Cutting off the flow upstream

Excess paperwork is a barrier to access to care. The equation is simple: If a physician is spending time dealing with filing and forms, they are not actively seeing patients (or tending to their own health and well-being). Yet paperwork itself is necessary to provide access to care, often ensuring the right patients get the right help at the right time. How then, to cut out the excess? The answer to stopping the flood of paperwork is to ease the flow upstream, to make system changes so the physician does not drown in requests that are inappropriate or unnecessarily complex. These system changes could target forms, sick notes and the way information travels to the physician’s desk. CHANGE THE FORMS One step is to examine the forms coming in to ensure they are required and pertinent to the issue at hand. The Ontario Medical Association (OMA) has a forms committee that is doing just that. OMA members can submit forms to the committee for review, and the committee will reach out to the organization that produced the form. The forms could be from municipalities, insurance companies, police asking for evidence or other sources. The main focus of the forms committee is to make sure forms are appropriate and can be completed efficiently and effectively. Read: Study examines opportunistic salpingectomy as tool to reduce ovarian cancer risk “It has to be in the context of what a physician can actually offer,” said Dr. Scott Elliott, chair of the OMA forms committee and a family physician in Brantford, Ont. Forms need to be requesting information that actually needs a physician’s input. For example, a question about a patient’s ability to walk a certain distance could be directed to an occupational therapist instead of a physician. Forms need to be standardized so physicians aren’t filling out multiple versions of forms requesting the same type of information. The OMA meets with the Canadian Life and Health Insurance Association (CLHIA) once or twice a year, working with them to make a standardized form across the industry, Dr. Elliott said. There’s currently a draft form ready for the committee to review. The association confirmed that it is working with other medical associations across Canada to improve the claims process. The CLHIA has developed new standardized and simplified forms related to short- and long-term disability, hospitalization and mental health records, a CHLIA spokesperson said. Dr. Elliott said that the OMA forms committee has a good working relationship with Ontario Health, and provides input on how to standardize and update its forms. ABOLISH SICK NOTES Physician’s voices are getting hoarse from the cry to abolish sick notes. Their pleas were heard for a short while at the start of the COVID-19 pandemic when different jurisdictions asked employers to stop requiring sick notes, like in B.C., or even legislated that sick notes would not be required for short-term absences, like in Alberta. Read: Lower post-C-section opioid scrips means far fewer unused pills in the Toronto community: study “That was really helpful,” said Dr. Heidi Fell, a family physician in Calgary. The CLHIA has developed a COVID-19 ShortTerm Disability Form that doesn’t even require a physician’s signature, just a positive rapid antigen or PCR test. Insurers will even accept self-reported symptoms if the patient can’t access testing. Still, sick notes for other short-term illnesses remain a must for many employers. In the past, provincial legislation helped. Ontario had legislation where an employee could refuse an employer’s demand for a sick note for a minor illness, but it was later reversed. Currently, a bill stands before the Ontario legislature proposing that employers can’t demand that employees provide evidence from a health professional as proof of illness for a short-term leave. If provincial and territorial governments changed employment law so employers could not demand sick notes for short-term absences, it would mean less paperwork for physicians, and more appointments for other patients. TECH WITH GOOD DESIGN Health informatics has long been touted as the answer to decreasing paperwork. The Ottawa Hospital took the plunge to adopt the system-wide Epic health information system in June 2019. The system is spreading across Ontario. By June more hospitals in Hamilton, the Greater Toronto Area as well as the University Health Network will be using Epic. When asked if adopting Epic has reduced paperwork, Dr. Glen Geiger, the Ottawa Hospital’s chief medical information officer was quick with his answer: “Yes, massively.” Read: Rule out cervical cancer with the HPV detection test With the new system, information is transferred immediately; there’s no paper, no PDFs, the information goes into the physician’s in-basket. It’s a closed-loop flow, so each document has to be signed off so that no document is missed. A broader scope of information is available to physicians, Dr. Geiger said. This means less time chasing information from colleagues, making transfer of care easier. Dr. Geiger said this has been especially important transferring pediatric patients to adult care. There’s no longer a need for emergency room physicians