a change of control, the clinic decided they would exit five physicians. They advised me that my departure would be crafted as a retirement and that I would no longer be offered shifts in 6 months.
I was under a contract to the clinic which restricted patient solicitation and competition until the end of the six-month period. During that period, the clinic approached my patients to move them to the care of another remaining clinic physician much to the dismay of many of my patients (and Colleagues). Given the non-solicit clause in my contract, I could say nothing despite my patients probing. “Bind-fold the patient and muzzle the doctor” best describes the strategy!
Fortunately, many of my patients contacted me privately to find out where I was going. In answer to their question, I advised them I was moving to the another Clinic and not retiring. As one patient said “I am eighty years old and you have been your doctor for 15 years. I’m not starting to look for a new doctor now”.
Ethically I believe that patients should have right to choose their health care provider and should not be blind-sided by corporate contracts in the healthcare space. Both patients and medical records should move freely at the patient’s discretion. The clinic’s intent to “lock-up” patients by withholding information from patients should be challenged. Moreover, your policy on Continuity of Care should set out a policy whereby the patient cannot be controlled in the interests of a business enterprise.
CPSO should implement a “Full Disclosure” policy (the converse of a non-solicit) obliging corporations and physicians to fully inform patients about decisions affecting patients’ continuity of care.
In Transition of Care, Line 211 and 212, referring Physicians should NOT be the responsible party for notifying the patient of the appointment date and time. This is an activity that would be expected of the consultant physician at all times.
With respect to the Availability Policy, the language and expectations are very vague. For a FFS family medicine provider in Ontario (not part of an after-hours mandated group), what expectations would these be? Currently walk-in Clinics and ER are the after-hours plan for many FFS physicians.
Thanks and look forward to reading more.
This is great that the CPSO is tackling this issue. Whether or not people have appropriate continuity of care can make all the difference in their health outcomes.
2 quick things:
i) I appreciate the idea of patient engagement. And certainly, encouraging patients to take a more active role in their own health care is key, but I like how you mention that “patient engagement is not meant to absolve physicians of their responsibilities”. I think this is worth stressing. There are many patients for whom various barriers may exist that would prevent them from being able to oversee their own continuity of care in any type of meaningful way. If a patient can become a second set of eyes helping to monitor their continuity of care, and remember their old test results…etc, then that is great. But the assumption should always be that it is the physician who is primarily responsible for the continuity of care and test results management of the patient.
ii) The transitions in care portion of the policy is an excellent step in the right direction. I certainly agree that the availability and response times between health care providers is a key part of continuity of care. Can there be stronger language around ensuring that specialists’ offices communicate in a more timely manner back to the family physician and patient when/if they have availability for a first appointment. It seems ridiculous that some patients along with their physicians wait for weeks just to hear back from a specialists office only to find out potential availability. There also appears to currently be ambiguity surrounding which physician is responsible for following up with the patient once the referral is made, so I applaud you for tackling that. Specialist’s offices need to be part of this process.
Overall it seems clear that inefficiencies in this part of the health care system can potentially have very negative consequences on a patient’s health outcomes depending on the condition for which they need the specialist. So certainly some strong, clear rules and procedures surrounding referrals, consultations, specialists…etc is long overdue.
I am a pathologist and recently was informed of a critical value pertaining to a patient of a nurse practitioner clinic. I endeavored to contact the ordering nurse and the clinic had closed for the week at Friday noon. No contact information for coverage by the nurses was available. The message said go to emergency or phone telehealth, which opened at 5. After a long frustrating search I managed to contact the patient and informed him/her of the result and recommended a visit to emergency. I think continuity of care should apply to nurse practitioners as well, I am not sure if you can encourage this in discussion with their college.
I would like to bring your attention a situation which has the potential to compromise the doctor / patient relationship and the continuity of care and that is non-solicit clauses between physicians and corporations active in the health care industry.
Between the years of 1991 and 2018, I was in independent physician contractor to an organization.
Accordingly, I was under a contract to an organization which restricted solicitation and competition until the end of the six-month notice period. During that period, the organization approached my patients to move them to the care of another physician at the organization much to the dismay of many patients. Given the non-solicit clause, I could say nothing despite my patients probing. “Blind-fold the patient and muzzle the doctor” best describes the strategy!
The intention of the organization’s contract was to restrict Continuity of Care for the patient over-riding the existing doctor / patient relationship. The doctor / patient relationship was subordinate to a business contract. Patients should not be viewed as corporate assets with their contact information concealed by Confidentiality clauses.
I believe that physicians and corporations operating in the health care environment should be obliged to provide patients with Full Disclosure about any pending change in the doctor / patient relationship whether for personal or business reasons.
Consistent with this policy, I believe that the CPSO should provide direction to businesses operating in the health care environment advising them that contracts with physicians should exclude non-solicit clauses and physicians should have free access to communicate with patients at all times and as required.
Yours truly
Walk in clinics are having to increasingly play a major role in provision of primary heath care.
Many patients either do not have a family physician or their family physicians are too busy to see them in a timely fashion.
The family physicians are too busy seeing many patients for simple routine, repeat visits to monitor blood pressure, lipids or blood sugars.
These simple follow ups could be done by allied health professionals under supervision of the family physicians.
One must remember that walk in patients are often total strangers for the walk in physicians
These walkin physicians face a great challenge of having a new patient not only to build a rapport with, but to also deal with the immediate problem and to gather data like the past history, the medications being taken, the social history and any allergies present- data that the regular family physician does not need to gather at every visit.
Often the walk in patients also want to burden the walkin doctors with other problems problems that have accumulated since the family physician has not been available!
We need to definitely rethink about the challenging roles for the walkin doctors- before they burn out faster than the family physicians!
This is petty. It’s a minor task. Someone just DO it! It’s a disappointment that this is being given this time and effort.
Thank you for the opportunity to respond to your initiative.
To me, much of what is proposed should help patients while creating some additional work for physicians – who should be compensated accordingly.
I would like to see, in these policies, a greater indication that physicians should be aware of and willing to work with a community of caregivers. Patients can be supported better with their decisions; a team can be stronger with key players working together; and there can be less onus on/work for any one individual.
Recently, I’ve had an opportunity to be part of a restructuring of health care delivery in Halton/Peel and this is the direction that is being proposed. It’s exciting and I ask that you consider more support of this role for physicians.
Yours truly
As a member of the public, I strongly oppose this policy.
privacy of my medical file is very important to me. you should not mandate walk-in clinics to automatically send my file to my family doctor, unless I sign the permission form. To do otherwise would be a violation of my privacy rights.
I think your walk-in policy should mandate that doctors provide comprehensive care to patients without regular follow up. These patients are vulnerable and this type of care is well within our scope of practice.
Response in PDF format
I do not have a problem with our Doctor but with the running of his office. Our Doctor has a family practice/walk in clinic and we are patients of the family practice. The problem is that if you call to make an appointment, the people he has working for him will NOT answer the phone. I try many times during the day and on different days and they are there but will not answer. I had a mammogram 2 weeks ago and he told me to come back after and yesterday my husband and I had to drive to his office to make the appointment and I do not feel that we should have to do that. I had been calling off and on for the past week. I don’t know if we should try and switch doctors as it is very frustrating.
Some feedback…my impression is the family doctors do not think Walk In clinics contribute to continuity of care for their patients.
http://www.the-boardwalk.ca/wp-content/themes/theboardwalk/pdf/why-we-ask.pdf
Thanks
“Referring physicians must communicate the estimated or actual appointment date and time to
the patient unless the consultant physician has indicated that they have already done so or
intend to do so.”
Why would CPSO place the responsibility of booking appointments on the family physicians? Why should family physicians be responsible for paying for administrative staff to call and relay specialist appointment times? This creates an inconvenience of unnecessarily having family physician offices act as the middle man, particularly in situations where the initial appointment time given does not work for the patient.
“All physicians who order tests10 must ensure that critical test results11 100 can be received and
101 responded to 24 hours a day, 7 days a week. Unless physicians choose to be available
102 themselves this will necessitate making coverage arrangements for those times when they are
103 unavailable (e.g., participating in an after-hours call group, telephone triage, or making specific
104 on-call arrangements with other physicians or practices).”
I would hope that clarification is made that specialists are responsible for after hour coverage of their own lab values. In our city we have a family physician call group and are finding more frequently that specialists are telling lifelabs to call the family doctor when a value they ordered is critical. Please consider adding further clarification that specialists are responsible for this.
I am writing re Continuity of Care , specifically lines 211-213.
I believe that patients and specialists’ offices should communicate directly. Having the family physician’s office act as a go-between poses logistical and patient safety issues. Only the patient knows when they can and cannot attends for a specialist appointment. This needs to be discussed directly with the consultant’s booking person, not the referring physician’s staff. There is too much opportunity for missed communications and dropped contact points for this to be the preferred method. Our department has looked at this issue closely, and we feel strongly that once the referral is received, the specialist’s staff should book directly with the patient and fax/email back the appointment info to the referring physician. Any other method leaves potential for error, delay and harm.
Please contact me if there is further discussion on this.
I love that we are trying to have an organized approach to continuity of care. But as a family doctor in private practice, working with 7 others and excellent coverage to our patients, there needs to be MORE consultation with physicians to make this work in a way that is effective and STILL allow physicians to spend more time with patients instead of adding to expenses, more paperwork and burnout.
We cannot be available 24/7 for critical results in the community, unless we develop a larger centralized network to review them.
We would love to enhance technology & improve communication and access, but we are limited by exorbitant & rising costs, as well as limitations based on privacy. We need support to do this in a cost effective and uniform matter.
We have many more ideas in the community, please access these ideas before implementing plans that will make physicians burn out and not be able to provide the high quality care they deserve.
Response in PDF format
Hello, here is some feedback:
1) re Managing Tests: lines 85/86 “Physicians must either personally follow-up on test results or assign or delegate this task to others”
feedback: I did not see anywhere in the draft a clear statement that the physician who orders a test is responsible for timely followup of the result. I think lines 85/86 should be replaced with: “A physician who orders a test is responsible for timely followup of the result, including clinically significant or critical results.” That’s clear.
2) Re managing tests, as below,
169 Additionally, physicians who become aware, even incidentally (e.g., physicians who are cc’d on
170 a report), of a critical or clinically significant test result where they have reason to believe that
171 the ordering health-care provider did not or will not get the test result, must make reasonable
172 efforts to inform the ordering health-care provider or the patient of the test result.
feedback: Unless the ordering health care provider has failed to follow up on results of tests s/he ordered in the past (in which case I’d stop referring patients to him/her) or I spot an error in the results chain (eg name mixup/wrong address) I’ll assume the ordering provider (or his or her call group) is checking and handling results, including critical results, in a timely way, 24/7. Just like I do. I might phone the patient to inquire if s/he has been informed of the result, however, I don’t want to become the default critical result handler for a physician who opts not to have 24/7 coverage, simply because I’ve been cc’d on a test requisition.
3) re Transitions
157…Physicians are also advised to be mindful of
158 whether the consultant physician is accepting patients and whether the consultant physician’s
159 practice is accessible to the patient (e.g., location, physical accessibility, etc.)
feedback: Every physician has an obligation to ensure his/her office is accessible (I believe this is legislated). Thus, the consultant physician is responsible for his/her wheelchair ramp, elevator, accessible bathroom etc. Patients also have an obligation to go the specialist to whom they have been referred–even if it means waking up a little earlier and/or taking two buses.)
Finally, consultant’s should book appointments directly with patients. It’s simpler, uses fewer resources, and safer (less room for errors) since the consultant’s schedule and the patient’s schedule are in direct communication.
Respectfully yours.
I absolutely agree: as a family doctor who is copied on tests that specialists have ordered I end up being the one who is responsible for these results – no matter that I perhaps haven’t seen the patient in months or years or sometimes am not sure why the test was even ordered. I cannot tell you how many times I am left running around trying to figure things out while specialists do not follow up in a timely manner and sometimes not at all.
It should be obvious that the doctor who orders the test is responsible for the result – regardless of speciality.
And of course the consultant should book their own appt: we book our own appointments for which we bill. It is part of our business to communicate directly with patients to book them. Why create extra work and a “middleman”?
Moreover, it is not right that specialists require a referral letter every year for patients whom they’ve been following for the same condition long-term. It’s an unethical billing issue that creates work for family doctors and the patients who have to go seek the referral. If a specialist is following a patient for a chronic long-term condition, I should not have to send a new referral letter every year.
Hi,
I also would like to comment on the transition of care policy. Specifically, the current draft requires referring physicians to communicate the estimated or actual specialist appointment date and time to the patient.
It is unclear what the rational is for this wording. All other jurisdictions with similar policies (Alberta, BC, NS) have put the responsibility of appointment notification on the consultant so long as the referring physician provides demographic data (patient’s phone number, email).
There is no compelling evidence that patient care or safety is negatively effected whether it is the referring physician or the consultant who contacts them with an appointment. As such I feel the college is falling outside of its mandate by putting even more stress on an already overwhelmed primary care system that is responsible for the bulk of system navigation. The referring physician has to not only be responsible for own office tasks, but also administrative tasks of other offices as well.
I would like to stress that I support clear college guidelines that ensure patients are not ‘abandoned’. I simply ask that the college appropriately ask the consultant that is providing the appointment to also communication it to the patient, a task that is all but their own administrative workload. Having the referring physician do this task only creates a middle person which is inefficient.
It has come to my attention that most x-ray labs & specialists do not send reports in a timely fashion, some of my patients return months later to find that their reports have not arrived despite abnormalities found, my investigations found that these X-RAY labs & specialists send their report by fax only in order to cut costs & therefore shifting their costs to us family physicians, the faxes occur frequently after office hours when our machines were turned off to prevent junk mail from reaching us.
It also became known to me that these X-RAY labs & specialists send their faxes through machines that do not alert themselves that the faxes have not been received or perhaps these messages were ignored.
If I can suggest that one sure way to ensure timely reports get received is by regular mail, to cut costs, the x-ray labs & specialists can save up their reports & sent them weekly or biweekly.
We should be responsible for the tests we order: as a family doctor who is copied on tests that specialists have ordered I end up being the one who is responsible for these results – no matter that I perhaps haven’t seen the patient in months or years or sometimes am not sure why the test was even ordered. I cannot tell you how many times I am left running around trying to figure things out while specialists do not follow up in a timely manner and sometimes not at all. We seem to accept that it’s okay for some specialists to not be checking their labs on vacations etc while we must arrange coverage 24/7 even for tests that we did not order and have no clinical context in which to place.
It should be obvious that the doctor who orders the test is responsible for the result – regardless of speciality.
And of course the consultant should book their own appt: we book our own appointments for which we bill. It is part of our business to communicate directly with patients to book them. Why create extra work and a “middleman”?
Moreover, it is not right that specialists require a referral letter every year for patients whom they’ve been following for the same condition long-term. It’s an unethical billing issue that creates work for family doctors and the patients who have to go seek the referral. If a specialist is following a patient for a chronic long-term condition, I should not have to send a new referral letter every year.
I have 4 main areas of concern with this draft policy:
1. I do 5-6 walk-in shifts per month. The proposal to require myself and/or staff to provide a copy of the encounter (including test results and follow-up care) to the patients primary care provider is completely unreasonable. I see 35-45 patients per shift and I do not have the time personally or the resources to pay my staff to comply with this proposal. Placing this type of undue administrative and financial burden on physicians practicing in walk-in clinics will discourage walk-in practice leading to more patients seeking care from ERs.
2. I am a family physician working in my office 4 days/week as I do alternative work on the 5th day (to make up for the ongoing unilateral cuts to my income over the last 4+ years). Currently I do not allow patients to leave voice mail messages outside of office hours as typically these messages are difficult to hear and/or patients do not leave their name and/or call back number (despite the instructions on the voice mail to do so) so responding to these in a “timely manner” would be near impossible. Also, nobody would be checking these messages outside of office hours as my staff is not going to come in evenings & weekends to check the voice mail so I do not understand the proposal to mandate an outside hour voice messaging requirement. Again, this is just placing undue administrative burden on physician offices/finances. Do teachers, dentists or bank managers return phone calls outside of office hours?
3. The proposed requirement for referring physicians to contact patients with their appointment with a consultant physician makes absolutely no sense. Especially as the proposed policy requires the consultant physician to contact patients re any additional appt info, prep, change of appt time, etc. Again I have a finite amount of staff resources and I should not be subsidizing consultants practices by booking their appointments for them. Consultants should book their own appointments & coordinate appt info, prep, appt date changes, etc directly with patients. Having the family physician as the middle person just creates duplication & confusion.
4. The proposed policy to mandate physicians to arrange coverage of their practice by another physician for a temporary absence is burdensome, expensive and often times not even an option, especially for those in rural areas or highly specialized fields. If I am acutely unwell and unable to attend my office there is no system in place for me to find a locum physician on short notice (unlike teachers for instance who have a supply teacher list). Even finding a locum for a longer term mat leave or a 2 week vacation is extremely difficult to find as I know from personal experience. Paying for coverage is also very expensive and I don’t think it is unreasonable for offices to be closed for a sick day or vacation. My patients have the option of attending the urgent care in my building if something acute comes up in my absence, which is open 7 days/wk & connected to my practice via a shared EMR.
I demand the CPSO to listen to the feedback of physicians and ACT on that feedback. Physicians in Ontario are already overburdened by administrative tasks and struggling with resources due to the ongoing unilateral cuts to our incomes for the last 4+ years. We cannot cope with additional unpaid work, especially when it makes no logical sense. This entire draft policy feels like a “cover our ass” policy to protect the CPSO (not patients) & allow the CPSO to be able to streamline complaints & dole out punishments to the hard working MDs of this province.
I am also concerned with respect to the proposed policy. The additional requirements for copying all documentation and tests to the family doctor from walk in clinic visits adds unnecessary administrative burden (unpaid) and would be unnecessary should Ontario actually have a universal EMR (paid for and supported by the Ontario govt) that ALL physicians were plugged into and a part of. Most patients in Ontario assume this is already the case! 24 hour access again unpaid is also a frustrating additional burden as is the onerous administrative burden (unpaid again) to allow 24 hour telephone answering system that must be replied to.
Dear CPSO:
My feedback on your proposed continuity of care plan:
Some of the proposals have some merit. As a family doctor, it would be very helpful to know within at least a few weeks if a specialist whom I am referring a patient to is going to either reject the consult completely, or be unable to see the patient for a very long time.
It would certainly be ideal if a copy of every urgent care encounter was sent to the family doctor, although their needs to be further work by the MOHLTC on an IT system that would allow this, without creating excessive administrative burdens on family physicians.
The proposals on patient notification of specialist appointments seem destined to create confusion. Having two different offices notifying patients is asking for contradictions and also duplicating work. I would suggest this element of continuity be sent back to the table for review.
The suggestion that primary care physicians should be able to respond to telephone messages and manage patient care 24/7 is both totally impractical and very unnecessary. On the one hand, nobody can do 24/7 call 365 days per year on their own, and if groups are going to be formed in which a doctor stands by for phone calls off hours, they would have to be properly reimbursed for such availability. At this time, there is no such system of reimbursement available or on the table. On the other hand, at a time when we are trying to educate our patients that health care is not like McDonalds, which is available at one’s convenience and at which one simply requests what they want (as opposed to an assessment and advice by a professional), it is a very wrong message to send to the public. Any health concern that cannot wait until 9 am should be assessed in an emergency room. The vast majority of problems can definitely wait until the next morning (and likely until Monday morning on a weekend) for a patient to call their own family doctor and receive further direction. If the public thinks that a medical opinion should be available at the time of their convenience, the province would need to spend a lot more money to entice health professionals to start working overnight for non-urgent problems!
The suggestion that primary care physicians should be required to chase down patients to ensure that tests ordered are performed is also impractical and ethically wrong. The administrative load such followup would require would be large. More importantly, it sends the message to the patient that either they are not responsible enough to followup on tests for their own health, which infantilizes them, or that they are not permitted to decide not to do tests, which is coercive. Either way, when a patient is given a requisition for a test, it is their choice and responsibility whether they want to do it and not that of their physician.
Public health has a system in place to ensure children get immunized, since they are indeed not able to do this themselves, and perhaps a system to followup tests for children would be reasonable to ensure no neglect takes place. The mental health system also has a system in place to ensure that those of the public that have serious mental health conditions receive their treatments. Other than those two groups that are not capable of making their own choices, the public at large should be given the responsibility and the right to proceed with testing at their discretion.
Ensuring that critical test results are dealt with expeditiously requires more than 24/7 availability of the physician (which is impractical). Labs and DI departments should work on contacting primary care physician, but should also have a backup plan for contacting patient and directing them to ER in critical situations.
I hope that you will seriously reconsider the proposal, which I feel is very flawed and is likely to demoralize the medical profession, create conflict between the various types of physicians, and ultimately harm the health of the public.
Unfortunately the entire policy is misguided and dangerous. This model of unrealistic expectations will be completely untenable in a system with limited resources. Physicians will move from community practice into anything else that avoids this outrageous policy. To continue in such a system would cause physician burnout and subject them to unjustified liability.
Consulting office should be responsible for all appointment booking and communication to patients and referring offices. The time and financial burden that some specialists download to Family practice offices is much too high.
This also is the case for “recommended tests and treatments” that are too often also dumped on family practice. This is a very significant amount of time that takes away from other patient care duties.
Lastly, referring and consulting md’s need to ensure transfer of appropriate information and in a timely fashion. Too much resources being wasted on duplicate tests, tracking down consult notes, etc.
