How can physicians hold themselves & their colleagues accountable to ensure the new referral consultation requirements are met?

College of Physicians and Surgeons of Alberta CPSA, Designing Quality, Designing Quality Blog 79 Comments

The College often hears concerns from both sides of the referral-consultation process. We hear from referring physicians that consulting physicians can be difficult to access or can refuse to see certain conditions within their scope. We hear from consulting physicians that referring physicians can provide insufficient detail or clarity, or don’t complete proper examinations of their patients before requesting the consultation. Frustration is apparent on both sides, and patient care ultimately suffers.

This was tragically brought to public attention in 2013, when the Health Quality Council of Alberta (HQCA) released its Continuity of Care study following the death of 31-year-old Greg Price. In its recommendations, the HQCA asked the College to review its standards of practice with the goal of improving coordination and provision of services.

“If sharing one good idea could save one patient’s life, let’s get serious about this and share as many as we can.”Dr. Michael Caffaro, CPSA Assistant Registrar & Complaints Director

CPSA Council responded by approving important amendments to the Continuity of Care standard in June 2015 and, at its September 2016 meeting, the Referral Consultation standard.

The Referral Consultation amendment – to take effect January 1, 2017 – requires physicians to meet specific time frames for responding to a consultation request (7 days to acknowledge receipt and 14 days to accept or not accept), and to improve communications with each other and patients to eliminate unnecessary delays. Read the amendment here.

For some this may mean significant adjustments. For Albertans it will certainly mean better care and outcomes. What will it mean for your practice?

We invite you to share your comments below. Your comments will help us develop advice for physicians.  We are currently developing an Advice to the Profession document to support physicians in implementing the Referral Consultation standard.


About Dr. Caffaro:
Dr. Michael Caffaro is a graduate of the University of Alberta Faculty of Medicine and completed a family medicine residency and extra year of surgical training in Edmonton. For more than 21 years, Dr. Caffaro proudly called Hinton his home, practising as a family practitioner with emergency room, obstetrical, surgical and Medical Examiner duties. In April 2015 he moved back to Edmonton and joined the College of Physicians & Surgeons of Alberta as the Assistant Registrar in the Professional Conduct department and the College’s Complaints Director.


Help us improve our formal consultation process

Did you miss the the opportunity to provide feedback on the draft Referral Consultation amendment during the formal consultation period from April 6 – June 7, 2016, before the standard was approved by Council? The request for feedback was communicated as follows:

  • April 6, 2016 – Email to all active members and stakeholders
  • April 11, 2016 – Twitter @CPSA
  • April 14 – The Messenger
  • April 21, 2016 –MD Scope
  • April 28, 2016 –Alberta College of Family Physicians web news
  • May 5, 2016 – Email to AMA Section Presidents
  • May 13, 2016 –The Messenger
  • June 6, 2016 – Twitter @CPSA

We want a robust consultation process and are open to exploring new ways of reaching our members. Please email your suggestions to consultation@cpsa.ab.ca

79
Leave a Reply

1000
45 Comment threads
34 Thread replies
0 Followers
 
Most reacted comment
Hottest comment thread
48 Comment authors
  Subscribe  
newest oldest
Notify of
Jahn

What happens when your general practitioner retires and has been giving you the  same medication for 7 years. And you look for a DR And that doctor and many other doctors will not prescribe those drugs to you? What does a person do.

Mr. David Price

Dear Dr. Caffaro, I would like to start by commending the CPSA’s and your individual efforts to respond to the recommendations contained in the Continuity of Care Report written largely about many of the events leading up to Greg’s death. I have taken a little time to look at the blog you are hosting that shows many different comments on the amended Referral Standard to take effect in January 2017. While it is certainly tempting to react to the comments questioning patient’s intelligence and our family’s inserting ourselves into health care affairs, I will not do that for it serves… Read more »

Adina McBain

Something I continue to hear from some of my patients who have visited specialists is that ‘your family doctor can find the information on Netcare’.  For example, rather than adding my name on to a lab/investigation requisition (CC’ed) I am expected to go looking for the results.  Sometimes I haven’t even received a consult note back.  I hope that this will soon become something of the past.  The vast majority of consultants are fabulous & send back wonderful communication with all investigations coming thru to my EMR on a regular basis.  This is very much appreciated & I hope that… Read more »

Dr. Michael Caffaro

Adina The coming Advice document will include direction that it is inappropriate to direct a colleague to ‘look it up’ on Netcare – we do not have a mandate that all MDs in the province have an EMR, therefore physicians on both sides of the process are expected to provide all relevant investigations directly to the other physician in non-urgent/emergent cases. If you are on the phone and summarizing investigations on a patient needing care immediately, you can always offer where the complete investigations can be found if the other physician agrees. There is no ‘stock’ letter – I know… Read more »

Maria Filyk

I think the timeline is unreasonable. As a specialist in a non-medical community office with limited administrative support, with patient care limited by the office to Mondays only, I cannot possibly comply if this is mandated. 