to call the children’s hospital to get all the files for a 19-year-old patient faxed over; the Children’s Hospital of Eastern Ontario is also on the Epic system. The billing workflow has changed; now, billing flows directly from your actions. “For me personally, that’s been an enormous advantage,” said Dr. Geiger, who is an internal medicine specialist. Previously, billing information was kept as small cards and the information was re-loaded into the billing software. Adoption of the hospital-wide system has reduced paper, true, but Dr. Geiger said that some physicians were aghast with the number of files landing in their in-basket. For example, nephrologists get information on all their patients’ many, frequent tests. “I think many physicians are struck by how busy their in-baskets are,” Dr. Geiger said. “Some physicians found electric review of information a bit intimidating and overwhelming at times.” There are shortcuts and tricks to managing electronic files, and physicians can set up default actions, but it takes a bit of study to learn them. While the system has improved communication and reduced paperwork within the hospital and with other hospitals also using Epic, it doesn’t include community physicians. They still have to fax in requests for referrals to specific departments. It’s this lack of bridging between systems where the promise of health information technology has yet to come to fruition. Alberta’s health information systems are another example. The province has Alberta Health Sciences (AHS) Connect Care; Alberta Health’s Netcare; and community physicians’ own EMR systems. There are some connections between the three systems, like a registry that lists all the patients for whom a physician is providing care; and the community encounter digest, where a patient’s file for the past year goes into Netcare. Consultation letters can also go into Netcare; so emergency doctors can see the last consultation letter written by a community cardiologist. Summary documents from AHS’s Connect Care can go into Netcare too. Still, referral requests are not standardized. Physicians either fax a request, log into the eReferral portion of Netcare or can connect with AHS departments through Connect Care. There’s also another process through Alberta Surgical Initiatives, said Dr. Fell. She has an interest in health informatics and has represented the Alberta Medical Association at various tables with government and the AHS. Read: Accelerated partner therapy for chlamydia and gonorrhea All the systems are only half-implemented, and together are an ungainly patchwork in what will hopefully transform into a graceful information system. It’s still going through puberty: almost there, but not quite. “That technology has definitely not fulfilled the promise of creating less paperwork,” Dr. Fell said. “If anything, the paperwork is increasing.” There is more to be added or completed in health information systems across Canada; like e-prescriptions so there are fewer faxes from pharmacists and standardized referral processes. The CLHIA noted that insurers are starting to introduce their own electronic systems to manage disability inquiries, where physicians can complete forms via a secure portal. In order for these systems to actually reduce paperwork for a physician, they must be designed with a physician’s workflow in mind. Dr. Fell warned that all health information systems must work for physicians; information must be curated from a patient care perspective instead of an administrative perspective. “We have to be very careful moving forward that we make that situation better,” she said. For example, the design of health information systems must make sure information is not created in silos, so physicians don’t have to spend time requesting information from various places. Also, the information needed for the clinical encounter, or for patient management, must be easy to find, so a physician doesn’t have to spend hours sifting through pages to find the relevant information. Dr. Fell said you can get bogged down with information that is not clinically relevant. One Medical Post reader gave the example of getting a report whenever a nurse checked the patient’s I.V. site, generating a lot of extra information. “Integration in communication has to continue,” Dr. Fell said. “If we do it poorly, it will make things worse." EASE THE FLOW Dr. Elliott said that physicians are getting more and more requests for information. Patients are not the only ones being told to “ask your doctor.” Everyone seems to want a physician’s input. All the streamlined forms and health information technology can’t help when there’s just too much paperwork to handle. Moving forward, the question will be not only how to limit the workload created by requests, but how to decrease the magnitude of requests for information to a trickle of appropriate appeals. It is a noble goal that requires well thought-out action from all those who seek physicians’ expertise, but if achieved would improve access to care for Canadian patients. Read: Two new menopause guidelines on sexuality highlight new treatments

Cutting off the flow upstream

Register for free access or login.

Related Topics