Thank you for allowing us the opportunity to comment on this draft policy.
I agree that consultants should aim to contact patients themselves to inform them of upcoming appointments and/or necessary preparation. It is a cumbersome task that no office wants to undertake and finance, yet ultimately for reasons already mentioned in other comments, it is the most reasonable and efficient way to go.
As far as the expectation for walk-in physicians to communicate directly with the patient’s family physician, I feel this is unreasonable and in many cases not feasible. The responses patients give when asked why they did not visit their family doctor range anywhere from “I don’t want them to know about this issue” to “I hate my doctor and avoid seeing them when I can”, or even “I don’t know if I have a family doctor” for younger patients. With very few exceptions, patients understand the information that is given to them during an appointment, as well as the recommended treatment plan and investigations necessary. Should they choose not to pursue this, the onus is on them and we should not be held accountable for their decision to not follow through with advice. There are simply not enough resources (time and financial) for physicians to hold patient’s hand this way in a sustainable and efficient way.
In terms of providing comprehensive care to walk in patients, this would change a 10-15 min visit to a 30-40 min one. Most clinics already have a 2-3 hour waiting time to be seen and adding this additional component will make it impossible to efficiently and safely get through the list of walk in patients waiting to be seen that day. Reviewing with a woman whether or not she is due for her pap and mammo, and if she has been screening for diabetes given her family history (when she only came in for a urinary infection), has the potential to discourage another patient with chest pain from sticking around for an additional hour (on top of the 2 he already waited) to be assessed.
As someone who can choose whether or not to work the walk-in clinic in additional to family practice, I will definitely not be taking any walk in shifts if this policy goes through in the way that it is written. Although I strive to provide the best quality of care, I cannot afford to have that level of involvement with a walk in patient.
As a physician who has worked in very remote and now works in a somewhat remote area, parts of this policy are utterly unreasonable and unworkable. I am approaching retirement but if and when this policy is imminent, I shall simply retire. We treat our dogs better than the inherent attitude in this document in my opinion with reference to poor physician availability areas. Get real, Ontario rural is very different than Toronto or Ottawa. These standards are too severe for remote areas and wise physicians working in remote areas should be encouraged to leave the remote areas now.
Draft: “Physicians practising in a walk-in clinic must provide the patient’s primary care provider with a record of the encounter and take reasonable steps to identify others who would benefit from knowledge of the encounter and provide them with one as well.”
Preface with: “When in the patient’s best interests, “.
Rationale: patients are often scolded or discharged for using outside services because physicians with rostered patient practices are financially penalized by OHIP when patients use walk-in clinics, even when medically necessary. Communication with the primary care physician should take place when medically it is in the patient’s best interest.
Hi,,
I think the policy recommendations make sense.
I understand where this policy is coming from. There are however a few unrealistic expectations. For example
All physicians who order tests must ensure that critical test results can be received and responded to 24 hours a day, 7 days a week. Unless physicians choose to be available themselves this will necessitate making coverage arrangements for those times when they are unavailable (e.g., participating in an after-hours call group
There are physicians who are in solo practices and do not have the possibility to join other physicians in a call group for test results, as there may not be other physicians of that specialty available.
Also, the middle-of-the-night critical test results are largely due to batching by private labs, who courier blood samples to large overnight labs and run them at, for example, at 2 a.m. when most of the world is sleeping, for cost-effectiveness. It is not fair to then expect physicians to be woken up for some low neutrophil count which the lab thinks is critical and for which no intervention is required and which can easily wait until morning.
We have enough physicians burning out and committing suicide in this province. Sleep disruption is a huge factor in this. Disregarding this evidence at the behest of labs which choose to run overnight is irresponsible when the physician has ordered the bloodwork during daylight hours.
When referring a patient, the referring physician should fax in a referral to the consultant indicating if need be, if there is any urgency. The consultant’s staff should be the ones then contacting the patient directly and faxing back the date of the appt to the referring doctor for their information only indicating that they have contacted the patient. Patients should have the option to turn down an appt time that very inconvenient for them and the best way to do this is having direct contact with the consultant’s office. There will be less “no shows” as well.
As a family physician, I feel that the CPSO should follow suit of other provinces in that specialists offices ought to communicate directly with patients regarding booking of consultations, follow up appointments and information regarding their appointments/procedures. Not only is the current system a logistical nightmare for our busy practices but there are too many opportunities for missed information, missed connections and mistakes to occur. It is in the interest of quality improvement and patient safety that communication be direct between patient and specialist office. Additionally, communication regarding receipt of referral letter within a timely fashion is advisable to ensure nothing falls between the cracks. This has also been done in other provinces and ensures timely and safe access for patients
Re: lines 211-213.
I feel that patients and specialists’ offices should communicate directly. Having the family physician’s office act as a go-between poses logistical and patient safety issues. Only the patient knows when they can and cannot attend for a specialist appointment. This needs to be discussed directly with the consultant’s booking person, not the referring physician’s staff. There is too much opportunity for missed communication and dropped contact points for this to be the preferred method. Our academic department has looked at this issue closely, and we feel strongly that once the referral is received, the specialist’s staff should book directly with the patient and fax/email back the appointment info to the referring physician. Any other method leaves potential for error, delay and harm.
I am a family doctor working 30min East of the GTA and I work in both an office based and walk-in clinic setting. There are some significant problems with some of their policy recommendations:
1) Having every encounter and test result forwarded is completely unreasonable. Majority of walking clinic visits are for minor issues such as URI’s , rashes and MSK issues. I’m sure most family doctors, including myself, don’t want our faxes flooded with a lot of these insignificant visits. Also the administrative time required for my staff to fax every encounter and test is not feasible. I work in a clinic setting within my group where our physician to staff ratio is 1:1. My receptionist handles all my billing, phone calls, faxes, bringing patient’s into rooms, and handles all my labs. Having her stand in front of a fax machine sending walking clinic encounters is wasteful and actually hinders’s patient care overall.
I also hope the college realizes that patients MUST consent to have their information sent to their family doctor. I see many patients visit our walk-in clinic because they DON”T want to see their family doctor. Either because the patient is seeking a second opinion or want a treatment their family doctor doesn’t want to provide. I can see many patients being upset if the walkin clinic forwards their encounter to their family doctor
I do agree that if a physician sees chronic or more complex visit which requires a patient to followup with their family doctor then the appropriate information should be CC’d.
I am also curious to know why this policy change is only being applied to walkin-clinic. Why not the ER or home-visit doctors?
2) Having appropriate coverage for a temporary absence is also very troubling. If I’m sick with a bad cold or pull out my back and miss 1-2 days of work; there is no way a physician can find coverage on short notice let alone for a short time.
3) Lastly, patients’ are autonomous beings. They are capable of making their own decisions, it is NOT the responsibility of a physician to followup and see if patient’s complete tests or follow orders. Am I suppose to call all my high risk cardiac patients and ask them if they are following my orders on diet and exercise let alone tests?
Also should add: due to the possible delays incurred by the family practice office being unable to contact the patient, there are missed appointments, which is a waste of time and resources.
Totally agree that specialist’s office should be responsible for arranging the appointment and letting referring physician ‘s office know details of appointment. Not only does this help prevent miscommunication and no shows, but as the consulting physician is receiving a fee for the consultation they should bear the administrative costs of arranging the appointment. I was in family practice for 35 years and this issue always bothered me. I am glad it is finally being addressed.
I am a recently graduated and practicing family physician. In addition to my primary care practice, I work in the emergency department and as a hospitalist. Contrary to many of my colleagues, I decided to forgo locums in favour of establishing a practice.
However, the implementation of these new rules will most certainly force me to abandon my primary practice in favour of full time locum work and ED / Hospital coverage. As it currently stands, I am already working 2+ hours a day doing unpaid administrative tasks including following up on paperwork, lab tests, imaging, etc that I personally order. These new rules will only serve to add more administrative burden to my day, resulting in less time spent caring for patients and actually practicing medicine. Additionally, placing the burden of having my clerical staff contact patients on behalf of specialists is one extra and redundant step that takes up precious time in an already busy day. Patients complain that they have to wait on hold for 15+ minutes as is, without the phone lines tied up making calls to set up appointments for other physicians.
At the end of the day, I just want to practice medicine and do best by my patients. There is far less administrative headache and bureaucratic burden providing ER and Hospitalist coverage, and at least my time is compensated for this work. It’s really no surprise that many of my colleagues have gone this route and not set up their own practices. I feel that if these policies go through, it will make it even more difficult to attract physicians to primary care.
I do hope the CPSO reverses course on these poorly conceived policies.
Thank you.
Please note that I have already emailed this letter to the CPSO and my local CPSO representative on May 28, 2018. The letter is better and more complete because it includes screenshots with annotations to illustrate the specific points.
Months ago, I was alerted to a policy that the CPSO is drafting regarding “Continuity of Care” as can be found on page 186 of the CPSO’s Annual Financial Meeting of Council for May 24 and 25, 2018.
I have serious concern regarding a proposed requirement in Appendix D, “Transitions in Care” section. Specifically, on page 234, under the section of “Communicating with Patients”, Line 211 directs that “Referring physicians must communicate the estimated or actual appointment date and time to the patient unless the consultant physician has indicated that they have already done so, or intend to do so.”
I was alarmed to find to that the the CPSO is drafting a directive that is in direct contrast to that of the already existing, comprehensive policy of the College of Physicians and Surgeons of Nova Scotia, where on page 2 they state that the consultant physician “should schedule the appointment directly with the patient”: https://cpsns.ns.ca/wp-content/uploads/2017/10/Referral-and-Consultation.pdf
In the interest of patient care, it is far more efficient, timely, and accurate, if the consultant physician schedules the appointment directly with the patient. It is the consultant physician who has direct knowledge of the appointment time, and alternative options if the appointment is not agreeable for the patient or if it should need to be rescheduled. It would be a redundant, needless, intermediary step to for the referring physician to have to relay information from the consultant to the patient.
Furthermore, on Line 214 of the CPSO’s same policy, the CPSO is directing that the consultant physician, quite appropriately, be the one to notify the patient of any instructions or preparation prior to the appointment. Here, the policy is directing conflicting, redundant effort. In the interest of patient care, it should be the consultant physician who contacts the patient for all of this information in a single communication. In your draft policy, Lines 211 and 214 are directly contradictory. Why have *both* offices contacting the patient? It is the CONSULTANT office, who has all for the information first hand, that should be communicating all of the info, both scheduling and prep, to the patient. The Referring Physician is a needles middle-person in your proposed process.
One can only imagine the administrative and communicative chaos when the Referring Physician is an Emergency Physician, for instance. Is it the CPSO’s intent to have Emergency Physicians fax referrals to consultants; then have the consultant contact the Emergency Department with an appointment time; then wait for that Emergency Physician to return to the department for her/his next shift; then have have Emergency Department contact the patient? What if the given appointment is not agreeable for the patient and then needs to be rescheduled?
Unrelated, but perhaps most clear and important of all, in Ontario’s Schedule of Benefits (http://www.health.gov.on.ca/en/pro/programs/ohip/sob/physserv/sob_master11062015.pdf), on page 9 of the General Preamble, it explicitly specifies that it is the responsibility of the billing physician, in this case the CONSULTANT physician, to “make arrangement for appointments for the insured service”.
This is appropriate given that, since it is is the consultant physician who is generating the revenue from the service in question, then it should be the consultant who also incurs the administrative burden and overhead costs associated with the service. I cannot fathom a business model in which this would not be the case.
In summary, for all of the reasons above, I implore the CPSO the revise its proposition on this matter. Specifically, in the CPSO’s draft policy on “Continuity of Care”, under Appendix D, “Transitions in Care”, under the “Communicating with Patients” section, on Line 211, that it specify the “CONSULTANT physician must communicate the estimated or actual appointment date and time to the patient.”
I want to address the suggestion that family physicians are required to communicate specialist appointments to patients. This makes absolutely no sense whatsoever. This creates opportunities for communication breakdown and detrimental effects on patient safety. Specialist offices should certainly be required to contact patients directly to book appointments, and then can send a notification to the family physician that the appointment has been booked. It is clearly completely not patient centered to have a specialist’s office book an appointment at a random time which may or may not be convenient or feasible for a patient, then require the patient’s family physician to contact the patient with this information. This creates an unnecessary additional step in the communication between the specialist’s office and the patient, which could lead to an appointment not being communicated correctly and ultimately to patient harm. The only justification for the process being advocated (that specialists contact the referring family physician requiring them to contact the patient) seems to be to reduce specialist office workload, which is an entirely unsatisfactory justification. Ensuring that the referring physician knows an appointment is booked could easily be done by sending a confirmation to the referring physician.
Other provinces (e.g. Alberta) with similar policies require specialist offices to contact patients directly for appointments. We should be striving to improve the extent to which effective, patient-centered communication is a principle of our health system, and requiring family physician offices to communicate specialist appointments to patients does not support this aim.
I am writing re Continuity of Care, specifically lines 211-213.
I believe that patients and specialists’ offices should communicate directly. Having the family physician’s office act as a go-between poses logistical and patient safety issues. Only the patient knows when they can and cannot attend for a specialist appointment. This needs to be discussed directly with the consultant’s booking person, not the referring physician’s staff. There is too much opportunity for missed communications and dropped contact points for this to be the preferred method. I feel strongly that once the referral is received, the specialist’s staff should book directly with the patient and fax/email back the appointment info to the referring physician. Any other method leaves potential for error, delay and harm.
In regard to your Continuity of Care policy I have several comments to make. A general comment is that, while the policies set forward represent care in an ideal world, they do not take into account the reality of practice in Ontario. These regulations will add a significant burden to physicians both financially and in terms of physician and staff time. The regulations will have a particularly adverse for physicians in solo practices, and in remote and rural areas, for whom the coverage required by the new policies will be extremely difficult, if not impossible to implement. These physicians are at already high risk of burnout. I fear that many may choose, or be forced, to close their practices, which will leave already vulnerable communities without medical care.
As a specialist practicing chronic pain management in a tertiary centre, I am concerned about the regulation regarding the acknowledgement of referrals within 14 days. Our pain clinic receives hundreds of referrals every month. Our triaging is provided by a nurse and a physician, who do not have dedicated time, but rather take on this responsibility in addition to their clinical duties. The hospital does not have the budget to support a dedicated triage staff. This is a common situation experienced across specialties in our hospital. Although we process referrals to the best of our abilities, we cannot respond to all referrals within 14 days, and referring doctors are made aware on this on our website. The CPSO mandating that we complete the process faster will not provide us with the resources that we would need to do so.
I would also like to express my concern on the duty to inform if lab results are received in error. While it may be reasonable, if onerous, to inform the lab/testing facility of the error, it is not reasonable to expect a physician to contact a patient with whom they have no therapeutic relationship, and in fact no legal right to access that person’s medical information. It is dangerous from a medico-legal perspective, as the physician has no knowledge of the patient’s underlying condition, or of the context in which the test was being ordered. It also should not be the physician’s responsibility to inform the ordering physician. The lab/testing facility should correct the error and send the results to the right physician.
Finally, I am concerned that the new policies will encourage unrealistic expectations on the part of patients. A growing segment of the patient population feels that their doctor should be available to them at any time of their choosing. I notice that what constitutes acceptable access to appointments includes allowing for same day visits. This is of particular concern for specialists who may only have one or two clinic days per week, with responsibilities to other services in their hospital for the remainder of the time. I am concerned that the new regulations will lead to a rise in College complaints from patients who feel that they are not being seen fast enough, without an understanding of the limitations that the system places on physician practice.
Thank you for the opportunity to comment. I hope that the College will consider that any new policies put forward must take into account the fact that we are working in a healthcare system with increasing demand and decreasing resources, and not punish physicians for the shortcomings of the system.
Thank you for the opportunity to provide feedback on the “ Continuity of Care” draft policy. I am currently in a focused practice role. As such I see the issues both as a primary care provider and a consultant since many patients are referred by their family doctors. I find some of your recommended changes quite prohibitive and/or problematic.
1. Voice mail response.
We respond to our voicemail within 24 hours during weekdays. Our message clearly states our hours and availability as well as where to access care if the need is urgent. I am concerned about your requirement for answering voicemail on a “timely basis”. Who decides what is “timely”? Sometimes patients do have issues that may require they seek health care outside of our availability. I believe it is our responsibility to communicate as clearly as possible when and where they should seek urgent care but not necessarily act as a call Center to triage their requests! We simply are not resourced to do this. I can’t imagine how my collegues in busy full time practices could possibly fulfill this requirement.
2. Physicians in a “sustained patient-physician relationship” must arrange for another health-care provider to provide patient care during both planned (e.g. vacation) and unplanned (e.g. illness) temporary absences from work and inform patients of the coverage arrangement.
What does “ sustained patient physician relationship” mean? I find this a vague and problematic use of language, should there be an issue. We follow some patients for the duration of diagnosis and treatment for which they are referred to us. Is this a “sustained” relationship? Although we are not the primary care providers for most of our patients, many do not have family doctors. We cannot be expected to fill this role. How do you suggest we ensure coverage if sick or on vacation? Again, I would reiterate I believe our role is to communicate to the patients when and where they should seek care if we are unavailable.
Patients, not just health providers are responsible for ensuring their health needs are met. We simply can’t be all things to all people. It’s is not appropriate or necessary. I believe whole heartedly in continuity of care and see the problems of fragmentation of the system. I simply to not believe these proposed continuity of care changes will address the problems and they may create further problems!
I have issue with the ability of patient to access their doctor via telephone 24/7. Any testing be it screening or focussed has a context behind it that could affect the importance of a result. Also, the normal ranges vary from person to person and the trend is more important than individual results. By asking doctors to answer calls 24/7, you will be increasing enabling patients to act on “noise” from lab results and the actual “signals” ie true positive and true negative results in a significant clinical context, will to be drowned out. By enacting this policy, you will cause untold harm to patient as physicians will end up reacting to the noise that testing inevitably generates, while actual important (ie clinically significant) testing will be harder to respond to. In addition you will be causing higher rates of physician burn out and stress which will make the outcomes for patients even worse.
I don’t often respond to this kind of thing, but the CPSO’s actions are placing doctors and patients at risk. Not to mention you will be turning patients into “clients”. Patients are not clients. As we have found out through the excellent choosing wisely campaign, if we increase responsiveness (ie we respond to the patient’s wishes as opposed to what is clinically important) then we cause increased harm. The opioid crisis is a case in point. Cancers caused by radiation due to unnecessary medical imaging are another. Part of medical stewardship is explaining when somethings that the patient wants may not be in their best interest. This makes our job somewhat “disagreeable”. However we as doctors are not in the profession to be agreeable. Our job is to look after our patients’ health.
I am writing re Continuity of Care, specifically lines 211-213.
I believe that patients and specialists’ offices should communicate directly. Having the family physician’s office act as a go-between poses logistical and patient safety issues. Only the patient knows when they can and cannot attend for a specialist appointment. This needs to be discussed directly with the consultant’s booking person, not the referring physician’s staff. There is too much opportunity for missed communications and dropped contact points for this to be the preferred method. Our department has looked at this issue closely, and we feel strongly that once the referral is received, the specialist’s staff should book directly with the patient and fax/email back the appointment info to the referring physician. Any other method leaves potential for error, delay and harm.
Excellent and very Cogent thinking! My wife and I, both family physicians working as FHG and WIC drs. are seriously considering early retirement due to draconian CPSO guidelines and policies, and MOH indifference and disrespect.
No wonder new docs are wary of working in Ontario
I work in a walking clinic many many time the patient for confidentiality / personal/ trust ….issue related to sex , dose not want his or her Family Dr. To know about the visit this is included patient seeking 2nd opinion , who for a reason do not want there Family dr to know about the visit , I would say 80-90 of time Thank
1) If physician availability was increased then there would be less ‘inappropriate utilization of walk-in clinics/ER’-physicians should be required to work a specified number of hours/week based on their roster size. Their office hours should be spread over a reasonable number of days eg. not just 2 full days/week
2) Discharge summaries – should be timely. Family physicians are required to see a patient within a week of discharge from hospital – it would be great to have a discharge summary not just a med list at that appointment.
3) Hospital care – if a family physician is required to followup on tests or book ongoing tests after discharge then this should be outlined in the d/c summary. It can’t be assumed that the family physician will f/u on each abnormal test result generated during a hospital stay – often the tests don’t reach the family doctor or the family physician may assume that the f/u test will be arranged by the hospital
4) Consult notes should be sent to the family physician after each assessment – don’t have to be long, just keep the family physician in the loop.
5) Walk-in Clinics should be expected to meet the same standard of care as an office family physician – See patients in person (not on a video screen), follow-up test results, notify family physician if urgent f/u required
I strongly believe that the requirements set out in the new draft for WI doctors is unreasonable and puts all the onus of health care continuity on the WI doctor instead of being shared with the patient. WI doctors do not have the time/resources to fulfill all of these requirements and this will not necessarily result in better continuity of care. Patients can and should decide how they will follow up and with whom this f/u will occur. WI doctors are here for acute/episodic care and should not be expected to act like a patient’s family doctor. These new policies will close down WIs and send more patients to the ER unnecessarily.
1. Family Doctors should not be responsible for paying for extra staff, phone lines, toner, computer software to keep track of and COMMUNICATE the specialist appointment and special instructions. WHERE DID THIS COME from? I am so upset that specialists get away with ONE part time receptionist while I have 2 full time staff AND their phone lines are NEVER answered and I have 3 phone lines. If I request a specialist to consult on my patient AND provide you an amazing referral / all contact info … the least you can do is manage it from there and communicate the appointmnet you have given to my patient directly!