Furthermore, I agree with others’ comments on having the patient take some initiative in the process and on sharing of alternate ways to contact patients (like email). For example, once the referring doctor knows the specialist is accepting the referral, the patient be asked to book their appointment with the specialist’s office.

Jeremy Reed

After my initial glowing review, I must admit that I failed to read the fine details of the plan, and that it is being implemented on Jan 1, 2017. 7 days/14 days is not a reasonable timeline Mike.  2/4 weeks would be much more reasonable.  When one considers OR time, or time in outpatients, or cast room, or MTU team call, or the cath lab, or the endo suite etc etc, it is entirely possible for some specialists to not see their office for a week, even without holiday/CME time taken into consideration. Sending out a notice every time we… Read more »

Adeleye 'Lemi ADEBAYO ,MBChB,FRACGP,MMED,FCFP(SA),CCFP

  I agree with Christin, I believe advising Specialists or Physician colleagues to check Netcare is appropriate and more importantly all regulated members should be mandated to do so to make sure they have access to NETCARE to improve patients care. If the referring physicians already added appropriate information as expected and the patient is seen 3-4 months after, clearly some medications might have changed, also new investigations might have been ordered by other doctors, in my opinion, clearly patient care would be better if the physician checks Netcare. It’s possible that during the wait time for Specialist consult, new… Read more »

Jeremy Reed

3 minutes, times 40 patients, is 2 full hours a day. I agree with Dr. McCollum.

Dr. Michael Caffaro

Physicians should always consider Netcare as a source of updated information on their patient (whether the consultant or the attending) . However as Netcare access has not been mandated for all physicians it is a breach of the Standard to simply direct a physician there for the information required by either the consultant or the referring physician. The Standard is not a ‘knee jerk’. All physicians were afforded opportunity through the Consultation process to participate through several communications. I have previously made suggestions as to the situation of the solo practitioner and considerations for meeting the requirements of the Standard.… Read more »

Timothy Jordan

  Let patients directly make their own appointments with specialists. It is time for patients to take more responsibility, show some initiative and this would reduce the number of  actions required to complete the process. Hiding behind a veneer of stupidity for some patients is no excuse. There should be a central booking office funded by AHS. Why has Netcare not resolved this issue? A simple process with their input, would no doubt become unmanageable. Why do we not use patient e-mail addresses for contact? More often than not, patient details are not up to date on Netcare. Congratulations to… Read more »

Jeremy Reed

Hi Tim…. Your right, there’s no reason why the referring doctors office needs to be involved with booking an appointment for another doctor – RADIOLOGY INCLUDED!!! It constantly amazes me how some groups can just cast their hand and say “we don’t admit”, or “we don’t book appointments for your patients”….. We’re all doctors, act like it.

Elisabeth Wagner

 I agree with Troy Pederson’s comments. Very nicely put. As a consultant the two items I am most frustrated about are the timeline being too tight, not allowing for staff holidays, or physician’s time away. Why can’t it be extended to 4 weeks?  My office already practices the timelines stated except contacting the patient within 14 days to let them know the  status of the referral. I am unclear why this is necessary? In a small office, this is extremely challenging ( my office mate gave this a trial ).  There does not seem to be any  onus on the… Read more »

Dilini Vethanayagam

The referral-consultation document from CPSA has not taken due consideration two important areas: 1. Some of our most vulnerable populations, such as those living on First Nation settlements in some of the most northern / remote communities are at risk for further isolation (I am not referring to reserves within an hour or two of a city / town). Many of these reserves do not have continuity of care from primary care – that forms a more concerning long-term issue. Who follows up on the consultant’s recommendations? This can lead to delays in management – including cancer assessments. I think… Read more »

Michael Caffaro

Your concerns with vulnerable populations are recognized. Ideally the consultant and attending family physician should be having the discussion about how to make follow up relatively seamless for the patient – but if there is no primary care physician at the other end, consultants do need to accept that they have a professional obligation to quarterback that care. As to the impact on AHS clinics – we have previously approached and continue to reach out to AHS leadership in this area. We are very aware that clinics will need physician input into the expectations – we are also aware that… Read more »

John Dushinski

I agree with and empathize with the specialists in solo practice who find the new rules overly burdensome.  Fortunately we can simply turn off our fax machine and we will be in compliance with the new rules.  That doesn’t help the patients needing access, but gets us out of trouble.  Maybe the college should have consulted us ahead of time and not bowed to external pressure from biased non-physicians with an axe to grind.