2. HRM / EMRs are drowning family doctors in hours of admin work. EMRs take 3x longer to review labs / reports AND record visit SOAP notes. HRM is sending us so many useless documents “patient arrived at ER” no other details “pt had xray done” but no xray results “patient discharged” but no discharge summary. Recently HRM has had a lot of problems and “dumped” reports back to 3 weeks ago in my INBOX just incase they had screwed up and missed some… now I have 6 extra hours of work to do BECAUSE OF THEIR MISTAKE and nobody is compensating family docs for their mistake!
3. There is no role for walk in clinics! Need more comprehensive care doctors providing quality medicine and followup! Why would a busy city with over 100 doctors in FHO’s need walkins 1/2 block away from them. Patient’s ALWAYS end up back in my office after seeing walkin clinic. Government, OMA or CPSO need to do PR campaigns to educate patients on HOW to seek care for their concerns. What is a family medicine concern vs. emergency
4. 24 hour primary care is ridiculous – if you have a concern that cannot wait 1 day to see your family doctor … it is an emergency.
Thanks for making these policies available for review, and for inviting feedback.
Like others who have posted on the online forum, I have concerns about requiring voicemail where patients can leave messages after hours. As a family physician, I feel that I do have an obligation to make my staff reasonably accessible during working hours. It is not clear to me why an after-hours message service is needed; anything of an urgent nature should not be left on voicemail anyways, and everything else can wait until the next day. Rather than leaving the responsibility with the patient until she contacts us, leaving a message now shifts the responsibility to my staff, who are unable to clarify anything with the patient in real time. While this kind of “push” messaging (email functions the same way) may be convenient for the patient, I suspect that it will generate more work for my office staff, who will now need to track down the patient for further discussion unless the issue is perfectly clear (most aren’t).
I also take issue with the oft-trotted-out implication that family medicine offices should implement “advanced access” in order to accommodate urgent issues. The footnote (line 64) refers to HQO’s Quality Compass Regarding Timely Access, whose site lists subjective patient data about the inability to get an appointment “when needed” (whose definition of “need”?) and whose recommendations consist solely of “expert opinion” (i.e. no hard data here). Working in a community Emergency Department, I have heard numerous patients complain about how some “advanced access” practices function in reality: a frustrating telephone rush for appointments in the morning, with the inability to book an appointment at a later date even if that would suit the patient. However, it seems as if the superiority of this approach has reached the level of dogma in several medical organizations; to the contrary, I will continue to book most appointments in advance and leave call-in spots for the minority of problems that require urgent attention.
The more bylaws , the more regulation , the more political tasks on community base Physician with a very much absolute rescues, Will negatively impacts the quality of care to the client , we are all ready running on maximum speed on a gravel road , more weights on will tip the the bus, we have to deal with each individual case by its on .
Thanks
I am a family doctor in a small community east of Toronto. I have always been a fan of continuity which is why I have continued to do inpatient care along with previously doing ER and obstetrics in order to provide various levels of care to my patients.
Many parts of this proposal appeal to me such as consultants responding to us in timely fashion about appointments but I have concerns that I have below which is a reply I gave to the OMA
“1 Leaving messages on an answering machine is a time bomb. Historically, we have been advised by CMPA and other groups that this is not advised. Physicians are facing been burnt out with reviewing results sent to us 24/7 via remote access on our EMRs . This will do many of us in.
2 Follow up on tests. I already remind many of my patients to do follow up but I find many of them still do not. Some times they decide that they don’t want the tests, despite discussion or they can’t fit it into their day. When does it go from our responsibility to patients’ rights and responsibilities? After reminding once or even twice , I leave it alone. “
I just reached 25 years of practice in an underserviced community. What I have found is with EMR and fax servers, my “days off” and “vacations” still find me logging in to check messages, tests and med repeats when I am trying to have a break. Please ensure that this will not worsen or I may have to consider closing my practice sooner than I had anticipated..
I strongly disagree with the draft policy regarding communicating referral appointments with patients. Specialist offices should schedule appointments directly with patients, rather than downloading this responsibility on to the referring doctor’s office. It’s much more patient-centred for the specialist office to contact the patient directly, in terms of convenience and patient safety. It allows patients to have their questions about the appointment (instructions, location, parking, etc) answered directly and would reduce no shows as the patient could communicate their availability at time of booking. This would simplify an unnecessarily complex process, cut out the need for the family doctor’s office to serve as intermediary, and improve patient care.
I am a family physician. My concern relates to Managing Tests Policies – If I am reading this correctly, I don’t understand why the family physicians have to follow up on labs/test results that are ordered by another physician. Especially if the ordering doctor ordered something very specialized that is not usually within the scope of a family physician.
I believe it is the patient’s responsibility to do the tests as requested. I do agree we should have the tests ordered on record but I do not think we need to chase after the patients to have the tests completed. Yes, if I am very worried, I would follow up but I feel that asking us to track all “Urgent” tests is quite vague and open to interpretation. This burden of work would be unbearable and how do you define what is ‘urgent’?
I do not think having a voicemail 24 hours a day is particularly helpful. I don’t think we will truly be able to help patients to improve their health with this. I believe it will be difficult to follow up with these messages.
I do not think it is feasible to check lab results/ diagnostic imaging results every weekend for the entire year. this is an unrealistic burden on doctors.
I have been retired from practice for many years and am reluctant to comment because I am no longer involved. But I am very disappointed in the direction this care has gone, due to underfunding and consequent reduction in quality of long term management. There are some examples of careful follow-up programs but they are not used as examples. Poor funding has reduced quality of many programs and also the co-ordinating ability of CCAC.
I recently experienced an example. A couple whom I have known for some years has had marital problems due to violent behaviour resulting from Chronic Behavioural Disorder. As this became more serious one person (the patient) began striking the other and the police were involved When the police witnessed their behaviour they took the patient to Emergency. I sat in Emergency with their partner for 6 hours before the patient was admitted to Psychiatry. On medication she improved and was sent home on psychotropic drugs. After some time they paid me a visit. The patient could hardly walk or speak….grossly over medicated. The patient’s partner had asked their GP for help but was told the referral to Psychiatry by the GP was not answered. In consequence the next day this patient was sent to Emergency (!) by the GP where and the patient was re-admitted to psychiatry. Finally the patient was put on an appropriate medication, behaviour controlled and now is followed up in a Geriatric I Centre.
This is a long story but illustrates a number of failings and why a program needs to be well developed, funded, supported and evaluated.
I am a family physician. This speaks specifically to the referral process section of the policies, whereby family physicians will have to notify patients of appointments made by specialists. After having read this, I spoke to members of the public and have not found a single physician (family or specialist) or patient in agreement with this. I did take a poll in July among my own patients but stopped within 1 week after 100% felt that this would be an unwarranted, inefficient burden on the family physician. The specialists I spoke to found this “quite insulting to family physicians” and “unsafe for the patient”. Interesting comments from some specialists who themselves are asking family physicians to notify the patients: Although they continue to do this from their private offices, they are not necessarily in favour of setting this as a College policy. Perhaps they feel that a policy against family physicians might also adversely affect them in the future? I don’t know. By human nature, I admit that I would be more inclined to refer to a specialist whose office will notify the patient and then send us a notification of this appointment. That is how I feel proper communication should be handled.
I believe that this section of the draft policies is not in the interest of patient safety. The responsibility of notifying patients belongs to the office that created the appointment. Sorry to be so strongly negative about this policy but it is very important to our patients. If your group cannot yet come to a consensus on a good policy for this, then leave it out for now and at least don’t put in a bad one.
Thank you.
Hello,
I have various concerns regarding this policy
Most importantly
I don’t believe that a letter should be sent to the FD for every walk in clinic visit. Not only will it add burden on the walk in physician who has a room packed with waiting people which will add to slow wait times. But also I don’t feel it’s necessary for me to know that Mr. X had a cold on Tuesday and was told to take Tylenol. I can understand for life changing treatment but family physicians are already over burdened by paper work and to add an extra requirement that most often is completely unnecessary just adds another layer of complexity.
While I am reading your policy
I realize that what you are asking is completely unreasonable.
Especially ensuring that your patient has the done the test that you have ordered.
Our patients should be responsible for their own health.
The administrative time spend calling people to make sure they have done their testing is not feasible.
It is the responsibility of the patient to make sure they are doing the tests.
If I provide a patient with a chest x day and they decide not to go that’s their responsibility.
Asking us to supervise them is inappropriate. I am not a paediatrician. My patients are adults and should be treated as such.
This policy should be revamped.
“All physicians who order tests must ensure that critical tests results can be received and responded to 24 hours a day, 7 days a week. This will necessitate making coverage arrangements for those times when they are unavailable”
Hi, I would like to comment on the above recommendation in the continuity of care recommendations. It is near impossible with our resources to be able to meet this expectation. Physicians cannot be on call 24 hours per day. If a lab result is that urgent, the lab, whose technicians are up during the night, can recommend that a patient go to emergency. This would indeed be a rarity. This is an appropriate policy for an emergency department, not for a physician office setting.
“Tracking test results for high-risk patients is an important component of test results management. Doing so will help determine whether a patient has taken a test or, whether a test result has been lost or missed. Therefore, the content in the current policy with respect to tracking test results for high-risk patients has been retained and clarified”
The above recommendation is a good one, but we simply must have an emr that can help do this for us. At present, I feel that most emr’s are still not sophisticated enough to let us know appropriately what tests have been done, what have not been done. There are big gaps in the technology. This is a particularly onerous task for family physicians, who have multiple different tests that they order, not just a few. How will we be assisted to accomplish this? Who will be defined as a high risk patient?
I have reviewed key elements of the draft CPSO policy on continuity of care. I do not feel the policy is practical in its current form. My concerns are outlined below about specific elements of the draft policy which I have cited:
“Physicians must have an office telephone that allows voice mail messages to be left during operating hours AND outside of operating hours reviewed and responded to in a “timely fashion.” The voicemail outgoing message must be accurate and up to date regarding practice hours, closures and coverage information.”
CONCERNS: What is timely? Would voice mail messages have to be archived? Is this even feasible?
As stated in feedback by a physician on the CPSO website: “I have issue with the ability of patient to access their doctor via telephone 24/7. Any testing be it screening or focused has a context behind it that could affect the importance of a result. Also, the normal ranges vary from person to person and the trend is more important than individual results. By asking doctors to answer calls 24/7, you will be increasing enabling patients to act on “noise” from lab results and the actual “signals” ie true positive and true negative results in a significant clinical context, will to be drowned out. By enacting this policy, you will cause untold harm to patient as physicians will end up reacting to the noise that testing inevitably generates, while actual important (ie clinically significant) testing will be harder to respond to. In addition, you will be causing higher rates of physician burn out and stress which will make the outcomes for patients even worse.”
“Physicians must co-ordinate care for their patients during temporary absences from practice – both planned (e.g. vacation) and unplanned (e.g. illness) and inform patients of the coverage arrangement. Physicians must arrange for another provider to provide care during these absences. Physicians must also inform patients of coverage arrangements during temporary absences.”
CONCERNS: How is this feasible for an unplanned absence, which is by definition sudden and unforeseen? How can an unaffiliated health care provider of the same specialty gain access to the absent physician’s office and EMR? With shortages of specialists and long wait lists, finding another physician to cover even a planned absence is usually not feasible. What happens when multiple specialists are away simultaneously attending a specialty CME conference?
“Physicians in a “sustained patient-physician relationship” must have a plan in place to coordinate patient care outside of regular operating hours.’
CONCERN: If the plan does not allow for “going to ER, going to a walk-in clinic, seeing the primary care physician, or calling Telehealth” as the menu of choices provided, it is a recipe for specialty physician burnout.
“Physicians must be able to receive and respond to critical test results 24 hours a day, 7 days a week, or make coverage arrangements with another health-care provider to do so.”
CONCERNS: This is especially challenging to do for physicians in a solo practice. It is a recipe for burnout, and physician retirement ahead of schedule. This policy will drive physicians to other jurisdictions, worsening the Ontario physician supply in future. As physicians, we advocate a balanced lifestyle, as a precondition for good health and wellness in our patients. How ironic and counterintuitive that the CPSO policies promotes the opposite view for its health care practitioners. See above re the impracticalities of obtaining coverage.
“Physicians must copy the patient’s primary care provider on all tests ordered.”
CONCERNS: This is already done in general, but laboratories often fail to carry through, claiming that they cannot identify the physician to be copied on the test results, despite clearly printed instructions on the lab requisition.
“Physicians must track test results for “high-risk patients” (e.g. calling patients to verify they did the test and/or contacting the diagnostic testing facility).”
CONCERNS: High-risk patients may not be known in advance; only in retrospect when their behaviour identifies them as such. High-risk patients may be the most difficult to contact (fail to answer their phone, have no voicemail, change phone numbers or have no phone, no fixed address, etc.) It is unrealistic to expect physicians to phone high-risk patients and/or diagnostic facilities to verify that patients have done their tests. CPSO fails to mention the patient. Should a physician be solely responsible for ensuring that an ordered test is completed by the patient? Even high-risk patients must at least bear some of the responsibility to comply with a requested investigation. Physicians should not be expected to police our patients.
“Physicians who receive critical or clinically significant test results in error have an obligation to report the result to the patient or others involved in their care. If the test result is received incidentally (ie., physician is copied on a report), physicians must make “reasonable efforts” to notify the patient or ordering health-care provider if the physician has reason to believe that the ordering provider will not get the test result.”
CONCERNS: What is a reasonable effort? Some system must be in place to protect the patient and the doctor equally. The ordering physician is ultimately responsible for any test ordered, and the lab is responsible for properly relaying the results to the appropriate health care providers. The lab should be accountable. The labs should carefully verify they have the correct physician address, phone number, cell phone, home phone number and fax. Physicians in Ontario are already overburdened by administrative tasks on their own patients and struggling with adequate resources due to the ongoing unilateral cuts to our incomes for the last 4+ years. We cannot cope with additional unpaid work. It seems unreasonable that physicians have an obligation to notify a patient they have never met for fear of discipline from the College. I don’t want to become the default critical/clinically significant result handler, simply because I’ve been cc’d on a test requisition, or worse received a test in error.
“Consultant physicians must acknowledge referrals no later than 14 days from the date of receipt and indicate whether the referral is accepted and provide the actual or estimated appointment date and time. They must also indicate whether this information was communicated with the patient.”
CONCERNS: Fixed timeframe may not be feasible if volume of referrals is high or the consultant is away from their practice for more than 14 days.
Overall:
In conclusion, I cannot state my concerns more eloquently than a patient already has on the CPSO feedback page:
As stated by a member of the public in feedback on the CPSO proposals: “I think that these policies are overreaching and draconian. As a reasonable person, we as patients must accept some degree of responsibility for our care. Asking our doctors to be available 24/7 is ludicrous. What if they need a vacation? A small town doctor may not be able to find a replacement, should he then never be able to take time off? This will only serve to force doctors out of small towns. And as for having my doctor hold my hand to make sure I get a test done…. He has better things to do. If he tells me to get a test done after we talk about why I came to visit him, I sure am getting that test done. If I don’t, that’s on me and only me.”
I can understand the rationale for the policy, however at this point in time, the policy is extremely ill conceived. Ontario does not have the infrastructure to easily share information between physicians. In its current form, the administrative burden to physicians, given the current state of negotiations with the government, would cause many physicians to essentially work for almost free. If this policy is enacted, then the government needs to create a continuity of care code to cover the expense of transfer of records. The cost should also be pressing the government for a unified emr strategy that readily allows the sharing of medical information. Applying this policy to walk in clinics, but not to emergency physicians also does not make sense. I suspect that the reason for not including ER physicians is that the cpso knows that the cost to the system would be too high and too burdensome at this point in time. If that is the case, the cpso needs to hold off implanting any such policy until the standard can be applied to all levels of care fairly and uniformly.
I have serious concerns about the policy as it relates to specialist referrals. As a family physician with approximately 900 rostered patients, I make approximately 5 referrals per week to specialists. My staff endeavour to facilitate the bookings directly with specialist offices but this is increasingly time-consuming and challenging to track all referrals. It is in the best interest of patient-centred care if the patient is able to book their appointments directly with the specialist office, in order to prevent “broken telephone” of appointment timing, what to bring to visit, and contact information. Family physician offices still need to receive some notification of the appointment but do not need to be involved in appointment booking. It is unfair to expect that all of the time and effort falls on family physician office staff and not somehow a split responsibility with the specialist offices.
Please find here PARO feedback on the CPSO Continuity of Care suite of policies.
I have concerns over walk-in clinics.
It is difficult for patients to get a family doctor; if the physicians staffing walk-in clinics would set up regular offices, this would be much less of a problem.
Many years ago, when I contemplated reducing services to a remote community where I had voluntarily initiated a service, a senior government physician threatened to report me to the CPSO for “abandonment”. By their very nature, walk-in clinics feature “abandonment”.
In over 4 decades, I can’t recall more than one instance where a walk-in clinic physician has let me know what happened when one on my patients has been attended by them.
It is my opinion that the CPSO should strongly discourage walk-in clinics, and encourage all physicians to attach themselves to a permanent practice.
I feel it is part of the “social contract” of the CPSO with the people of Ontario to supply equitable medical care to the people of ALL of Ontario. Allowing walk-in clinics violates this contract.
I support the CPSO policy of sending the report to Primary care physician so that they are in the loop to maintain the continuity of care.
I work comprehensive care family practice with 3 evening after hour block/ week and each Saturday. Still my patients are going to various Walk in clinics as it happens to be convenient for them.
I regularly have patients decline an appointment even on same day as they want a specific time that is taken usually after 5 pm, and say they will go to walk in clinic instead
Many of those doctors working in the walk in clinic can simply open a practice and choose not to. They can do shifts as they like. They can see multiple patients in a shift with mostly non complicated issues whereas we have to spend at least 15 to 20 min. per visit to cover the elaborate list of issues patients bring to us.
I also think that follow up or referral should be done by PCP only.
No referral except to ER.
Now a days patients are very demanding and they bring a elaborate list of things they want to be done .
They threat the family physician that if list is not fulfilled they will go to another Family physician and they regularly do that.
When a doctor terminate a patient they need to follow a procedure prescribed by CPSO. But any patient can change family doctor anytime specially within GTA without giving any hint to the family physician.
CPSO should bring on policy which should ask for patient accountability as they are adults who are aware of their rights but not responsibility. Most of the family physicians now, specially who are practicing in GTA are frustrated about their patients going to WIC and can do nothing about it.
This is very frustrating for me and CPSO should come forward with something that will prevent this trend.
Wow, __________ rolls downhill. Family doctors are already at the bottom of the rung and high overhead and now we must do more? Leaving messages 24/7 on an answering machine…..what a waste and huge medicolegal risk. No Way! Availability 24/7? ….why bother when patients can go to any walk in clinic they wish as many times as they wish and we get negated. And we do a lot of on call coverage. Walk In clinic NEVER send us any information. If a patient doesn’t want us to know they went or why then they should find a new family doctor. Many specialists also do not send us reports.
Am I supposed to be responsible for any lab result the specialist orders? even if I don’t know what it is or what it means clinically? Labs do call us with critical results….even if I didn’t order it.
Between the CMPA and the CPSO we have tighter and tighter requirements, higher office overhead and our OHIP Billings are reducing. How are we supposed to make all this happen?
Professionals that have control over their schedule and flexibility in their working hours are able to have healthier lifestyles.
Having time for family, exercise is very important to maintain a healthy physician.
All the pressures that have and will be inflicted over physicians will have impact on patient’s care.
All the impact of these demands that will be enforced on us will be noticeable somevyears from now.
I am a happy physician who is healthy and still providing high standards of care , if I do not have the time to exercise , have family time and be off work on vacation , I will be in the position of many Canadians currently suffering from obesity, chronic diseases , depression and anxiety.
I work in a walk-in clinic and it is completely unreasonable and burdensome for the College to expect MD’s to notify every single FP with our encounters, as well as any other MD’s possibly involved in the patients care.
Really??
We function in a digital age. Surely there could be a secure portal set up so that all MD’s could share information about a patient (and their encounters) without the burden being placed solely on the walk in physician.
There also seems to be a lack of acknowledgement that patients have a responsibility to participate in their own health care particularly around test results.
Re: Managing Tests Policy, specifically “test tracking” section
Most physicians will ensure that patients and their test results are managed in an appropriate way, including according to the guidelines set out in this policy. Many will also go above and beyond to make sure patients understand their testing requirements and results.
With this in mind, I object to some of the policy suggestions under the “tracking” section, which suggests that:
-physicians should track down high-risk patients who have not done their tests as requested
-and that physicians should track down laboratories to ensure they have the test result
This is not entirely appropriate for the following reasons:
1. Patients need to take responsibility for their health, and health care. If a physician requests a patient do to a test, and the patient is competent, it is the patient’s responsibility to get that test done. Patients already are unaware of how much their health care providers do for them behind the scenes, and they should not be given yet another excuse to add to the work! It is not the job of physicians to chase down patients, hound them, remind them constantly, etc. They need to take responsbility. Obviously, if a patient is high-risk, most physicians will take the onus to call the patient to ensure they are doing the testing that is required. However, it should not be a legally mandated practice.
1a) What defines high risk? Every physician will define this differently, and I think this should be removed from the policy. Perhaps phrase as “physicians are ENCOURAGED to contact high risk patients to ensure testing was completed”, not “physicians MUST contact…”
2. Most physicians will contact laboratories if there is confusion as to whether the test was done / received, etc. However, it is not physicians’ jobs to chase down labs and make sure they are doing their job properly. Laboratories need to be held accountable too – if patients do a test, but the lab doesn’t process or send the results correctly, that is the lab’s fault. Legislation should be provided to labs on this end. The work of sorting that out is often dumped on the physician, but should not be a legally mandated practice.
3. Physicians do so much behind the scenes to ensure quality patient care. Legislation and policy should be focused on enhancing that care, without further contributing to the administrative workload that physician and physician offices face. If the CPSO wants to add to the workload, then please also provide funding for each office to add extra staff, secretaries, etc, to help physicians deal with the extra administrative tasks.
Sincerely,
Specialist MD in Ontario
I am writing about line 211 of this proposed policy. This has been discussed by a large Urban Hospital Executive Committee as well as our Departmental Rounds. Our physician group feels strongly that the potential for delay in care, error in booking and patient harm is unreasonably high when consultants use our offices to book their appointments. Once a referral is received in a specialist’s office, that office must communicate directly with the patient in order to streamline care and avoid foreseeable booking errors. Informing primary care offices of the appointment information is very important, but not for the purpose of communicating with the patient. Placing our admins in the middle of their booking process will inevitably lead to delay, errors in booking and fragmented care for the patient. As Family-Physician-In-Chief at large Urban Hospital in Toronto, I want to ensure that the CPSO understands the importance of getting this right and the potential harm in getting it wrong.
All the draft policies are very well on it’s being a drafts, with current health structure in Ontario the implementation of these policies are only possible in a in FHO structure where the is an nearly unlimited resources available, other than that a small or a solo community clinic will be forced to close with it’s current limited resource , I think the Ministry of health / governments organizations have to be involve in there support for the implementation of these policies in a form of either conversation/ planning or advice etc.
We are having more than four health systems now in Ontario, one the have all the support and not following their obligations to patients care and and other are struggling to meet the demand of their patients and the demands of other groups patients.
We are going to be forced to close our door for patients of other group whom we offering services now and eventually this will negatively affect the patients or it will be impossible to operate and closed I think we need to have a policies to protect all but we need to also think about its implementation on the front line otherwise it will either fail or gives negative outcomes
It’s difficult to take this comment seriously when you start off with the statement that FHOs have “nearly unlimited resources available”. I’m in a FHO – we don’t have any more resources than any other physicians. The only difference is the payment structure.
Having read the draft policies, I find myself concerned for the future of medicine in this province, especially in more rural and remote areas. Expectations for 24/7 availability (especially in communities where you have a very limited number of physicians) puts an unrealistic burden on us and will only serve to drive more people out of clinical practice. The policy is also very vague, with many allusions to “the type of day, the type of community, etc.” that gives no real concrete guidance.
The expectation for providing coverage when you are away is equally excessive. It is difficult to find coverage, particularly in smaller communities and to add that burden if you are off for a serious illness or family emergency is almost punitive.
I agree with several of the other comments posted with regards to the responsibility of booking patients for consult appointments. It seems to just add another layer of work to have that done through the family physicians office, especially if that initially provided date needs to be rebooked, etc.
If these policies in their current form are adopted, you will likely find that many physicians, myself included, would have to reconsider their role within Ontario’s healthcare system.
I don’t quite understand why the college feels it is in the patient’s best interest to mandate that the referring physicians communicate estimated or actual appointment date and time to the patient. The referring physician does not have access to the consulting physician’s appointment book nor does the referring physician have any control over the consulting physician’s triage process. Furthermore, the appointment time handed down by the consulting physician to the referring physician’s office to communicate sometimes does not work for the patient. Unfortunately, the patient nor the referring physician’s office cannot offer a different time. It works best for the consulting physician’s office to communicate appoint dates and time directly with the patient to find a mutual beneficial time and cut out the phone/fax tag.
Regarding your draft policy:
• Referring physicians must have a mechanism in place to track that the referral has been received and that an acknowledgment of the referral will be provided. The urgency of the referral will determine the degree to which the referring physician must monitor the referral request.
• Referring physicians are also advised to engage patients in this process by, for example, informing patients that they may follow-up with the referring physician if they have not heard anything within a specific time frame.
This is an unreasonable request and expectation. As a specialist in Internal Medicine, it is routine for me to discharge 25-30 patients in 1 week. It is impossible for me to follow-up on all of the referrals for these patients. In a year, that’s almost 240 referrals to follow.
Patients will often choose not to attend specialist appointments. I am not going to track or engage 240 patients to call me back and ask about their followups. There needs to be an onus of responsibility with the patient, which this draft policy completely neglects.
This also propagates paternalism in Medicine, where we have to herd our patients like children to their appointments.
I am a qualified family physician who practices in a combination of settings: 35-40 hours per week in a walk in clinic alongside 2 family docs who have FIG practices plus 6 hour coverage for a different family physician / different town/ FHO group . I am CCFP credentialed , have been randomly audited by the CPSO in 2017. I treat every person as though they are my patient with a comprehensive perspective. The majority of patients seen at our WIC are new to the area having moved from Toronto, Mississauga, Oakville etc and have a family physician “ in name” only . They are actively seeking primary care closer to home but there are NO physicians in our area accepting patients . In fact, everyone is beyond full having absorbed the practices of 2 recently retired family docs.
I give this background to let you know that many of us are providing comprehensive care within an episodic setting for FFS.. no rostering “ perks” by the way.
Additionally, it has been my experience that some (30% maybe) do NOT want their regular family physician copied on results or the visit.
If our physician governing bodies want to enforce continuity/ sharing of information with other physicians ( which I’m all to , personally) then they need to allow us to do so without reprisal from the “ privacy police”.
Also: if a patient moves out of a geographical area that prevents him/ her reasonably accessing a rostered family physician, shouldn’t that spot go into an “ availability bank” of some sort. I believe that there is more “ vacancy” than initially meets the eye if we only had a way to track it / swap spaces etc c. Patients will keep themselves rostered in Toronto but get ALL of their family ‘s care in their new neighbourhood in Stoney Creek.
Thanks for reading. I am a conscientious family physician who dreams of greater PATIENT accountability.
As much as I applaud the College looking at expectations of walk-in clinics and managing test results, I suspect the lack of anyone on this guidance committee having practiced in rural or remote Ontario has resulted in the Availability and Coverage draft being yet another policy that negatively targets physicians in rural and remote regions as compared to their large urban counterparts. The College makes several allusions to wanting to balance burnout of physicians (which impacts patient safety and care) and direct patient safety in following up tests and providing 24/7 coverage for patients but does not outline how this is possible in an underserved system. As such, I outline how this impossible burden on physicians already stretched to capacity will result in reduced patient care, reduced patient access to services, and reduced patient satisfaction within rural and remote Ontario.
Within the Availability and Coverage document, the College outlines the expectation that “physicians must have an office telephone that is answered and/or a voicemail that allows messages to be left during operating hours and a voicemail that allows messages to be left outside of operating hours.”
The out of pocket expense to the physician of having someone answer phones seven hours a day, five days a week, and be able to go through all the messages on the phone, dictate into written form, and arrange appropriate follow up is $31,000 per year at a meagre hourly rate of $15 per hour plus benefits and taxes. One of the many difficulties in rural practice is in finding qualified personnel to work in the office and so this may be impossible in many areas. However, assuming such extra staff exists, to offset the extra cost in a rostered family practice setting would require 193 extra patients to be rostered at $160 each, just to cover that cost, further diluting care. At 2.4 visits per year for the 193 patients at 15 minutes each, you would need to be available 115.8 hours more per year, or 16.5 more days per year in the office beyond what you are currently providing. As many rural physicians work their offices around surgery (primary or assist), emergency room coverage, hospitalist care, home visits, long term care and hospice/palliation, this will undoubtedly negatively affect patient care as something else will need to be dropped to continue to carry office patients. Or physicians will leave office work behind them all together, as the cost benefit ratio becomes too prohibitive.
I also question the utility of being able to leave a voicemail on the office after hours. In the example in the recent Dialogue, “a pregnant woman who has been bleeding was instructed to call her family doctor for the result of her ultrasound test” but can’t get hold of her doctors’ office to go over the ultrasound results. This does not sound like a scenario appropriate for leaving a message after hours to be dealt with within a litany of other messages sometime the next day. This sounds like an appropriate visit to an emergency department, or a call to Telehealth, which is a provincial program that provides after hours direction to patients without putting another cost onto physicians. Voicemail in this instance may very well lead to a bad outcome for the patient.
The College draft also outlines “Physicians must structure their practice in a manner that allows for appropriate triaging of patients with time-sensitive or urgent issues” looking at appointment availability, specifically same day access for urgent care within family practice. Although this continues to resonate as a theme among health policy makers, the data indicates that increasing the number of spots of same day access does not translate into improved patient experience or satisfaction (in fact, there is an 8% decrease in satisfaction for every 10% increase in same day access spots1 or decreased number of emergency room visits2. In the Commonwealth Fund’s 2016 International Health Policy Survey of Adults in 11 Countries, they indicated longer times to see primary care and in emergency were likely due to the fact that “Canadians consult with physicians more often than people in other countries.” and that Canadians “visit emergency departments more often than people in other countries”3. In fact, what the literature shows is that patients want most is to schedule an appointment at a convenient time for them, more so than having speed of access, unless experiencing a brand new issue1. This is reflected in findings that show patients generally attend walk-in clinics for convenience, not due to lack of access. In Szafran, et al “Of the 106 patients who attended walk-in clinics, 43.3% attended during weekdays (ie, Monday to Friday 9:00h to 17:00h) when their family physicians’ offices were open, 52.8% did not call their own physicians before attending the clinics, and 10.4% went to walk-in clinics within a week of seeing their own family physicians.”4 Access to primary care in Ontario is generally regarded as favourable already5 and is comparable to levels of care in other countries3. That being said, ensuring you have a supply of same day appointments necessitates the lost of pre-booked appointments in order to care for patients safely.
The largest bottleneck in out of hospital care is in specialty wait times3 and this is not mentioned within this draft policy at all.
Based on this data, it would make most sense for energy to be expended at decreasing Canadians overall health care usage through education, rather than providing even more access at the detriment of patient safety due to dilution of physician supply and patient satisfaction.
The College also states “Physicians providing care as part of a sustained physician-patient relationship must have a plan in place to coordinate care for patients outside of regular operating hours. The nature of the plan will depend on a variety of factors.”
As already discussed, Telehealth already exists in Ontario and provides after hours information for patients. When there was a small stipend available for physicians to also be on call to answer questions and calls that came up through Telehealth, we felt this did work out quite well. Patients were cared for from a call group who was able to access patient records if they worked in a group. A small stipend was enough for most physicians to feel as though they were able to retain some autonomy and were not being taken for granted once again for their services. Both do affect burnout6 of course. However, if you are not part of a call group, and you are working in remote or rural Ontario who do you get to provide after hours call with you? As perhaps the only opiate replacement provider for a 45 minute radius, who is this physician to team up with to ensure that patients can call at all times of day and night without putting undue burden on the physician? Who will help facilitate this, or is the answer to simply stop providing that service all together?
The College also states in its draft policy “During temporary absences from practice physicians providing care as part of a sustained physician-patient relationship must make coverage arrangements for patient care, the nature of which will depend on a variety of factors, and all physicians must make coverage arrangements for test results.” In areas of Ontario, where we struggle with finding locums, and the boots on the ground are already stretched to breaking due to a lack of physician providers7 how will this expectation be met? Or is rural Ontario again to be left behind as physicians find they cannot keep up with the rising costs of providing care in these areas, and simply leave this vulnerable population to hope the Ministry pays for a nurse practitioner clinic (that does not have the same expectations and so will not meet any of these requirements set out by the CPSO anyways)? Without a plan in place to assist rural and remote physicians to meet these requirements, rural patients will again be hurt.
As much as I applaud the safety mindedness of these draft policies, and see improvements in continuity of care with some of the suggested material, I feel it is another unfair burden on generalists in rural and remote Ontario to expect 24/7 coverage without providing the infrastructure on which to build such coverage.
References:
1. Salisbury C, Goodall S, Montgomery AA, et al. Does Advanced Access improve access to primary health care? Questionnaire survey of patients. Br J Gen Pract. 2007;57(541):615-621. http://bjgp.org/content/57/541/615.abstract.
2. Rose KD, Ross JS, Horwitz LI. Advanced access scheduling outcomes: a systematic review. Arch Intern Med. 2011;171(13):1150-1159. doi:10.1001/archinternmed.2011.168
3. Canadian Institute for Health Information. How Canada Compares: Results From The Commonwealth Fund’s 2016 International Health Policy Survey of Adults in 11 Countries – Accessible Report.; 2017. https://www.cihi.ca/en/health-system-performance/performance-reporting/international/commonwealth-fund-survey-2015.
4. Szafran O, Bell NR. Use of walk-in clinics by rural and urban patients. Can Fam Physician. 2000;46:114-119.
5. Premji K, Bridget C. Patients ’ perceptions of access to primary care L ’ opinion de patients sur l ’ accès aux soins de première ligne. Can Fam Physician. 2018;64:212-220.
6. Seidler A, Thinschmidt M, Deckert S, et al. The role of psychosocial working conditions on burnout and its core component emotional exhaustion – a systematic review. J Occup Med Toxicol. 2014;9(1):10. doi:10.1186/1745-6673-9-10
7. Charlebois K. ‘Crisis situation’ | Kenora Daily Miner and News. August 22,. http://www.kenoradailyminerandnews.com/2017/08/21/ontario-ndp-leader-meets-with-local-physicians-on-lack-of-healthcare-resources. Published 2017. Accessed July 22, 2018.
The WIC requirement to burden already overworked and underpaid physicians with having to notify a patient’s PCP of the visit is unacceptable.
Firstly many patients, probably on the order of 30% to 40%, specifically come to a WIC for a second opinion following a visit to the FP, or they are at the WIC for a private matter (i.e. STI) they do not want to discuss with their FP.
If we are required to notify the family physician about these visits without the patient’s consent we will be opening ourselves up to a huge medicolegal risk that is already significant in these settings.
There are also another 30% of patients who are registered to a family doc in a geographic locale far from where they either live or work now, but have been unable to find a new family doctor at that location. The WIC becomes their interim PCP until they are able to find a new doc which may take several years. To have to send a note to an old physician an hour or more away who no longer remembers that patient is just a waste of time and money, both of which are already in short supply with our burned out and depressed front line docs.
And last this would just be a huge administrative burden at the end of the day to have to look up the contact info of each patient’s physician and send a note. Only rarely does a patient ask to have a note sent to their physician so this clearly is not a priority for them, but if they request a copy of their investigations I will give them a copy of that. It then becomes the patient’s prerogative of what happens to that information.
It is pretty clear the College is over-reaching once again without having the knowledge of the potential collateral damage a policy will do out in the field.
This policy if implemented will only serve to encourage more FPs to leave OHIP medicine or the province altogether making the current physician shortage even worse.
This is INSANE. My family doc is already overloaded. Walk in physicians that I visit always seems stressed out. This proposal will turn family doctors and walk-in physicians into the equivalent of medical secretaries.
One principle that seems to be valued by the College, the government, and the public is that medicine should not be paternalistic. Patients should be involved and actively participate in their own care. Yet when it comes to policy positions the College continues to regard patients as helpless sheep. The responsibility for follow-up, continuity of care etc. is more and more rigidly regulated but all the rules apply to the physicians. There is never any responsibility assigned to the patient. What about trying to incorporate some reasonable expectations in terms of patient responsibility with respect to follow up issues? If we truly want the doctor-patient relationship to be a collaboration, the patients should also not be treated like helpless children and should have explicit rules which outline their responsibilities with respect to their care.
Canadian Medical Protective Association
Please see here for Feedback submitted to the College from the Canadian Medical Protective Association.
Thank you for this extended consultation opportunity.
I am writing to add my voice to the many respondents, both specialists and family physicians, who have pointed out that the consultant’s office is best suited, in most instances, for making appointment arrangements directly with the patient. The reasons are self-evident, being the same ones as expressed in the expectation for
Consultant physicians to communicate with the patient directly regarding any instructions or changes in the
appointment date and time.
For routine referrals (i.e., competent patient, non-urgent condition), my office has adopted an additional practice that has proved effective. Our referral letters include the line, “The patient will contact your office a week after this letter to arrange an appointment.” We engage the patient in the referral process by providing them with a copy of the referral letter, which includes the consultant’s contact information, so that they can book directly. This works extremely well.
There is no doubt that the appointments made at the specialists Offices have to be made and confirmed by the specialists Offices. It is inappropriate for private practice physicians outside that specialist office to make the appointments and remind the patients of those appointments. I certainly would like the Specialists secretaries to make all of the appointments in all the family physician offices and confirm those appointments. It certainly would save the Family physicians secretaries a lot of work.
1. It is my understanding the CPSO continuity of care proposals suggest that family physicians’ offices be responsible for the booking of specialist appointments. This is simply unacceptable. This should be the responsibility of the specialist. I personally, experienced a “missed appointment” when the specialist to whom I was referred faxed a fax to the referring physician with appointment date/time…a fax that was never received..hence I was never notified of the appointment. The consultant is getting paid for a “new consult”, the referring physician is not paid for the time it takes to write the referral/send appropriate documents, etc.
Surely part of that consult fee should include both the making of the appointment by the specialist, AND a consult note (which is not always sent to the referring physician, by the way).
2. Patients are still being discharged from hospitals/emergency departments, with no information provided in a timely fashion (often not at all) to the family physician–even when the FP is clearly identified on the patient chart. This should be the hospital’s obligation. and time after time family physicians are seeing patients
post discharge with NO information..which compromises patient care.
When e.g. mole excisions are done, the referring physician should be copied with pathology. Recently I had a pt who was told by the specialist that her mole was fine…yet when I was finally able to OLIS the pathology (NO copy was sent to me)…it was clear this required further excision…AND the specialist initially declined to do so, without a new referral. How is this continuity of care? When
a surgeon does surgery, why do they not followup for suture removal?
(I had a patient last week who attended my office for what she insisted was suture removal-no discharge notes re her cancer surgery, and no information from the specialist re pathology, nor whether these sutures were in fact to have been removed–indeed these were not to have been removed and fortunately I did not remove them.
3. It is my understanding the CPSO somehow expects family physicians to be able to track/ensure receipt not only of every imaging test they
order, but also every lab requisition /lab results that are ordered.
Most EMR systems approved for use in Ontario-do not offer this capability, which makes this CPSO expectation impossible. There have been laboratory glitches, there are non-compliant patients.
It is not clear when the physician’s obligation ends and the lab/patient’s obligation begins.
Our office does all we can to track important imaging, but even last week we discovered an MRI result that was never faxed to our office (the ordering physician), and calls to the chief of radiology about this issue/to medical records at the hospital in question, have not been returned.
4. The refusal of many specialists to continue to follow those patients they have been following for years without a “new consult”
referral from the family physician every 6 or 12 months is unacceptable. There are specialists who have followed patients for more than a decade who refuse to see their patients, or will clearly indicate they will be put on a long wait list unless the family physician complies with a new “consult” referral–which does little more than add a consult fee to the specialist’s pocket. Surely this is not continuity of care.
5. there is no consistency between (for example) accredited mammography institutions when an abnormal result is found.
Some will proceed to arrange for further testing (eg. magnification views/ultrasound), others will fax a report to the family doctor insisting a new requisition is sent for these further tests ..which adds one more level where things can go wrong. Other facilities notify both the patient, and the physician that further tests have been ordered…but there is usually no notification to the physician if the patient doesn’t show up for the further testing.
Hello,
Thank you for the opportunity to consult on these policies.
I have a few comments.
1) Diagnostic tests: there are some nuances for physicians who practice primarily in hospitals that may need to be worked out. For example, relating to follow-up of Diagnostic Test results, the EHR at my hospital does not allow me to assign other providers to receive/track the results. Therefore it may be difficult/impossible to comply with the policy for technical reasons, which is completely out of the physicians’ control. Unfortunately, is no way in my EHR to track which tests are ordered but not yet completed (or not yet resulted).
2) Referrals in hospital: Again, for those who practice in hospitals, it may be difficult to create a system to track referrals (both in the inpatient and outpatient setting). Physicians may have limited control over the administrative policies/practices/resources/technology in the hospital. In some cases, the hospital may mandate practices that are not consistent with this policy – for example, at our hospital it is considered the consultant’s responsibility to arrange follow-up with their service, not the MRP.
3) Referrals: I strongly believe it should be the consultant’s responsibility to communicate with the patient about the appointment date/time. Adding an extra step to the process only serves to increase the workload for the referring physician and introduces another step where the process could break down. By communicating directly with the patient, the consultant’s office could book a mutually agreeable appointment date/time, rather than choosing an arbitrary date and having to re-schedule later with the patient. In sum, the consultant should be responsible for booking the appointment and communicating with the patient. By this token, the referring physician must provide up to date contact information in their letter. This policy is an opportunity to shift the system towards a more optimal future state, rather than simply reinforcing the existing state.