Michael Caffaro

Please note that a) turning off the facsimile machine will not be in compliance with the Standard unless you have previously indicated to your referral base (or can indicate via auto return from your facsimile machine) that your office is not accepting consultation requests, and b) the consultation process was identified to all regulated members in spring 2016, with a request for feedback sought over a two month time frame. The push for a renewal of the Standard does not come just from external parties ‘with an axe to grind’ or a HQCA report – our own regulated members (on… Read more »

John Dushinski

2 months is a very short time for consultation for something that is generating this much controversy. I take it from your comments that the “un-named party with an axe to grind” did influence the new guidelines. Shameful.

Michael Caffaro

The new guidelines were informed by a wide range of parties. Those individuals with negative experiences under the previous Standard rightfully provided input to suggested change – and the vast majority of those were our physician colleagues.

We can send a package 10,000 miles across the ocean and track its status. I don’t see why tracking a referral inside a province should be rocket science. UPS can do it and the technology is available for doctors to do it so we need to just start using it.

Tim Jordan

Too many doctors, specialists and GP’s, are trying to disrupt the system in an attempt to generate as much income as possible, in the shortest time and to the detriment of the patient. I often read specialist reports especially of in-patients and the conclusion appears to be a mishmash of unintelligible nonsense. Geriatrics is often a case in point. Placing people in positions of authority for which they are unsuited is a recipe for disaster. On numerous occasions, I meet up with patients who have had the incorrect surgery performed because specialists haven’t had the decency to undertake a comprehensive… Read more »

Nikolett Raguz

I would urge the college to reconsider these rule changes. I understand that the spirit of these rule changes are to enhance patient care, but they are not realistic in all practice settings and are far too rigid. As a specialist in solo practice, I feel these new rules are unattainable.  I only have one other employee in my office, my MOA.  When I’m away I have my MOA scan the referrals and I triage them from a remote location. However, these new changes don’t consider that my MOA also requires a vacation. I see the need to ensure that… Read more »

Michael Caffaro

As mentioned previously, the solo practitioner (and their staff) should be in the position to take a holiday. With appropriate notification to the referral base in advance (my previous recommendation has been 14 days in advance of an absence/office closing) should be the opportunity to get away and not have to worry about the review of incoming referrals until the office is open again and the physician/staff.

Chris Rudnisky

Practically, how does one inform every and any physician (and optometrist) who refers to you that you’re going to close your office? Without a centralized system, you can’t possible tell anyone who might think of you while you’re on holiday.

Dr. Michael Caffaro

This may require a retooling of how you keep tabs on who your referral base is – however keeping track of those physicians/optometrists is possible. Many of our regulated members keep track of all patients they have ever seen and regularly contact them by post or other means (think cosmetic services) – so we know this is possible. You can decide whether this notification is by phone, facsimile, E mail or post. Another consideration – maybe this is the time for solo practitioners to consider joining together in ongoing practice or ’virtually’ to cover each off during office closures? Physicians… Read more »

Donald Hamilton

I hope that it has been noticed that solo practitioners have issues with the timelines when they won’t be in the office. I am a solo practitioner. My office can immediately confirm the receipt of a referral when it is open. The problem comes when my secretary is away on holidays which happens so she is refreshed and willing to keep working. at other times. I do not believe she should be the one to triage patients so they can not be triaged when I am not available which also happens from time to time and sometimes for a few… Read more »

graham hunter

This Standard is a complete waste of paper and hot air. I am expecting to receive a stream of “consultation denied” or “not accepting referrals at this time” once it becomes law. We KNOW where the bottlenecks are and we live and work with them. The CPSA cannot legislate good sense and decency. Just because there was a high profile failure of the system (in which the patient/victim apparently shares some of the blame, according to published reports) is not a reason to produce yet another Standard. There are numerous specialities which cannot satisfy this standard and their only recourse… Read more »

Christopher Cham

I understand what the CPSA is trying to achieve with these guidelines, but as others have commented, I also am ONE specialist with a solo office. I am not against amendments which lead to better communication… BUT…  1. These rules become overly restrictive and burdensome on myself and my ONE very competent, caring, professional and thorough staff member. She puts all the incoming documents in my EMR’s folders for me to review.  Can I not even allow her one weeks vacation (let alone myself)? To my embarrassment, I have not learned how to do her part of running my office.… Read more »

Ian Hurdle

Unfortunately there is no easy cookie cutter rules as I too have lived through both ends. I review every referral and try to triage within my five month referral wait. I also sort out those not in my current surgical practice area. An acceptance is faxed back with approximate wait time which varies with changing OR times and clinic space. I could be away up to five weeks on vacation although I usually sneak into office midway to contain the paperwork ( my spouse called me after seven hours this year to check where I was ). My staff call on patients one… Read more »

Kevin Wiebe

I am also concerned with the strict timelines being imposed to acknowledge a consult (7 days) and respond to accept a consult (14 days) and contact the patient (14 days).  I agree also that the process should be made better for the referring physician and also for the specialist and ultimately for the patient.  However, the timelines listed are too tight.  Even a 14 day vacation (which is not really excessive) is impossible in a solo practice under these timelines.