4) Overall:
-For hospital settings, I think there needs to be an acknowledgement in the policies of the shared responsibility of the physician AND the hospitals in terms of creating (and funding) systems/technology to ensure to achieve the goals in these policies
-There should be an acknowledgement of the shared responsibility of the MOH/Province of Ontario to facilitate/create/fund the optimal technology and systems (i.e. EHR) that are required to implement these policies in a meaningful way
-A risk of these policies is that they generate additional administrate work for physicians and their support staff; no mention is made of how to mitigate these risks
Hello team,
I am quite concerned re: the cpso’s Draft policy on walk in clinics and continuity of care. My colleagues and I are caring physicians who try to provide effective, compassionate care and advocate for our patients wherever we can, however increasingly we are faced with patients expectations that are increasingly demanding and often we feel bullied. Despite having family physicians, many pts simply attend our clinic because it is more convenient. Other patients who don’t have family physicians, when referred to local family physicians accepting patients, will refuse to enroll with them, and insist that we assume the role of their family physician, either because “they like us” or again, our location/hours are more convenient. When advised and educated about the importance of a family physician, we are met with resistance, and in some cases hostility. We feel that our profession is being devalued, and that increasingly patients are treating physicians as if they have no rights at all. My colleagues and I are caring physicians, and as such we do order tests, make referrals and do our best to help the patients we see, but there has to be defined limits on what patients can expect in this setting.
I am a patient advisor and am reviewing the Continuity of Care and plan on writing a review which is going to be time consuming. My question is once the deadline passes and you can draw more conclusions and put together a final draft will it become mandatory or just suggested?
I have a question to the powers that be, Once a final draft is established do the findings become mandatory or voluntary
Mandatory until the physician is not well.
I am an active patient advisor involved with numerous healthcare agencies ad I read the proposed piece and saw some interesting points however after reading comments and talking to some area doctors I will not make any comments. You need to get your house in order, There seems to be large gaps in positions between the actual doctors and the members of the college. If some of the issues were instituted the issues between doctor and doctor and patient and doctor and could ruin what we have now, it’s not great but better than having all the wheels fall off. I would be willing to look at a revised statement
I am in agreement with the majority of the responding physicians indicating concern for: 1. management of lab tests; 2. management of after hour phone calls; 3. WIC physicians’ responsibilities; 4. specialists’ offices should be responsible for advising referred patients of an upcoming appointment, not the FD or WIC. That is all I can remember for now.
I would suggest in the future drafters of policies should include rural and urban physicians. I am not convinced there were any physicians drafting this document? Practising in clinics?
This policy draft has only served to anger, frustrate, and concern physicians, and does not convince me that the people at the CPSO are 1. realistic; 2. cognizant of the incredible resource burdens that physicians, both urban and rural, are dealing with, while also working with an organization (the government) which also has no respect for our profession; and 3. concerned about physician health and well-being.
Thank you for the opportunity to provide feedback.
re tracking (81) a physician may order a test with copy to the family physician (eg a throat swab pos for strept ordered in a walk-in clinic). The ordering physician must be responsible for the f/u and cannot rely on “copy to” expecting the f.p. to carry out the treatment. OR he /she should speak personally to the f.p. to confirm that treatment has been carried out and by whom.
re communication of results(189) There is the occasional patient (eg with hypertension)who may have some routine but relevant test ordered but he or she refuses to do the tests. The physician in this case may be unaware that the patient has not complied. The physician cannot be held responsible. The same sort of thing can happen with vaccinations; ie, patients don’t f/u for vaccine appt.
As a family physician, my main concerns with these proposals relate to the large administrative burden that will be placed on me and my colleagues with minimal benefit to our patients.
It is proposed that copies of all walk-in clinic encounters should be copied to the family physician. I’m confident that the information from the vast majority of my patients’ walk-in clinic visits would be of no value to me, and having to review this information and add it to the patient’s chart would have no impact on the patient’s ongoing care.
It is also proposed that copies of all tests should be sent to the family physician. Lab tests done by specialists to monitor patients (such as regular blood work for patients on certain medications) are already being reviewed by the specialist. My having to review them as well is simply a waste of time. Hospital inpatients get a lot of testing done, but I have no need to see all these tests while the patient is being managed as an inpatient. If I need a test result, I can get it through OLIS (assuming the government funds it adequately to cover all testing rather than the patchwork that exists now).
Calling patients to follow up on tests they haven’t done is a paternalistic approach that I thought we were trying to move away from. Patients have the responsibility and choice to act (or not act) on the advice that I give them – it should not be my job to chase after them. Should I also call them to see if they’ve quit smoking yet, or whether they’re exercising, or whether they took the medication that I prescribed?
If I receive a test in error, my responsibility should be to let the sender of the test know that they have made an error – any further responsibility should be theirs. I fail to see why I would have a duty to notify the health care provider or patient when I have no knowledge of the context of the test, or in the case of the patient, whether this disclosure would be detrimental.
I don’t see why I need a voice mail system when I have an answering service answering my phone 24/7. Neither do I see why I need to provide an opportunity for people to leave messages that I have to respond to. This is simply a convenience for the patient, and one that I cannot afford. It adds the administrative burden to my office of recording the information and trying to track the patient down, when the patient could just as easily call back during the day. It is not unreasonable to expect patients to call during office hours for elective matters, and urgent matters should not be managed by a patient leaving a voice mail.
I recognize that the College is an advocate for the patient, but the College should recognize that physicians’ time is valuable and our resources are finite. Placing further demands on physicians is not in patients’ best interests. Time and financial resources used on administrative tasks will be taken away from patient care. The funding cuts to physicians cannot occur without some loss of service – better that that loss should occur from tasks that are unnecessary, simply a convenience, or could be delegated to the patient.
I run a very busy speciality practice for more than 16 years. I strongly feel patients are becoming more irresponsible and demanding. Physicians are overworked and burntout. Its so easy to complaint to the college regarding any physician, these new policies of continuty of care will add to more complains to the college. Being available by telephone. I believe this section has more to do with office management than it does with patient care. I believe the CPSO is in place to ensure that physicians practice safely but placing more demands on physician.
totally agree,
Dear Colleagues:
I reviewed all five draft policies. The documents are well written and I agree with most of the information/policies contained therein. However, I do have some concerns/suggestions:
Continuity of Care: See comments in the other sections below.
Availability & Coverage: After-hours coverage for specialist physicians may represent a challenge. The healthcare system does not compensate some specialists to be on call after-hours and some physicians are not part of large specialty groups to provide such coverage. Often times, patients are instructed to “present to the nearest ER” in times of need when the clinic is closed. Other issues include patients needing to be more accountable, and having the CPSO, OMA, and MOHLTC discuss better strategies to ensure every patient in Ontario is linked to a primary care provider.
Managing Tests: In the section on “Receiving Test results in error…”, asking physicians “who become aware, even incidentally (e.g., physicians who are cc’d on 169 a report), of a critical or clinically significant test result where they have reason to believe that 170 the ordering health-care provider did not or will not get the test result, must make reasonable 171 efforts to inform the ordering health-care provider or the patient of the test result.” is not reasonable. The physician only needs to sent the report back to the issuer of the report, and not be expected to make a clinical judgment for a patient they do not know. I do agree that The physician must also make reasonable efforts to contact the laboratory and/or diagnostic facility that sent the test result.” The other components of the document look good.
Transitions in Care: Because we currently work in a “broken” healthcare system where continuity/transitions of care remain a challenge due to system factors (lack of adequate nursing staff in hospitals, lack of funding, lack of a common electronic medical system across the province, high volume of very sick patients to be seen in a finite time period, etc.), asking physicians to make a decision about whether or not they can accept a referral within 14 days may not be reasonable as many specialists do have any control of clinic space or nursing support when trying to book urgent referrals. In this context, the wording of the document should change to say “within 14 days, if feasible” rather than making this a mandatory time period.
Walk-in-Clinics: No changes recommended.
I run a very busy speciality practice for more than 16 years. I strongly feel patients are becoming more irresponsible and demanding. Physicians are overworked and burntout. Its so easy to complaint to the college regarding any physician, these new policies of continuty of care will add to more complains to the college. Being available by telephone. I believe this section has more to do with office management than it does with patient care. I believe the CPSO is in place to ensure that physicians practice safely . I do not believe it is helpful to have a voicemail system in an office setting where phones are often ringing all throughout the day. It is not feasible to be checking messages while also answering the phone and talking care of the patients who are physically present in the office. Moreover, offering an after-hours voicemail to patients who may leave detailed messages about urgent issues will raise liability concerns if these issues should be addressed in the policies clearly.. In general, if a after-hours message clearly states the usual office hours and the appropriate time to call back, I think that is sufficient.
I run a very busy speciality practice for more than 16 years. I strongly feel patients are becoming more irresponsible and demanding. Physicians are overworked and burntout. Its so easy to complaint to the college regarding any physician, these new policies of continuty of care will add to more complains to the college.
Upon review of the draft policy. I have the following suggestions:
Lines 98/99: I would argue that all aspects of discharge information be written for the patient. As a patient, service user, caregiver and formal health care provider, this is critical. This information should also be provided to the PCP providing follow up care
Lines 117-128: The discharge summary should also include contact information (email/phone etc) for the MRP in the event the PCP needs to follow up/has questions re: discharge summary
Line 142: What does the MRP do in instances where patient doesn’t have a PCP?
1. I think it is unfair to require all physicians to be on call 24/7 to respond to lab results. Why not have the lab contact the patient and advise going to ER?
2. When receiving correspondence that belongs to another physician, it should be sufficient to notify the party who sent the correspondence. I should not have to try and figure out who is the intended recipient, or talk to a pt I do not know.
3. If a patient decides to ignore my advice and does not get their test done, they should bear the responsibility.
So if a pt has a life threatening issue, and I tell them to go to ER, do I have to call the ER and make sure they arrived? Where does this end? Patients need to take responsibility here.
Ontario Association of Medical Laboratories
The Ontario Association of Medical Laboratories has provided the CPSO with their feedback.
This can be found here
Thank you
I commend the committee for recognizing the potential for disruption in continuity of care when referring physicians (usually Family doctors) are expected to communicate specialist appointments to patients. By eliminating this unnecessary step and instead having consultants book appointments directly with patients the potential for error declines dramatically. It makes intuitive sense to eliminate the “middle man” in order to improve efficiency. Timely acknowledgment of receipt of a a referral, as well as appointment notifications to family doctors, are key in ensuring a streamlined process. As Undergraduate Hospital Program Director for Family Medicine Clerkship, I am keenly aware of how our medical trainees learn the inner operations of our health care system. I want our future physicians (both family doctors and specialists) to see a streamlined, collegial and logical referral system that serves in the best interest of patients and maximizes efficiency while minimizing potential for error.
There were no suggestions from OAML about what to do when the physician is on vacation. It looks like they want an arrangement for a covering physician to be on call (live 2-way call, not voicemail) 24/7. Do groups cover for each other 24/7? Would this change the outcome regarding the trip to the emergency?
I take lab call for my own patients by pager 24/7 but not when I am on vacation. Physicians in our building can cover one another but only during regular office hours.I am part of a long term care group that covers 24/7 year round. It works there because the lab calls the nursing station and the nurse calls us with the patient’s CURRENT PHYSICAL ASSESSMENT and CHART ready.
I cannot fathom dealing with a call from the lab for a patient I have never seen, of a physician in private practice, without sending the patient to the emergency. I would not be able to adequately assess a patient not known to me over the telephone for a critical result without a nurse there to be my eyes and ears.
The bottom line is: Whether the lab calls the patient or the lab calls the covering doctor who calls the patient about a critical result, the outcome would most likely still be to send to the hospital. So why would any physician, solo or group, need to arrange coverage 24/7 when it is not themselves taking the call? As well as having the correct contact number for the ordering physician, it would be more important that the lab has the correct contact number for the patient.
I would like to add my comments on the referral process. I feel strongly that it is the consultant’s responsibility to contact the patient directly. Booking an appointment is an administrative task that is time-consuming for whoever is tasked with this responsibility. Everyone is equally busy. However it is far simpler for the consultant’s staff to speak with the patient directly, find a mutually acceptable time, and relay any pertinent instructions to the patient. This helps ensure a better and more meaningful consultation. It also improves patient safety and continuity of care.
I had trouble loading some of your documents so was unable to review all of them. Is this a problem with your system? It also highlights some of the issues with technology and how sometimes it can be difficult for both doctor’s and patients to manage. Our office tried on-line booking for our appointment but it was not always successful and some of the older patients were not able to deal with it.
A few other issues, I don’t think having an answering machine take messages 24 hours per day is very practical. Someone has to listen to all the messages the next day and unfortunately some people may leave inappropriate messages at night like “I’m having chest pain what should I do?” It is poor patient care to let them leave messages when we can’t answer them til the next day. They are better with an outgoing message which says if they have an emergency this is the after hours coverage if not available go to the ER. This way the patient is not lulled in to false sense of security and care is delayed. I believe this is what all the specialist do when they are not in the office.
I would like to have some clarity re critical results. If the specialist orders the test I will likely get called as well. Who is responsible for the follow up in this situation??
It is not always practical to track all the tests you order. There is a certain responsibility the patient has to get the testing done. If they don’t do the tests when requested how can I be held responsible for a bad result. I can track all of the test results I receive and my response to them easily and this would be reasonable. If someone doesn’t do their follow up lab work for say their diabetes, I can’t call them every month to remind them. I tend to hold refills of there medication til they do it but its kind of like a hostile situation. If I order an ultrasound for follow up of an ovarian cyst, I can tell the patient why the test is necessary and to see me in follow up but if they take 6 months to do the test again I can’t call them and remind them every day to do their test. The patient has autonomy, correct ,and this does influence their care and is outside of my control.
Some of these policies are definitely not practicable in a busy family doctor’s office . I do not think they improve patient care from these points of view.
Communicating directly with patients about all results directly is not reasonable in some areas. Like colposcopy or cancer screening. Many/most patients are anxious in colposcopy. A physician reviews all results and delegated RN calls patients except if cancer is extremely reasonable. Patient anxiety is not a reason to not delegate appropriately. RNs and NPs can be trained to handle these calls.
What happens if a physician’s coverage falls through while they are on sick leave/maternity leave etc. Do they have to come back earlier? For most Canadians taking a maternity leave is guaranteed. Their job is protected for a year and they can’t lose it for reasons of pregnancy/parental leave. So if all efforts are made for coverage but something happens then what…
This policy suggests patients get seen whenever they want. We live in a society that wants instant access. Symptoms that may well be non-urgent and will resolve with time (ex a cold) but patient feels urgent and wants to be seen now. Who decides? Looks like in the policy it’s whenever the patient feels it’s urgent. That can be very problematic. I can think of a handful of patients that feel there is an urgent issue. Is urgent risk of death? Is urgent miserable symptoms because that would be everyone in my subspecialty clinic….
Once a referral is accepted by specialist it should be communicated by specialists office to the patient .
That would make sense because it is possible that this particular date and time does not work with patient and they can directly communicate with appropriate office to reschedule .
Wasting extra resources by notifying family doc who then will notify patient does not make sense .
I am an urban physician where we have I am sure the highest concentration of geriatric sick patients. When we book an appointment with a specialist it is the specialist which is receiving significant funding to complete the consultation. The time spent contacting the patient is by far the most time consuming. Somehow my secretary’s now work for free to assist the consultants. Faxing the consultant requires some minimal time. Faxing back to the family doctor requires some minimal time. However contacting, speaking with and notifying the patient requires a great deal of secretary time. Appointment is with the consultant. They are the ones getting paid. I cannot fathom why it is a family doctor who should be notifying the patient of an appointment with a completely different doctor.
*Moderator Comment* Submitted as a word document.
I write on behalf of a group of family physicians who meet regularly for mutual education. We work in an academic medical centre, some of us in individual fee for service practises, others in groups (FHO or FHG). We wish to comment on some of the policies proposed in this draft, as we have understood them.
(1) Physicians must have an office telephone that allows voice mail messages to be left outside of operating hours and responded to in a “timely fashion”.
We wonder, what gap is this meant to be addressing? We have concerns people will use this instead of seeking appropriate after hours care, and not use those services, or worse not listen to instructions meant to direct them to those services. We also have concerns about the definition of “timely” . In our offices, messages will not be retrieved until staff is present – so timely on Monday evening will be Tuesday morning. Timely on Friday evening of a long weekend will still be the next Tuesday morning. Both would be fine for a patient leaving a message to change an appointment, but neither is fine for someone with symptoms or a stroke or a critical lab result. This needs clarity / more specific definition to delineate the responsibility more clearly.
(2) Physicians in a “sustained patient relationship” must arrange for another health care provider to provide patient care during both planned ( eg vacation) and unplanned (eg illness) temporary absences from work and inform patients of the coverage arrangements.
It is unclear to most of us what this actually means in practise. Every time I leave on vacation, do I need to inform my entire practice? Additionally should I have the misfortune to become ill, do I have to inform my entire practice? Who will pay for this sharing of my personal information? What is adequate coverage? Do I have to find a locum to cover all of my hours? Who will provide the locums? Who will cover this cost ongoing? What about the personal risks to myself of letting a large community group know that my home or my office may be uninhabited for some time? Most of us already have group coverage, and an after hours system of call and staff on the phone known already to the patients to direct them to appropriate levels of care in our community in our absences. We think this is enough. And, in considering the previous recommendation regarding voicemails, if patients phone and leave a voicemail after hours, our staff who know them do not have opportunity to help direct them.
(3) Physicians in a “sustained patient physician relationship “ must have a plan in place to coordinate patient care outside of regular operating hours.
Most of us already have a call system and on call group and provide after hours care ( as obligated by our MOH agreements and CPSO policy). This is advertised in our offices and on our phone messages already as required. Most patients do not require after hours urgent service with great frequency, and don’t remember the details of this. They are less likely to do so if they are sick and anxious. It is a common experience for us to see patients in after hours clinic and to have them express surprise that we provide after hours care, despite the fact that all of us have been doing so for more than 30 years. Additionally, we have no control over patients who seek care for convenience only, not for need or quality, or desire to seek continuity with their primary care provider.
(4) Physicians working in walk- in clinics must provide a copy of the encounter ( including test results and follow up care) to the patient’s primary care provider.
We applaud this as we think it will decrease duplication of care and save money. We wish it would be extended to emergency departments and urgent care clinics that are hospital based. Please add a condition that the information needs to be legible. This also supports our clear and appropriate obligation to follow up abnormal results.
(5) Physicians working in walk-in clinics are advised to offer comprehensive primary care to patients without a primary care provider.
While we applaud the extension of better preventive care for unattached patients, we are uncertain how the WIC MD is to ascertain the patients status in someone’s roster. Patients themselves do not understand these details, and we have received transfer of records requests to WIC MD’s that patients do not actually realized they have signed. The corollary is that many patients are asked in walk-in clinics for their primary provider, and assume therefore that their records and test results will be forwarded to that person, when they are not.
(6) Physicians must be able to receive and respond to critical test results 24 hour a day, 7 days a week, or make coverage arrangements with another health care provider to do so.
We believe in the current system of care this is impossible to universally respect. It would involve the community labs having access to all the on call schedules of all the community doctors that the lab serves province wide. Currently the labs do not work in this way. Possibly this could be a function for THAS, which is already obligated to keep updated and accurate call schedules. This would not solve this issue for patient’s unattached to FHG, FHO, FHT or CCM models. This is also further complicated by patient choice. We give lab requisitions to relatively well ambulatory people who we do not think need emergent care or advice. We likely advise them when they should attend for the lab tests, but can’t control their compliance with our advice ( a common example of problematic tests here would be the INR). Additionally, we don’t control when the lab actually processes the sample after it has been obtained. Lastly, we feel the need to point out that guaranteeing individual 24/7 365 day a year availability is impossible, and deleterious to a physician’s health and well being.
(7) Physicians must copy the patient’s primary care provider on all tests ordered.
We find this unreasonable. AS a primary care provider, I do not wish test results that I do not understand (eg complex investigations ordered by specialists) or that I should not reasonably be expected to take action on ( eg a blood gas results from the ICU). I am happy to have and appreciate a copy of test results ordered by others and the actions that they have taken to deal with them, or requests to take on follow up as appropriate to my scope of practise as a primary care provider. Important information that we need to have should be included in discharge summaries, consult notes and follow up notes. Of note, the current communication systems regarding lab results are not evolved enough to prevent any of us duplicating each other’s requests.
(8) Physicians must track test results for “high risk patients” (eg by calling patients to verify they did the test and/ or contacting the diagnostic testing facility
Could you please clarify the definition of a high risk patient? Please help us understand how I can enforce compliance on all my patients to follow my advice. How do I apply this to a low risk patient who chooses not to follow agreed upon directions? We all have informal systems for doing this, and this is reinforced by our staff’s relationship with these patients as well. As far as we understand, individualized care in a democracy allows for patients to make less good choices than we might recommend, and we feel it is unreasonable to fault us for patients’ noncompliance.
(9) If physician receives a “critical or clinically significant” test result in error they are obliged to report the test result to the patient and “others involved in their care”
How is this recommendation to be integrated with privacy legislation? How are we supposed to interpret a result for a patient for whom we have no information? How are we to find the primary care provider if the lab cannot? Who might the others be? How would one balance the distress to the patient from communication from a provider unknown to them with the result when one cannot reasonably interpret it? This also seems to be unreasonable in terms of individual physicians’ mental health in terms of correcting errors that others have made.
(10) If physician receive a “critical or clinically significant “ test result incidentally (eg cc’ed on the test) the physician should notify the ordered health care provider if they believe the ordering provider will not get the test result.
How can one know the ordering physician is expected not to receive the test result? This would seem to obligate all copied health care providers to communicate with each other over every single result.
(11) Consultant physicians must acknowledge referrals no later than 14 days from receipt and indicate whether the referral is accepted and the actual or estimated appointment date.
We applaud this if it works. We are concerned about unintended consequence – that is that many consultants will begin to simply reject all referrals causing us much more work resending requests for consultation multiple times.
(12) Consultant physicians must communicate any additional appointment instructions or information, including appointment date changes, directly to the patient.
We absolutely support this, and would additionally be pleased to be copied on this communication so we can act as ongoing resource to our patients.
(13) Consultant physicians must distribute the consultation report and any subsequent follow up reports to no later than 30 days from the patient assessment.
We support this. Our experience is that most initial consultations are received in a timely manner, but that many follow up reports are not received at all.
(14) Physicians providing in hospital care must coordinate with other health care providers to keep patients informed about who is their most responsible provider.
This seems reasonable, civil and patient centered. Given our practice location in an academic centre, patients are also often additionally confused by all the levels of medical learners involved in their care.
(15) Physicians handing over patient care in hospital are strongly advised to have a “real time and personal exchange of information”.
We also support this, but as it is not part of our everyday practise, we do not know how realistic this expectation is.
We hope our opinions are useful to the CPSO . We feel that this draft should not become policy in its current form.
As a patient who worked in information technology, it amazes me that in this day and age, it is incredible that there is no eHealth automated patient notification system of appointments, abnormal test results, etc. that is centralized. Currently, I get the call from the family doctor who did the referral, sometimes both. Specialists are so slow to respond, you usually have to chase them yourself.
Everything is manual. Please don’t fax fellas. This is no longer a secure form of communication — circuit switched telephony where the fax doesn’t leave a trace in transit is long gone. It’s all voice over IP.
Policy is good but if each patient signs up with either notification by voice or SMS and the system calls and asks the patient to acknowledge/confirm once when the appointment is set, and again two days before … problem solved. This should be an eHealth initiative. Doctors from all over the province input the date, time, patient name, their address an phone number for directions, etc. and any special instructions, and the system does its robocall or sends the SMS message. Patients who are unreachable or do not respond to the automated call, well, the system will try again several times, and both doctors get an acknowledgment that the patient got it.
Voicemail after hours — it fills up.
Continuity of care is very difficult if a patient wants to switch from one doctor to another (say, when one is about to retire) while maintaining identical treatment during the switch with no discontinuity. It’s not so much the switch but that the new doctor has a different style. I’m not prescribing that.
I tried once and the new doctor said, oh well, we have to re-run the sleep study and to do that you need to stop all meds for 3 weeks. Are you mad? That’s contraindicated. I saw a smooth switch only once and that was when the doctors were friends. Doctors have to talk to each other, and even then.
A lot of doctors ignore CPSO policy. Accepting new patients … “essentially he is accepting patients who need a family doctor but who are otherwise fine now. No chronic injury or chronic problem, no workers comp, no narcotics, no car accident …”. The only thing they left out was no lawyers. Gutsy I must say. You can’t do that you know. Doctors can choose — GPs — oh really. Hey, this isn’t a job interview.
Doctors are afraid. I saw one leave skid marks on the floor when I said, well, I’m currently prescribed Vyvanse … a pediatric dose.
Where is patient responsibility in this policy?
Peterborough Clinic
Please find here Feedback Submitted by the Peterborough Clinic in PDF format.
South West Primary Care Alliance
Please see here for feedback submitted by the South West Primary Care Alliance
Ontario Hospital Chiefs of Staff
Please see here for feedback submitted by Chiefs of Staff from an Ontario Hospital.
As a physician in my second year of practice, who was trained in the US, I must say that I am considering returning…
The continuity of care guidelines being proposed by the CPSO is something to strive for in a perfect world.
The reality is that any time spent working and operating a business should result in adequate compensation.
I find it odd that Physicians in Ontario continue to be asked to work harder and longer for less money as the cost of living and running a business increases.
Certain elements of these proposed policies are entirely unrealistic for anyone in solo practice (family physician or specialist). If a physician cannot find a locum for proposed time away, what are they do to? How can a solo practitioner actually be available for results 24/7 without entirely burning out? If a patient does not get their bloodwork done, or no-shows for their CT scan, am I now expected to track them down and harangue them? Where is patient accountability in any of this? And let’s not even get into how these policies will add even more unpaid work to our already busy schedules. I’m disappointed in the CPSO’s apparent lack of recognition that doctors are already overburdened and burning out rapidly.
Ontario Medical Association
The Ontario Medical Association has provided their Feedback on the Draft Policies, due to upload restrictions it is available in three sections:
(1) Cover Letter
(2) Executive Summary
(3) Revision Chart
I am a family doctor in Northern Ontario and these policies overall will have a significant negative impact on both my patiens and myself. While some subsets of the policy are not unreasonable, the overall tone of the policy is to burden doctors with the responhsibility to make up for system shortfalls and patient decisions in a way that would make practicing medicine much more difficult. This will be particuarly challenging in rural and Northern areas where doctors are for the most part working at or beyond their sustainable limits already. I have broken down my concerns into sections below.
Office Phones
Answering machines can be dangerous – patients may think their issue is being dealt with much sooner than the doctor is able to review it. They are also a massive drain on physician and staff resources with likely no benefit to patient care. While they may be an option for some clinics, making them mandatory would be devastating to many offices. As for triage, most doctors strive to triage when they can but to make this mandatory would force doctors to restrict the hours they are able to see patients for preventative care. Where a doctor shortage exists, as in much of the province, forcing a “one size fits all” solution on everyone will only make things worse. These issues are best left to physicians on the ground do decide, as they are able to assess their real-life limitations and unique circumstances. Dictating and micro-managing practice structures and office administration is not within the appropriate scope of the CPSO.
After hours
Emergency care can be provided in the emergency room or urgent care, any true emergency after hours is already taken care of. Provision of after hours care can be and is negotiated between physicians and the Ministry of Health, beyond contractual obligations, how much after hours care a physician can provide should be up to them to determine using whatever criteria they feel are relevant. This issue is outside the reasonable scope of the CPSO’s mandate, and if the government chooses to try and reduce system costs by providing more funding for primary after hours care then that should be negotiate, not imposed without compensation by the CPSO.
Absences
It is entirely unreasonable to expect that physicians are able to reliably find replacements for unexpected absences when even absences known about in advance can be difficult or impossible to fill in many areas in the province. How many physicians will keep working in the face of a serious illness because of this policy when they are unable to find a replacement, to the detriment of their own health? Will this policy lead yet more doctors to commit suicide when they are trapped into working with depression, unable to take time off under threat of sanction by the college unless they are first able to find a locum? This question is not in jest, nor should it be taken as hyperbole. Every doctor I know strives to find coverage as best they can when they are away, this expectation will in no way change their behavior as they are already doing their best.
Tracking results
Patients are assumed to be capable, and if a patient is not capable then they should have a substitute decision maker who is capable. For the CPSO to insist that a physician bears the responsibility of ensuring that a patient follows their recommendations is extremely troubling. If a doctor advises a patient to do a test they should explain the reason and then the patient is free to decide whether they will or will not do the test in accordance to their own values and wishes. This expectation crosses the line into expecting physicians to assume a parental role which is grossly inappropriate, even for “high risk patients”
This expectation could add hours of work every week for every physician and hours of work per day for support staff to call patients every time they fail to do their routine labs, etc. While physicians can and do choose to track critical tests on certain at risk patients, it is not reasonable to make this a universal requirement.
Referrals
The fee code for consultations in Ontario includes responsibility for booking the appointment, it does not make sense to involve the referring physician’s office at all when the consultant’s office will need to do the booking or re-booking anyway. This also has the potential to decrease no-shows and errors in appointment times given.
Walk in Clinics
This would increase the administrative burden on both family physicians and WIC doctors without a corresponding increase in patient care. Certainly WIC doctors need to release records on request as would any physician but the rest can be negotiated with the patient and need not be dictated by the CPSO. The only exception is providing followup for tests ordered by the WIC doctor – if I order an x-ray that shows a pneumonia then it is obviously my responsibility to deal with the result or see to it that someone else does. This should be a universally applied principle – “the person who orders the test is responsible for managing the results or arranging for someone else to do so”.
This attempt to make walk in clinics to convert into family medicine offices is misguided and harmful to the people of Ontario. Ideally each patient should have a family doctor but there are not enough family doctors to make that possible… In the mean time, WICs provide a vital “safety valve” for patients to receive interim care. Making WIC doctors provide comprehensive care will only drive many of them to close entirely rather than take on the extra, unpaid burden. I can say for a fact that the last in-person walk in clinic in a small town will closed to non-FHO patients EXPLICITLY because of the threat of this policy. It is not up to the CPSO to solve the issue of doctor shortages, and by trying to force existing doctors to bear more than they are able will only make things worse.
Concludion
The CPSO has gone well beyond its mandate with this policy and the cumulative effect of these changes will drastically worsen burnout, increase already excessive workloads and drive doctors out of practice (or out of Ontario). I hope that the CPSO goes back to its core requirement of protecting the public from malpractice instead of creating new duties and responsibilities to force on the overburdened doctors of Ontario.
With respect to the Continuity of Care draft policy, I think that from the perspective of a family physician, it is unrealistic to expect 24 hour 7 day per week coverage for critical results. The way most of us have our practices structured, we are available, or have someone available, to cover us during regular office hours, wherein I would guess my practice is representative of the average, at 8AM to 4PM. Outside of those hours, it would require a tremendous burden on the individual family doctor (especially those practicing by themselves/ rural or remote), to be on call “all the time” or else to essentially hire someone to be on call for them when they are not working. Unless there is a plan to offer a significant amount of monetary compensation for this service, I think it is an incredibly unfair expectation.
I have concerns with the continuity of care elements in the proposed guidelines. While I agree continuity of care is very important, especially for urgent results, it is not reasonable to expect a community physician to be available 24/7 to interpret abnormal test results. This is particularly problematic in rural areas. This makes complete sense in an on-call environment in the hospital.
In addition, I have a concern with the requirement for a walk in physicians to contact the patient’s family doctor. Some patients see a walk-in as they do not want their family doctor to know about the visit. Possible confidentiality breaches could occur as there is no referral. Also the administrative burden to fax reports to a family doctor would be great. This would only make sense if it was done seamlessly through an EMR.
In an increasingly overburdened healthcare system, it would be important for the patient to take more responsibility for their care.
Ontario Medical Association: Hospital Section
Please see here for feedback provided by the Hospital Section of the Ontario Medical Association.
Hello,
Thanks for looking for feedback from practicing physicians regarding the policy. Most of the policies seem quite reasonable. A few practical points:
- When phone lines are open and there is minimal patient waiting on the line, there is no need for voicemail after hours. Is it not better to have the patient call back when the office is open and they know they can reach a receptionist? I find whenever we call a patient back, it is a series of phone tag as they are often at work or busy. When we’re open, we’re taking calls, after hours voicemail will only add administrative burden without getting through to the patient. Our office admin will spend more time listening to voicemails than actually talking to patients and booking appointments.
- As a family doctor, the labs all have my cell number on file. If I am ordering an important test (like a baby’s total serum bili), I also write my cell # on the requisition just in case. But I hope you also don’t expect family doctors to be on call 24 hours a day, 365 days a year. If I go away for the weekend and my cell accidentally loses reception, what does that mean? Please remember the way family doctors are structured is that we are often private practices without larger structural government or administrative support. If this truly is what is recommended, we need a larger, more coordinated effort to manage this with government support of physicians to be on call 24/7, every day of their working life.
- If a patient is told to do a test, given the steps to do so, and told to follow up the test results, it will be a logistical nightmare to track down every lab req that was given to make sure the patient actually did it. This is a very good example of a shared responsibility that will overburden us administratively and take away from patient care time.
- For notification of referrals, it is a great administrative burden that neither family doctors or specialists want to do because of the cost involved. For our group practice of four, we need a part time employee just to do referral notifications and follow up (explain parking, what to do bring to appointment, etc). Since doctors pay for employees ourselves, it doesn’t make sense for the lowest paid specialty family medicine, to be having to pay for this as well. If you truly want us to do it, then I suggest there be some sort of extra funding to pay the administrative person whose sole job it is to notify the patient of all the instructions of their referrals.
Thanks for allowing this feedback!
I am in agreement with many other physicians who have posted before me that family physicians should not take on the role of notifying patients of consultation appointment information.
“Referring physicians must communicate the estimated or actual appointment date and time to the patient unless the consultant physician has indicated that they have already done so or intend to do so.”
Family physicians are skilled practitioners in family medicine and yes we are the central hub for our patient’s care. However, we are not the dumping ground for the administrative tasks of specialists. We pay our admin staff to do our bookings and specialists should rightly assign their administrators to notify their patients of their own appointment times.
Perhaps the fee structure and compensation for these tasks need to be reanalyzed instead of just shifting responsibility from one area of medicine to the next.
Feedback from North York General Hospital Department of Family Medicine
The draft policies were highlighted at our recent departmental meeting.
We discussed the draft recommendation regarding specialist appointment notification. The department members present voted overwhelmingly that the consultant physician should be the one to notify the patient directly of the appointment date and time as well as all the other details pertaining to that appointment.
In addition, here are quotes from family physicians at and subsequent to that meeting.
It would be unfair for the FP secretary to have to manage the specialist’s appointments- there could be a lot of back and forth with the patient before an appointment is actually confirmed- depending on patient’s availability and specialist’s as well- none of it having to do with the FP or FP’s office. The specialist should book the appointment directly with the patient and inform the FP about it. The FP does not know the specialist’s schedule or the patient’s schedule.
Active message box for patients/specialists to leave messages is fair.
Access for results 24/7 for critical results is fair, except where the physician is on temporary leave of absence- usually person covering the practice in the office would pick up that message- leaving message at the office is one option, faxing results to the office is reasonable. NO outpatient results will need to be acted upon in minutes; hours or half-day (12 hrs) is reasonable as time frame to answer/act upon results.
When physicians are on vacation (away, out of the country), it is unreasonable to deny their personal time- in a profession in which burnout is already high and suicidal rates the highest of all professions. If a physician is away and the lab/imaging dept. feels a result is that critical that it cannot wait a few hours until regular hours (would allow them to contact the physician‘s office), then they should send the patient to the ER- they have the patient contact info.
Consultants are getting paid very well. Part of that should be notification of patient. It is notification that takes large secretary time. Booking appointment perhaps 1 minute, call patient perhaps multiple calls and time.
Consultation- notifying patient of appointment details- Risks to patient with adding extra step- consultant to FD to patient instead of consultant to patient. Causes extra risk of dropping communication! CPSO is about protecting patients and public. How does this achieve this aim? Explain please how this is consistent with CPSO’s mission of protecting public.
Quality of care is crucial as is communication. This includes communication between family doctors, specialists and patients. Breakdown in communication can adversely affect quality of care. It should be self-evident that the booking of appointments should involve those directly involved in the booking, ie. When a consult is requested by a family doctor to a specialist for a patient it should be negotiated between the specialist and the patient, and the specialist then notifies the FD of the appointment. When the family doctor has the responsibility of notifying the patient of the appointment with the specialist this can affect patient safety on several levels (breakdown in communication, delaying access, removing the voice of the patient). This is in addition to the extra time FD’s staff has to spend in booking appointments.
Doctors need to cover- or arrange coverage- to respond to patient’s questions and lab results.
Patients need to give consent for doctors to release results to FD.
Critical results can be communicated 8 am- 8 pm- Nothing will change overnight.
Ordering tests- When ordering a test with cc to another doctor, sometimes the lab does NOT copy the test even when ordered as they state that the address of the doctor was not listed on the requisition. The lab does not print the address or contact information of the patient or the contact numbers of the ordering physician so when a physician receives the lab in error, how is the physician supposed to notify the patient? The physician could track down the ordering physican, maybe, but this would take time of our secretarial staff for people who are not even our patients. It should suffice thatr the office that receives the lab in error to just fax the result back to the source of the result- ie. The lab or imaging department. If it happened to be a consultant’s report sent in error, we should fax it back to the consultant. We do not call his/her patient.
I will only refer to specialists who are going to notify the patients. The same way that we cannot take on new patients when our practice is full, we cannot not accommodate new specialists who will increase the notification burden.
If specialists are required to notify the patients about the details of appointment- lines 214 to 218, why can they not notify them about the appointment date and time at the same call/fax/email?
FD should know about the booking even though specialists book them. Agree that it should be the specialist that notifies the patient directly. If this is going to be in a policy, then also put in the policy that the specialist MUST notify the FD of the appointment as well.
Coverage 24/7 is a good idea but what happens if a solo FD or partners in group are both away? The lab can call the patient if absolutely critical. Any covering FD would tell the patient to do the same anyway.
Verifying that the test has been done- should be up to the patient , and only the patient, to decide to go for the test.
Tracking results- it is up to the patient to follow our recommendation to come back to see the results when advised to or at least to call our office to inform us that they have gone for the test and whether the result is back? That is a good way to track if they have gone for the test. Patients have to take some responsibility.
I have concerns about this policy:
1. I am concerned about the proposed change of having a 24 hour voicemail service for patients. This would cause a huge administrative burden with very little yield in my opinion. Our office has 3 physicians and we would require to hire an additional administrative staff to deal with returning the calls and triaging patient concerns for messages left afterhours.
2. I am concerned about the policy stating that it is the physician’s responsibility to track that the patient has performed his test or labs. Our office does track this, however, I believe patients are independent individuals who also need to take ownership in their own health. It is not feasible for myself to follow-up on tests that have not been performed or attended.
3. I am concerned about the portion of the policy that states that the family physician should provide a date or expected date for the consultation service or test to be performed. It is often challenging for us to obtain a consultation date from a specialist. If I must provide a date, I will be suggesting something such as saying “in the next year” as most specialists offices will not book patients until a couple months before the consultation will occur.
Continuity of Care: Availability and Coverage
1. Lines 47-53 I’m concerned about the “voicemail that allows messages to be left outside of operating hours.” As a rural practice part our message indicates that urgent needs can be met through our local emergency. It will create a substantial increase in manpower to respond to messages left outside hours rather than having patients contact us during office time.
Continuity of Care: Transitions in Care
2. Lines 211-213: “Referring physicians must communicate the estimated or actual appointment date and time to the patient unless the consultant physician has indicated that they have already done so or intend to do so.” This may not be the best way forward. From a patient-centred perspective, having the CP office contact them directly would be preferable to the CP passing a message to the patient who then needs to call the CP back again if they need a different day/time for their appointment: especially critical in a rural environment when patients may need to travel 2 or 3 or 4 hours or more to make that appointment. Most often in our experience, the consultant’s office contacts the patient directly, without advising us of the information, so there is room for improvement which might be addressed by: “Office staff of the consultant physicians should forward appointment information to the referring physician once they have established an appointment with the patient. Should the consultant physician’s office have difficulty contacting the patient directly, the office of the referring physician would be expected to assist.”
3. Lines 262-266: “Consultant physicians must send consultation reports to the referring health-care provider and the patient’s primary care provider, if different.” I appreciate the work that has gone into these documents and this clarification in particular. We have significant challenges when a consultant physician decides to make a secondary referral and then the new consultant leaves us out of the loop.
I can see, very clearly, that if there is a failure to report the test results correctly and that failure causes harm, then there is an incentive to cover up the failure, in order to prevent the CPSO from discovering the human error and identifying the doctor as incompetent.
I feel upset that, rather than developing a system which works proactively to protect the doctor’s mental health, the CPSO and the CMPA work together to provide the incentive for a doctor to deceive his patients about their test results.
Lawyers for the CMPA can use falsified test results to defend negligence and the CMPA’s experienced medical expert is paid very well to provide a supportive opinion as non-monetary settlements are not communicated to the CPSO. In this way, the doctor’s reputation and livelihood is protected, but in time, it can affect his mental health and he may use fraud proactively. The CMPA’s lawyers and experts will then work to defend that.
If the CPSO learns of the fraud, the CMPA can work with the CPSO to help them see the doctor is mentally ill. Then healing for the doctor, rather than discipline, is called for.
Injured patients – who have had their test results “miscommunicated” can suffer with unexplained symptoms causing not only physical but psychological harm as well, greatly affecting their lives. They are not protected by this system with all its rules and regulations and legislation. And when they see the doctor is not disciplined for fraud, they can’t see it is because he is mentally ill and they feel completely unheard and completely unprotected.
Rather than working to create more and policies, I think it’s important to see that situations are created by the legislation which provides the support for deliberate harm to patients, and no doubt, doctors as well.
More Feedback from North York General Hospital Department of Family Medicine
Quotes from family physicians and residents:
Secretaries spend all day even during Saturdays to call patients about the specialist’s appointments. We have already spent time preparing, faxing all information that we think the specialists would want. We don’t get paid for the referral, they do. Why should they not be the ones to book and notify the patient? We have already done our duty.
Copying to FD- Even when the patient has moved, specialists keep copying to the FD. When I called a specialist’s office to stop sending the reports because the patient has already moved and found another FD, the specialist insisted that she keep copying the original FD that referred the patient. This is absolutely unnecessary and unwarranted as FDs do not want to know what to do with these reports. The patient is already under the care of another FD and the patient has told the specialist but the specialist keeps on insisting otherwise. Reports should not be copied to a doctor unnecessarily and should be authorized by the patient.
Verifying tests- We do not call patients to remind them to go for the test.
Tracking tests- We tell them to come back for the test results or call us to find out if they were ok. We cannot track tests that they did that went off elsewhere unless we keep calling them if they have done the test and if they did, we will have to search for the ones that did not appear in our clinic. Way too much work on office staff.
Patients have to take responsibility to call office and to tell us that they did the test to make sure that the result has come back and what is the result. They can call or return to the clinic for visit. Patients cannot just go for a test and leave it up to MD that no news is good news. They have to make sure that we know that they did the test. We can only follow up what we know.
On call 24/7- We have not been available like this during regular weeks or temporary absences. We will not be able to find anyone to cover like this while we are on vacation.
Tests received in error or incidental- If NOT our patient, we will fax the result back to the sender. We will call the patient to follow up with the specialist if this is our patient.
There are new announcements of specialists that are mailed to FDs as part of service provided by OMA. Some of the new notices have included a statement that their offices will take the responsibility to notify our patients and to notify us with the appointments. Kudos to these new specialists in getting things right from the start without having to be told by policy what to do. Also, excellent marketing strategy!
In the event that there remains no policy on requiring who notifies the patient, our office plans to ask these new specialists who have not confirmed their protocol on the announcement letter, to confirm their protocol prior to us starting to refer to them. We could fax a letter such as the following: “Congratulations on the opening of your practice. We would like to bring to your attention that our office is currently overwhelmed with providing notification of specialist’s appointments to the patients. As your announcement letter has not stated how you would like to handle referrals, please confirm if your office plans to notify the patients directly and us, of your appointments. We look forward to a long lasting collaborative relationship. Thank you.”
There are excellent specialists, both who notify patients and those who don’t. We just need to compile who does and who doesn’t.
24/7 for critical lab results: What about the imaging results? The labs have our contact numbers but I don’t think the imaging places do. They are not centralized like the labs. The labs have many locations but our contact numbers are at their headquarters’ specimen handling or results dept. Diagnostic imaging centres are much more fragmented. If those tests can wait hours, why can’t the labs?
There should be a system in place for 24/7 call. A central system operated, funded by government.
My FHO group is not covering 24/7. We cover our own patients 24/7. If we are away, then the group covers during business hours but not 24/7. How do we get this type of coverage? If FHO groups cannot manage this, then what for the solo FD? It’s hopeless!
Verifying if tests have been done- Absolutely NOT!
Family Practice residents at some teaching sites, not at North York General Hospital, carry pagers 24/7. They are on a roster depending on their block time so are not on 24/7 continuously for the whole year. The patients and labs call them directly. Residents are not responsible for being on call 24/7 year round. However, they do arrange coverage among themselves so that at least one of them is always available 24/7. If this rostering is possible for practising physicians, then that would comply with the 24/7 requirement during temporary absences. Hmmm… we would all have the opportunity to be like residents again!
Tests received in error- The secretary calls up the doctor to inform them of the error- sometimes, when the office has time.
Tracking tests- The office does not call patient to verify if they have gone for the test.
Referrals- Better to have the specialist’s secretary to inform the patient as sometimes, the patient doesn’t show up for the appointment then the FD’s office gets blamed. The patient tells the specialist that he did not get notified and therefore should not have to pay rebooking fee. The FD says patient was notified and has documented proof. The specialist and the FD both end up losing time and money.
Regarding 24/7: It is not reasonable on vacation days. The patients need to be more responsible.
There is currently no coverage for 24/7 on vacation days. If something needs to be taken care of within 24 hours then the patient should go to the ER.
Verifying tests: We do this for some tests. If the patient is going to be seen for a diabetes visit, the secretary will check to see if the results are ready, then call them ahead of time to encourage them to go for the test in order to have the results ready for the appointment. If the pharmacy calls for medication renewals, then the secretary looks up the chart for the lab result. If none done yet, then the physician would reorder a small amount while the secretary calls the patient to remind them to get the tests done soon.
If a lab result is received in error, the secretary will fax it back to the sender. Works well this way. Not planning to change for now.
Specialist’s appointments- Some specialists call patients directly. Finding that in 70-80% of referrals, FD’s secretary has to call. Secretary actually likes to do this as wants to know not only that the patient knows about the appointment, but to make sure that the patient has all the correct information about the appointment.
24/7 coverage- Pager during days and nights while the FD is working is ok. During vacation days, NO 24/7 coverage is currently in place for the group. I have never asked them to cover. I don’t know how I would even cover for them or vice versa if we wanted to do 24/7. The patients did not consent to the other physicians knowing their results.
Verifying tests done- NO
Specialist’s appointment notification- They (specialist) have to. Recently a patient was referred to a specialist . The specialist notified the patient that the appointment was missed. The patient did not even know about the appointment. The specialist said that the FD was supposed to have notified the patient. However, the FD’s office stated they did not get information to notify the patient. This could have been prevented if the specialist had notified the patient directly.
Labs in error- we just send it back to the sender only. We do not inform the patient. That would be a breach in confidentiality. They would wonder how and why another MD is calling about their result.
Discussion amongst some of us brought to light the policy upon which Alberta worked after the Price outcome.
Perhaps their approach is preferable re: referrals and responsibility for contacting patient. It is a high admin burden and cost to place on family physicians to be responsible to contact every patient for every test (hospitals are downloading this responsibility now onto our offices) and every referral as well.
This feedback was provided in PDF format.
This response was submitted in PDF format.
Ontario Trial Lawyers Association
Please see here for response from OTLA.
Division of General Internal Medicine, Western University
Please see here for feedback provided on behalf of Western University Division of General Internal Medicine.
Ontario Hospital Association
Please see here for feedback submitted on behalf of the Ontario Hospital Association.
I am a family physician practicing hospitalist medicine and anesthesia in rural hospitals across Ontario. While I appreciate the effort to improve continuity of care, I am deeply concerned and opposed to making physicians available 24 hours a day, 7 days a week for critical test results. First of all, as family physicians we emphasize the importance of well-being and work-life balance to our patients. How can we continue to do this when our college demands that our own personal time spent with family, recuperation, and trying to achieve this so-called balanced lifestyle be put in such jeopardy? Being available every minute of every day is not only not realistic but inhumane and unsafe for all parties involved.
Secondly, why should physicians be responsible for the completion of tests ordered? What happened to helping patients become their OWN health advocates? Physicians can only provide patients with information regarding the advantages, disadvantages and alternatives for the test in question. Patients have a right to decide whether or not they want to take the test. It does not make sense to have the physician ensure the test ordered is done. This violates the trust and patient-physician relationship that trust is built upon.
I fear these new guidelines will drive future physicians away from primary care and have us all practice medicine in way that primarily medico-legally protects us, putting patients and the healthcare system in serious risk.
We welcome any effort to optimize Ontario’s medical care. In some aspects, however, the new regulations will entail excessive administrative burdens, which will create particularly unsolvable problems for specialists working in underserved regions. This also threatens to further discourage medical specialists from settling in underserved regions. That many referrals cannot be processed in a timely manner is certainly a huge problem. It is caused by the lack of specialists in certain regions, but not by the specialists themselves. We find it counterproductive and unfair to charge those with extra administrative burden and associated additional costs who are willing to serve those regions. Specifically, this concerns the following passages:
194 “Physicians who are asked to consult on a patient’s care must acknowledge the referral in a timely manner, urgently if necessary, but no later than 14 days from the date of receipt. How quickly consultant physicians must acknowledge the request will depend on the patient’s condition and their need for a consultation, including whether a delay in acknowledgement.”
205 “Where a consultation is urgently needed, consultant physicians must provide suggestions to the referring health-care provider of alternative health-care provider(s) who may be able to accept the referral, and are advised to do so for non-urgent referrals as well.”
We supply a region in which the number of specialists of our specialty is only half of the recommended best practice average. Of course, this results in long waiting times, some colleagues have begun to not even accept new referrals. When we started our work, we inherited a waiting list of several thousand patients. Against this background, the new regulations, which provide that we inform each and every individual referrer and possibly even the patient concretely about the state of their referral, would mean a devastating effort for our already burdened to the stop management.
We therefore ask CPSO to reconsider the relevant regulations carefully and to adapt them to the available resources or to mitigate their binding effect accordingly by avoiding terms such as “must acknowledge” or “must provide suggestions”.
Thank you for the opportunity to provide feedback on this series of documents. The intent of these documents is laudable, but I do have practical concerns regarding how they can be effectively implemented in the current healthcare climate of constrained human and fiscal resources. Over the past ten years or so, I have seen my productivity (in terms of patients seen) fall significantly, as I attempt to meet the evolving standards of care. Like many physicians, I have absorbed the financial consequences of this, placing higher value on patient care. Despite this, I would estimate that I spend 50% longer to care for an equivalent volume of patients. At some point, the demands and standards imposed must acknowledge the time constraints that physicians are subject to, as well as the realities of a finite healthcare budget. Put simply: you get what you pay for.
Transitions in Care:
“physicians are advised to approach patient handovers in a systematic manner and set time aside to allow for a real time and personal exchange of information between health-care providers.” I note that the language is softened slightly in the detail section to indicate “strongly advised whenever possible”. Each evening, our 130-160 hospital patients are covered by a single physician. While our hospitalists provide specific warning and direction about patients of concern, any comprehensive hand-over of all patients for the overnight period would likely take several hours. This is not feasible. When one hospitalist completes a block of days (5-14), they will provide handover in several different agreed ways to the incoming physician. Where both physicians are simultaneously present an in-person handover may occur. As a rural hospital, many of our hospitalists live in urban locations and stay in our area only for their block of days. The outgoing hospitalist typically leaves in an evening, and the incoming hospitalist arrives the next day, with an on-call hospitalist providing nighttime coverage in the interim. For many months we have been unable to staff our schedule fully due to the extreme difficulty of attracting physicians to work in our somewhat rural location. It is difficult to conceive how we could expect physicians to stay an extra night or day to undertake an in-person handover without providing remuneration. To do so would likely provoke collapse of our program.
“Within hospitals physicians must coordinate with others to keep patients informed about who is their most responsible provider”. At weekends we reduce staffing somewhat and share additional patients at the start of the weekend in order to best balance patient list sizes. I make a point of letting my acute patients know that they will be seeing a different physician, but I often do not know which physician will be taking over until after I have completed my rounds, and am therefore often unable to tell them which physician is covering.
Continuity of Care: Availability and Coverage
The introduction states that this policy applies to all physicians regardless of practice area or specialty. However, the content largely seems to relate to office-based physicians, or physicians who have an office. For those who do not e.g. hospitalists attending inpatients, the requirements for an “office telephone” seem inappropriate when inpatients are located on units that have 24/7 telephone access to nursing staff.
Continuity of Care: Managing Tests
Physicians who work in their own offices have the ability to determine the most appropriate means of tracking high risk results, leveraging technology and office protocols to minimize risk. I would like to see the policy use language that indicates the shared responsibilities of hospitals, to work with physicians to ensure that the risk of unseen results and incomplete tests are minimized.
Many thanks for your consideration.
CPSO:
During drafting of the policy for Medical Assistance In Dying, I was first invited to consider participating following my early interest in this topic, both early federal then provincial discussions of this important topic.
Since then, when I receive an invitation to provide my thoughts on new draft or existing policies when revisions are being planned. I only reply selectively depending on the topic.
Having reviewed the several policies under the umbrella of Continuity of Care and the comments provided by others during the past 5-6 months, my comments are limited to:
MY POSITIVE EXPERIENCE consistent with the draft policy.
THE PATIENT MUST ASSUME SEVERAL RESPONSIBILITIES including good hygiene, on time arrival for appointments and tests, courtesy, honesty about relevant reasons and concerns, more ….
MY GENERAL PRACTICE PHYSICIAN since 2003 is a member of the Family Health Team in Guelph. I am grateful for my overall exceptional experience with this doctor and the staff in his office. This is a practice with 5-6 doctors and staffing by nurses and other well trained members of this practice.
ABOUT CONSULTATIONS presently I have been referred to a general surgeonfor a lower priority appointment for recent onset of new right lower quadrant pain likely due to small hernia – by my family doctor and ultrasound. The referral is a model of what is being described. The family doctor sent the request and relevant history on November 5 with surgeon’s email message to me November 16, ten office days following. I confirmed I accept an appointment during early February.
WITH RECENT MEDIA REPORTS in collaboration with a meeting of / about doctors health, sleep, more, it is critical for the CPSO to extend consideration to doctors in final draft of this document. THE PROVINCE HAD NOT SHOWN respect or fair compensation for doctors in Ontario. We need more doctors including in many specialist roles including neurology, ophthalmology, endocrinology, rheumatology, surgery, oncology, allergy medicine, dermatology, other critical medical roles currently lacking in numbers and regional distribution across the province.
I am a member of the public.
My experience as spouse of cancer patient (2009-2013) who received excellent medical for a large left frontal temporal primary brain tumour. His cognitive decline was early and progressed as a patient with dementia and cancer.
Unlike, the infectious disease specialist and brain tumour patient who shared his distressing experience, my husband did not have the choice for legally-medically assisted end of life care.
My early experience as a registered nurse was limited to five years (1968-1973) of mostly surgical female uro-gynaecology nursing in a 20 bed general hospital in Northern Ontairo. I liked that work experience however the unit was closed for hospital budget reasons, also I was married and mother of one young daughter. we relocated elsewhere in Ontario due to my husband’s work.
Test Results Management
Line 70-73
“if physicians do not receive test results for a high-risk patient, they must follow up with the patient to verify that the patient has had the test…”
Comment: This seems to take any accountability that patients have to look after they own health care. Why should doctors be responsible for ensuring patients go get their tests done, if we have adequately communicated the need for such test and patients indicate they understand during the appointment?? Shouldn’t patients have any responsibility at all to ensure that they get their tests done? I think it would be reasonable for the physician to say to the patient and document “this is a serious test, that you 100% must get. If you don’t get the test, serious consequences may occur. It is your responsibility to get the test done, and to follow up with my office one week after you get the test.” Primary care practitioners are already incredibly overburdened with paperwork, phone calls and we don’t get reimbursed for these things. Patients need to take responsibility to get tests done that doctors order. It can not be the doctors responsibility to chase patients around asking them if they’ve gotten tests done. Communicate the seriousness of the needed test during the appointment, and the rest is up to the patient. Until family physicians start being paid for phone calls, this policy will not work.
Availability and Coverage
Line 18-19
“critical test results can be received and responded to 24 hours a day, 7 days a week”
How is this supposed to work in the real world? A solo practitioner must be available every single second of the day, every day of the year to receive critical test results? Where is the work life balance?? Are you trying to turn people away from primary care in a system that already lacks primary care phyisicnas? If so, it’s working. An alternative could be that physicians write on requisitions “if critical result received, please contact patient to attend emergency room”. We can not be expected to be available 24/7, especially physicians that don’t practice in groups. Again, we are not being paid to work 24/7, so until that changes, this policy will not work.
Thank you for seeking input on the CPSO’s draft Continuity of Care policy. I’d like to provide feedback on three specific areas of the policy:
1. The CPSO suggests physicians be available to receive and respond to critical test results 24 hours a day, 7 days a week or make coverage arrangements with another health-care provider to do so.
While this makes intuitive sense, there is a gap in funding for this service. For family physicians in Patient Enrollment Models (PEMs), the provincial government withdrew funding for such coverage several years ago when it discontinued the weekly physician stipend payment for the THAS system (Telephone Health Advisory Service), which funded family doctors to be on call to receive calls 24/7. Furthermore, I don’t think funding for this coverage has ever existed for family physicians outside of PEMs. Until remuneration can be implemented for 24 hour coverage, it does not seem reasonable or feasible for the CPSO to require this in its policy. Being on call requires physicians to reorganize their personal and professional obligations. It is both a practical and emotional burden to be tethered to a phone/pager even when the calls might be infrequent. This is an issue that needs to be dealt with by the OMA and provincial government. In the meantime, I recommend that the current system continue (i.e., the lab continues to have a physician on-call).
2. The CPSO has proposed that it be the referring physician’s responsibility to communicate the specialist’s appointment date and time with the patient, but the consulting physician’s responsibility to communicate office policies (including missed appointment fees), preparatory instructions, and changes in the appointment date and time with the patient.
From the perspective of patient safety, quality, and efficiency, it makes little sense to divide responsibilities in this way:
• If the date and time do not work for the patient, the patient will have to call the specialist anyway (specialists may not be aware of how often this occurs).
• The consultant’s office is in the best position to not only reschedule the date but also communicate accurately their office policies and preparatory instructions.
• The consultant’s office is in the best position to answer patients’ questions about the appointment.
• Few specialists will have no office policies (like a missed appointment fee) that would need to be communicated to the patient, meaning that the specialist will need to communicate directly with the patient either way.
• Duplication of work will inevitably occur when specialists are charged with communicating some of the information and family doctors are charged with communicating the rest.
• The policies of the CPSA and the CPSNS on this matter clearly assign the communications responsibilities, for the reasons outlined above, to the consulting physician.
My suggestion is for the CPSO, in keeping with the CPSA and CPSNS, to recommend that the consultant communicate all appointment information, including the date/time, location, preparatory instructions, and office policies, directly with the patient. This is the safest, most efficient, and most patient-centred approach. The CPSO should also collaborate with organizations like the OMA to advocate for the provincial IT infrastructure (e.g.,, scaling up eReferrals) needed to reduce the potential errors, delays, and workload involved in this task. There is a technological solution to this issue, but our governments have been frustratingly ineffective in supporting the necessary infrastructure.
3. The CPSO has recommended that physicians copy patients’ primary care provider on all tests ordered.
This sounds like a reasonable idea on the surface, but my worry is that “more” does not necessarily mean “better”. Physicians are already overwhelmed by increasing amounts of data to manage. While some tests ordered by a patient’s non-primary care provider (PCP) might be important for the PCP to see, many (such as walk-in clinic throat swabs) are not, and to send copies of every test will not only add additional unnecessary workload to physicians, but may actually increase the risk of missing an important result as the volume of data increases. For the non-PCP, it is not always easy to find a physician’s contact information, which I believe the labs now require (in our region, at least, we were advised a few years ago by Dynacare that we must include not only the name of the cc’d physician on the lab requisition but also the address and fax number). This will take time on the non-PCP’s part, and could add up quickly in certain settings like walk-in clinics where patient volumes may be high. There are also privacy considerations as patients may sometimes deliberately seek care from someone other than their PCP in order to maintain privacy. My suggestion would be for the CPSO to allow non-PCPs to exercise their professional judgement and copy PCPs on results they deem may be important for the patient’s ongoing care. The patient should also consent for this to be done.
In summary, while I think most would agree with the aspirational goals of the CPSO’s CoC policy, the system is not currently designed to feasibly implement the policy’s recommendations. We need better infrastructure (like seamless interconnectivity through technology) and funding (to remunerate, for example, increased workload and after-hours availability). Furthermore, due to the lack of system supports, much of the work involved in operationalizing this policy would fall onto the shoulders of primary care, a sector that is already overwhelmed by the challenges of a dysfunctional, fragmented system, and a sector that is arguably the most important to preserve for the health of the general population.
Thank you for the opportunity to comment on the suite of policies to address Continuity of Care in Ontario.
Availability and Coverage:
The insistence on voicemail for patient messages after-hours and on weekends is not reasonable, and is actually dangerous. Aside from the additional administrative requirements associated with this, it puts patients at risk if they leave messages for urgent or emergent matters that are not reviewed immediately (for example, weekends, or simply its being a later message in the queue and earlier messages are being addressed), but they think it’s being looked after so they defer accessing other after-hours care. It also increases medico-legal liability for physicians. If the voicemail is full with other patient calls and a patient is unable to leave a message, is the physician held responsible for not having voicemail available? Or if a patient does not leave information for the physician to call back, such as a phone number, and so the physician cannot contact the patient, who is responsible? What about if a patient who is not a patient of that clinic, but calls and leaves a message requesting help with something that sounds potentially urgent – is the physician, with no previous contact with the patient, responsible for following up in the same way that the proposed Managing Tests policy requires follow-up of incidentally-received test results?
I agree that there is benefit to making sure there are options for prompt access to appointments for “time-sensitive or urgent issues”. However, a similar concern arises as with the full voicemail. If a physician has, for example, four same-day slots, and a fifth patient calls in needing to see a physician for a “time-sensitive or urgent” issue, is the physician at fault for not having a fifth slot available? Is the criteria what is ‘reasonable’ by some undefined criteria, or what keeps all the patients satisfied? What if the available same-day slot does not fit a patient’s work schedule or other commitments – is that considered the physician’s being unavailable to the patient? I am concerned that this policy risks furthering the modern inclination toward ‘vending machine medicine’ if not treated with extreme caution. Additionally, the statement about “utilizing other physicians or health-care staff within or outside their practice” is written as exclusive of “relying on walk-in clinics or emergency rooms”. In rural areas, it is not uncommon that the local emergency room is staffed by the local family doctors and serves as urgent care. To exclude emergency room use as an access option for purposes of this policy is unreasonable in this context.
The section of the policy on coverage is clearly designed for physicians in large groups with lots of coverage options. Physicians who practice in solo or small groups, particularly rural physicians, do not have lots of options for alternative coverage. While the policy specifically states “Continuity of care does not require individual physicians to be personally and continuously available to patients and other health-care providers involved in their patient’s care”, functionally it will require that a solo/small group physician will be so. For a physician outside of the patient’s normal circle of care to provide coverage, but not know the patient and possibly not have access to patient records to assist with assessing and interpreting a concern, or finding requested information, does not work – if the doctor ‘on-call’ cannot provide the continuity, it is no advantage over having no one ‘on-call’ for an office practice at all. This requirement will result in increased physician burnout and likely a switch in practice structure to limit ‘sustained physician-patient relationship[s]’ requiring this intensive coverage. I understand the good intent behind this policy, but I think trying to apply it in our current system will be disastrous, especially in underserviced areas.
Similarly, I understand the good intent behind “Coordinating After-Hours Coverage for Test Results”, but it fails in the same ways as described above. Additionally, if we are to assume that every lab test ordered on a clinically stable outpatient from an office may be critical and require immediate attention, then I believe the CPSO must work in cooperation with the appropriate groups responsible for laboratory services to ensure that labs are run contemporaneously when drawn – if I order a hemoglobin level on a tired but otherwise stable patient, it is drawn at 1000h at a lab, it is run at 2200h and discovered to be ‘critically low’, it is significant, but it was also critical twelve hours previously. Significant delays in running these tests, while outside the scope of the CPSO, can severely affect patient care as much as significant delays in being able to contact the physician and I think it unreasonable to place the full responsibility of this on physicians alone.
“Coordinating Coverage for Temporary Absences” runs into the same problems – how does a solo physician in a rural or remote area arrange for coverage? If he or she is fortunate, it may be possible to get a locum with enough advanced notice. However, for an ‘unplanned absence’, for example if a physician gets influenza and is unable to arrange short-notice coverage, is he or she expected to go to the office anyway, therefore providing care but risking passing the illness to others? If the office is closed for the day without formal ‘coordinated care’ because there is no other doctor in town, is he or she in breach of the policy? Or suppose the doctor is hospitalized somewhere else and unable to even contact the office to inform staff that the office will need to be closed and care sought elsewhere? Again, this works in a large group setting with understanding that they cover for each other, but not in areas of limited resources. Considering use of the emergency room has been explicitly denied as ‘continuity of care’ in other parts of the policy, is this one area where it would be considered acceptable in the case of limited local resources and unplanned absences in particular? If so, perhaps this should be stated, or you may have physicians reluctant to go to or stay in underserviced areas due to the escalating risk of burnout from the demands of this policy.
The section about “Patient Engagement”, I fully support. If we are going to consider autonomy as a critical feature of medical care, it is essential that patients take increasing responsibility for their health, especially in our fragmented system (fragmentation that will not be resolved by these policies, but needs to be addressed at a system level, as the CPSO has acknowledged).
Managing Tests:
The specifics for “Test Results Management System” criteria are reasonable in intent. However, the part that reads “If physicians are not responsible for choosing the test results management system, they must be satisfied that the system in place has the capabilities listed above” does not make sense. If the physician is not satisfied and has no input into the system chosen, should he or she simply refuse to order tests? Not work at that facility as long as that system is in use? This places responsibility on physicians with no corresponding rights to allow them to meet the specified responsibilities.
“[...] where ordering physicians are not the patient’s primary care provider, they must copy a patient’s primary care provider on the requisition form.” Presumably, if there is no primary care provider, this statement has no force. However, what if the patient does not want the results copied (e.g., STI testing)? Does patient autonomy overrule the ‘must copy’ statement in this policy?
Tracking results for high-risk patients makes sense – however there is no definition of ‘high-risk’. Does it only apply with respect to certain tests, or any test for this patient group? Additionally, this section in general seems to be moving away from patient autonomy and to a paternalistic model of medicine, where a patient should not be deciding not to go for a test if ordered by the doctor. If a patient is competent and has had the importance of a test explained, the responsibility should be on the patient to decide whether or not to go for the test. It should also be the responsibility of the patient to follow up on the test result, even if it is as simple as calling the office to ensure the results were received (but not necessarily being able to receive the results at that time, depending on the circumstances). This is particularly relevant in cases where the patient can go as desired for a test (labs, x-rays, etc.) as the doctor may not even know when to start checking for results if the patient delays going. Again, in specific situations, it makes sense that the doctor, exercising clinical judgment, should follow some of these things more closely, but if it is going to be a requirement that this be done for ‘high-risk’ patients, it either should be defined or stated that ‘high-risk’ is determined by clinical judgment.
For results received “in Error or Incidentally”, the obligation should be to inform the sending provider or facility promptly of results received in error, whether it is critical or ‘clinically significant’ or not, because the physician receiving it may have no way of knowing that it is clinically significant in this patient’s situation. It should not be required that the receiving physician contact the patient due to lack of context. It is reasonable if the physician chooses to act with additional prudence by contacting the ordering physician or the patient, particularly in cases where he or she is familiar with the patient and was copied with the results, and is capable of interpreting the result, but the responsibility for ensuring the results go to the ordering physician should be on the party sending the results, and responsibility for following up on the result on the ordering physician. In some cases it may even go beyond the expertise of the physician to interpret a test result, specifically in cases where a specialist has ordered specialized tests. To expect the family physician to take responsibility for contacting the patient and attempting to explain the significance of a specialized test flagged as abnormal is unreasonable.
Under “Communication and collaboration with other Health-Care Providers”, it states that physicians must use professional judgment regarding sharing test results with other health-care providers. However, as noted earlier, it is mandated that primary-care physicians be copied with all results. This is contradictory. Unfortunately, we are not in a system where patients are always comfortable with their primary-care providers and the limited supply makes switching difficult. So is it patient autonomy and physician judgment, or is it a requirement to share the results?
Transitions in Care
With respect to hospital care, I am generally in agreement with the policy. My two concerns are, first, that the requirements on physicians should also correspond with hospital policies and so this policy may require more flexibility for this or alternatively require consultation with hospitals to ensure policies are congruent; and second, somehow addressing the fact that the most responsible physician must ensure the discharge summary must be sent to the patient’s primary care provider – even though it is very possible the patient does not have one.
Regarding consults, I agree there are great concerns around delays or breakdowns in communication. While it would be ideal to direct a consult to an appropriate subspecialist in accordance with areas of focus and with awareness of wait times and accessibility, that information is often not available. It is difficult for a permanent physician to know all the details and preferences of the specialists; a locum brought in to ensure continuity in a small town may rarely know the specialists available, let alone their areas of focus or subspecialties, and accessible ‘location’ is generally a moot point because the specialists are rarely accessible from rural areas and may require hours of travel for an appointment. Without a central, up to date database where a referring physician can access this information conveniently, it is just as simple to send the referral and if the consulting physician declines, to redirect the referral, as to contact the consultant before sending the referral to see if it will be accepted or declined.
“Referring physicians must have a mechanism in place to track that the referral has been received and that an acknowledgement of the referral will be provided.” I do not understand the intent of the last part of this statement – is it that the referring physician needs a way to track whether an acknowledgement has been received? I think this needs clarification.
Regarding “Acknowledging a Referral”, strict guidelines are acceptable if “We have received your referral” default responses are considered to meet the criteria. As it is required to be accepting or declining the referral within that time, more flexibility is required – suppose a physician is away for two weeks; even with coverage for existing patients arranged in accordance with other parts of the proposed policy, it is not reasonable for a covering physician to accept non-urgent referrals on behalf of another physician. Alternatively, perhaps an automated or standardized reply declining the consult due to absence would work in these cases. As for consultant physicians being required to provide alternative suggestions for urgent referrals that they cannot accept themselves, it needs to be acknowledged that these may not be convenient to the patient at all – the next closest available subspecialist may be geographically some distance away, especially in rural/remote settings, and the consultant should not be held responsible for that.
“Referring physicians must communicate the estimated or actual appointment date and time to the patient unless the consult physician has indicated that they have already done so or intend to do so.” “Consultant physicians must communicate any instructions or information to patient that they will need in advance of the appointment, unless the referring physician has agreed to assume this responsibility.” Therefore, both offices must contact the patient, providing different aspects of information regarding the same appointment? This seems like an invitation to breakdown in communication. All information should come from the party best able to provide it – the consultant physician. Consultant physicians “must also communicate any changes in the appointment date and time with the patient directly and must allow patients to make changes to the appointment date and time directly with them” – so why should the original date and time come from the referring physician? If a change needs to be made as the initial date does not work, it is more efficient to deal with it in the same communication rather than requiring the patient to then contact the consultant’s office.
“Consultant physicians must send consultation reports to the referring health-care provider and the patient’s primary care provider, if different.” How is this intended to work with respect to locums providing continuity of care? Is the consultant responsible for finding the contact information at the time of sending the consult report? Or is he or she freed from that responsibility if it is indicated in the consult request that it is a locum covering for the primary care provider, and the report in those cases can be sent to the primary care provider only?
Walk-in Clinics
My first concern is with the definitions. ‘Walk-in Clinic’ is used to include urgent care centres, but not hospital-based emergency rooms. In rural areas, the hospital-based emergency room also frequency serves as the walk-in clinic/urgent care as there is no other facility available and it is run by the local family doctors. To categorically exclude emergency rooms limits the intended benefit from this policy. What is the justification for the exclusion? If volume, administrative, and time requirements are the concerns, these apply to urgent care as well.
With respect to coverage for contact from health-care providers and for critical test results, the concerns are the same as previously mentioned, though it is rare that a rural area would have adequate resources for a stand-alone walk-in clinic.
The requirement that primary care providers be provided with a record of the encounter runs into the same problems as mandating primary care providers be copied on all requisitions – patient autonomy and confidentiality. Ideally, it should not be an issue; however the patient should have the final say after discussion regarding the potential issues of the primary care physician not being aware of the additional health concerns. This would also need to be applied in a minimally-burdensome way – a walk-in clinic physician does not have time to write numerous letters for this purpose a day; if an EMR can automatically generate a summary it would help reduce the administrative burden of this.
I am concerned about expecting walk-in clinics to act as temporary family medicine clinics for comprehensive care. How long are they expected to do so? A year? What if the patient has not found a family physician by then? What if he or she decides not to look because he or she is happy with the care at the walk-in clinic, despite that not being the function of the clinic? The longer appointment times required for adequate comprehensive care would impair access for urgent issues – access that is already an issue in family physicians’ offices and one reason walk-in clinics are used instead. And again, in rural areas, the emergency room often serves as a walk-in clinic setting – while it was excluded from the definition, will there be a soft expectation that, because the services provided are similar, office-type comprehensive primary care should start being provided there as well? While I recognize this is ‘advised’, not ‘must’, I think it needs to be approached with extreme caution as it may jeopardize the current role of the walk-in clinic. It would be ideal for walk-in clinics not to be required for urgent care and be free to assume a different type of role, but this is not the system we currently have.
I greatly appreciate the intent of these policy proposals; however significant review and revision is needed to avoid making the ‘cure worse than the disease’, with the potential impacts to patient autonomy, physician burnout, and systemic issues.
Continuity of Care Submission:
A) Continuity of Care
B) Availability and Coverage
C) Managing Test Results
D) Transitions in Care
E) Walk in Clinic
I have reviewed all of the documents and primers, answered the online survey, and read all 250 posts on the forum.
Please carefully review my e-mail as I have spent 20 hours researching and drafting this submission. Thank you kindly in advance.
The continuity of care policy is important so doctors can discover opportunities to improve transitions. This can be addressed at New Patient Visits with patients.
However, stipulating onerous, burdensome administrative work is counter-productive.
I am concerned that the walk-in clinic policy is FHO driven. I hope the committee forming this policy includes family doctors from FHGs and walk-In doctors not just FHOs and specialists.
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1: Cost of increased administrative burden=Further Disruption in Continuity of Clinics/Admin Staff:
I am writing from the perspective of a downtown Toronto general practitioner in a FHG and a walk-in doctor also providing episodic care. At my family practice, for the past 9 years, I worked in a FHG model (70% of my time) and any unused appointments slots were available for walk in visits (30% of my time).
Two years ago, there was a sudden closure of the last clinic I worked at. Patients were left with a temporary locum and using walk in clinics until I could find a new location. With a clinic closing down, this is the ultimate fracture of continuity of care.
One aspect of continuity of care not addressed, is what results when clinics are unsustainable with the reduced OHIP funding (MOHLTC unilateral cuts) and increased admin requirements. Clinics are often not physician-owned and are business models trying to maximize profit. This results in sudden closures (in our case 30 days notice) with little regard for patients and doctors once a clinic is no longer profitable.
Due to subsequent burnout, I have since reduced my family practice to 45% of my time and I work at a walk in clinic 55% of my time. I am also looking for non-OHIP opportunities to prevent burnout. I will always work at 2 places now, in case 1 clinic closes down.
Furthermore, I have observed due to physician burnout at the new walk-in clinic I work at, 2 of 4 family physicians (within the first 2 years of graduating and opening a practice) left their family practice.
I have watched at the last three downtown Toronto practices that I have been involved with, that no family doctor was found to replace the doctors that left because it is hard to find doctors who want to commit to family practice anymore. It takes 1-2 years to hire a new doctor despite numerous candidates interviewing. Often it is an IMG or a Quebec graduate who is hired (who are not aware of the family doctor climate with the MOHLTC).
The cost of a person to answer voicemail, the cost of EMR software and hardware, and the cost of staff to fax walk-in encounters needs to be addressed or the requirements will be unsustainable. This is especially true within a climate whereby professional corporations have new strict tax rules, minimum wage is higher, and there are threats of further cuts from the MOHLTC.
Furthermore as admin staff has extra tasks assigned, there will be higher burnout and turnover affecting continuity of care. Currently there is turnover at least every 6-12 months. With each change, there are risks of system errors.
With increased admin requirements, the situations I described will become more common. Less people want to be family doctors and more clinics will close down abandoning patients. Family medicine is under-funded and has a high admin burden resulting in burnout. If walk-in also becomes too burdensome, people will shift to non-OHIP work. Ontario may May face having an even smaller supply family doctors.
Even if physicians are forced to take on family practice, patients will not benefit because the doctors may be disgruntled and burnout quickly.
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2: Walk-In Clinics
With new proposed negative negation for outside use in FHOs, FHO MD’s are likely fearful.
They have subsequently vilified walk-in clinics. MOHLTC created a system where FHO MDs have taken on more patients than they can accommodate. Many FHO MD’s were not concerned about losing their access bonus in the past. They still made a good salary by over-rostering even if they lost their access bonus. They could not accommodate same day appointments due to over-rostering, and patients just saw walk-in doctors instead.
While FHOs may want to make it difficult for walk-ins to function, ultimately, to respect patient autonomy, patients should be able to choose what MD to see.
a) Value of a Walk-In Clinic to Patients
Walk-in clinics offer value to healthcare.
i) Expertise:
Walk in clinics may be used for expertise that their own doctor may not have due to age, gender, religion, location. This also saves MOHLTC dollars in reducing specialist referrals.
-patients may want a 2nd opinion
-they may have sensitive matter they do not want their physician to know about such as an STI/infidelity/abortion for an unplanned pregnancy
-they may want a female doctor if they have a male family doctor
-they may need urgent care preventing ER Visits
-they may want access to a specialized area of the physician (mental health, migraine, PrEP)
-at the walk in I also provide PrEP HIV Prophylaxis for many MSM patients because many family physicians are not comfortable to prescribe this. Their patients still have access to this care, preventing huge costs to the MOHLTC by preventing HIV in gay men (1 in 4 in Toronto HIV positive, which is the highest rate in Canada).
ii) Productivity:
Walk-in clinics allow patients to be productive and not have to take days off to see their doctor. Instead, they can go to a walk-in MD close to their work over lunch hour for minor issues.
iii) Facilitate transfer of knowledge:
I was able to learn this new skill of PrEP due to the ability to work at multiple places. If I was restricted to my FHG practice, I would not gain these skills.
iv) Quality:
It is inaccurate to presume that walk-ins provide less quality care. I see the same number of patients per hour in a walk-in as I do in family practice and provide the same quality of care.
v) Variety:
Walk-in care provides doctors opportunities to meet new people to treat new conditions. It adds variety to the day to prevent burnout.
vi) Connect to New Patients:
Walk-in provides a way family doctors can connect to patients and take them on as patients as other patients leave their practice. I took on 50 people from the walk-in clinic to my family practice last year alone.
vii) Flexibility:
Walk-in provides an opportunity for temporary/flexible work such as if an MD is moving soon, retiring, or has a disabled child at home, or they themselves have a disability/medical condition.
viii) Coverage:
Walk-in clinics provide care for patients during temporary short term absences from practice for family doctors.
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b) Sending Encounter Notes from Walk-in
Patient Engagement needs to be utilized instead.
i) Family Doctor Perspective:
-a walk-in MD should not cc a report to me without me knowing context and if patient has been informed already of result. It creates unnecessary phone calls to the patient and review of results which is unpaid time. For example, if someone cc’s a positive throat culture for Strep to me a family doctor—it will prompt an unnecessary call and worry to ensure the patient has been treated.
-I already spend 1 hour per 6 hours of patient care reviewing messages and labs, I would be stressful having to review and sort through walk-in clinic encounters in addition.
Currently I receive notices that a patient has been admitted to the ER with “Abdominal Pain”. This page is not helpful to me. Often other times, I am faxed a page from the ER that is illegible—also unhelpful, but still takes up my time.
Walk-In Doctor Perspective:
If I order an urgent test in the walk-in clinic, the patient must book a follow-up appointment to review the test. I give them a copy to give to their family doctor at their next visit.
It is the patient’s responsibility to ensure their family doctor is informed. Patients can have copies of tests and communicate directly to their family doctors what occurred at walk-ins. Clinics can also request for copies of important test results.
The more time dedicated to admin tasks, the less time we all have for direct patient care.
Walk-in physicians are only compensated $20-$33.70 per visit. From this, they have 4.5% clawbacks to the MOHLTC, then pay 30-40% overhead out of this to the clinic, and then 35-40% of the remainder to taxes. This leaves a payment of $14.65 per visit on average. The MOHLTC is also proposing walk-in clinics get 25% less if they see a rostered patient.
Walk-in physicians are not adequately compensated for the work they do, let alone the admin required to fax encounters to family doctors. Also, there would be risk of breaches of very personal info with a clinic not used to faxing medical records if faxed to the incorrect fax. It would then make the fax busy for incoming consults and requests in the daytime.
The schedule of benefits does not state that a walk-in doctor has to send a consult as part of the A001/A007/A003/K codes. Transfer of records is a non-OHIP uninsured service.
It does stipulate that a specialist consult does require to send a note to the family doctor. I would say, even with this regulation for specialists, 35% specialists do not send consults and not in a timely manner. 90% only send one note and no followup notes. If specialists/ERs were not made to send every consult note to us for every visit in the past, why should a walk-in be held to a higher standard.
Alberta has an EMR system (Netcare) that the whole province can access with consult notes/bloodwork available. It has been in place for 15 years. Since being in Ontario x 12 years, I have seen hospitals wanting to keep their autonomy and no movement towards an EMR that connects hospitals. There is OLIS, but just for bloodwork. Why should walk-in resources be used to compensate for the lack of a continuous system being established even 12 years later.
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c) Walk-In Clinics: Setting Boundaries & Educating Patients
i) Physicians should be responsible for the follow up of their episodic care for example results and consult notes from non-urgent referrals.
ii) I don’t do non urgent referrals or bloodwork in the walk in due to lack of continuity of care. I advise the patient of a family doctor accepting patients immediately and get them connected to facilitate continuity of care
iii) The policy should stipulate providing non-urgent comprehensive in the walk-in if there are no Family doctors accepting in your city. Clinics do not have the continuity or infrastructure to support comprehensive care. This does not promote the patient finding a family doctor. Why would they, if they get everything they need from a walk in. It will further promote fragmented care. Walk-in doctors should not gave to take on added liability because the patient did not make their health a priority to take the time to set up a family doctor. Downtown Toronto, there are numerous clinics accepting patients.
Patients in centers that have family doctors accepting need to be directed there to have comprehensive care done. For example, if follow-up paps are needed in 6 months and a walk in MD leaves the clinic, and the patient forgets, this patient could fall through the cracks.
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3: Transitions in Care:
a) Specialist Appointments:
-I agree specialists should set up their own appointment with patients. Patient time and autonomy has to be respected. I give the contact info of the specialist to patients for them to call the specialist themselves to arrange an appointment. This way there are no lost referrals and they can set up a mutually agreeable time. People have work and families to schedule around. When someone books a hairdressing appointment, they do not just accept a date, there is a communication of what works best for both parties.
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4: Availability & Coverage:
a) Voicemail:
-in terms of using technology, voicemail is archaic. There is no accurate documentation, there is the possibility of mishearing a statement, and it is double time to listen, record, then call the patient back. Phone tag then occurs.
-physicians should have the option for receptionists to livechat during business hours and e-mail during business hours and after hours instead of voicemail. E-mails can be kept track of, are accurate, can be easily replied to. Physicians who have online booking and same day availability, Mon-Sat care, should be rewarded and not require voicemail systems.
-Other physicians are right that 90% of voicemails are inappropriate use of voicemail and non-urgent and ultimately require the patient to book an appointment. Symptoms, if emergent, should not be left after hours on a message, but instead be seen in the ER. Currently, our admin spends much of her time getting back to unnecessary voicemails which take days to clear. Subsequently, current patients cannot get through by phone in business hours because phone lines are busy.
-I do not take patient calls as this service is not covered by OHIP, most issues cannot be adequately assessed by phone, there are confidentiality issues/risks, and I always have same day or next day appointments available.
-for clinics to become financially sustainable, we are moving toward not having receptionists at the front desk, using online booking, and sign in i pads. We would have them only to initiate call backs for results.
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b) Temporary Absences:
I agree that finding a locum for short term and especially unexpected coverage is difficult. If someone is even available, there is an jnterview, there are contracts to be signed, the ministry of health needs 60 days to add a locum, a person needs EMR training & clinic training. This does not happen easily.
-I do agree that tests need to be reviewed
-other colleagues within the same clinic can cover, but also walk-in clinics can be utilized
-physician time-off prevents burnout
Thank you for taking the time to read my submission.
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