Michael Awad

This is a difficult issue to enforce on specialists. It is not fare that stiff unforgiving time line to be put on us to reply to referral. We all do our very best to try to see all referral on timely fashion. We will never please all the critics. To put X number of weeks to see new referral is totally unfair for us and unrealistic. Our offices is chock block for 3-4 months ahead? The referring MD knows well which office can see his/her patients faster than others. They should use that info in discretion. We cover labor and… Read more »

Dr. Michael Caffaro

Michael, the intent of the Standard is certainly not to render the lives of (solo or group practice) consultants impossible. To identify that a referral request has been received by a consultant’s office (followed by acceptance or rejection of the referral request) in the timelines provided was identified in the consultation as appropriate. The Standard is not mandating a time frame in which you actually see and consult on the patient – yes we’d ultimately like to see that shorter than it is now for many areas – and therefore we do not expect that you will be ‘rushing’ through… Read more »

P Marck

My staff request taking their vacation in a block, ( 4 weeks) a request that is in line with the employment standards of the province of Alberta (page 2 paragragh 4 employment standards of Alberta), how are we supposed to respond to requests for consults   (within 14 days) when my staff are taking a well deserved  contiguous 4 week vacation in the summer looking after their children who are out of school ? I am a specialist, my wait time for a routine consult is 1 year unless it is an urgent problem which can be handled by the… Read more »

Alanna

I am a clinic manager of a family practice rural clinic. So here is my 2 cents worth. There are a few bad apples on both sides of the equation that spoil it for everyone. My staff have literally spent days trying to talk to a specialist office. Once they get through, they are told what is the consult for, we read the letter to them, and on occasion are told we have to call the other specialist in that same clinic and we start the phone calling process all over, because we cannot be transferred to that consultants receptionist.… Read more »

Chris Rudnisky

I have read through the thoughtful comments and replies and have a few comments of my own: I note that Dr. Caffaro says that this standard is final. That is disappointing given the feedback received. Surely there is room to discuss things despite the window earlier this year. One of the problems note noted yet is that there were many standards out for consultation in a short time and there was fatigue to review them all. The main issue for solo practitioner (like me) is how do we take a vacation? The College needs to come up with reasonable rules… Read more »

Dr. Michael Caffaro

Chris, the feedback is being heard and considered – much of it will be used to inform the ‘Advice to the Profession’ document that will follow for the January 2017 implementation of this Standard. As far as ‘Standard fatigue’ in consultation, I can only comment that we try to limit the number of Standards out for review at any one time, but consultation is the main tool we use to seek feedback. The College has an expectation that regulated members show an interest in the Standards that are intended to guide practice and take whatever opportunities are presented at the… Read more »

Karen Kroeker

Access to care is obviously an important issue facing Albertans today. The need for these regulations likely speaks to the tremendous pressures facing referring and specialist physicians, alike. To further improve this process, I would like to make a few suggestions: 1. It should be stressed is that for urgent referrals, physicians should contact the consulting physician via phone or pager and not just fax this type of referral in. 2. Timing of 14 days to respond with a triage of a referral is a little tight, especially if the physician is away for part or all of those 2… Read more »

Dr. Michael Caffaro

Karen, the College is in absolute agreement with your first point on urgent consultation and ‘picking up the telephone’. With regards to the physician being away, it is possible to leave and (with messaging to the referral offices) not accept new referrals (to remain within the Standard) until you and staff are back to (appropriately) triage new referrals. Declined referrals are to be communicated back to the referring practitioner’s office. If the declining of a referral is in part due to information that is missing and yet would be reasonably expected, then that represents an opportunity to educate a colleague… Read more »

Dr. Karen Bailey

Some one needs to engage the patients in this process and ensure the patients answer their phones when we call to make appointments or return the calls when messages are left for them to call the office. The biggest delay we face seeing referred patients is getting the appointment set up in the first place. We often do not meet the time expectation of setting up an appointment because of difficulties contacting patients. We have had incorrect phone numbers for the patients given to us by the referring offices. We often only get one phone number for the patient and… Read more »

Dr. Michael Caffaro

Karen, thank you for commenting. With regard to incorrect and incomplete contact information for patients, I experienced some of the some frustrations in consultant practice myself. This is part of the communication piece required between referral and consultant MDs – your office needs to communicate to those offices your expectations regarding currency of contact information as well as a variety of ways (mailing address, alternate phone numbers etc.) to contact the patient. If you cannot get a hold of the patient by telephone after reasonable attempts at contact and the posted letter is returned as undeliverable, the College would not… Read more »

Douglas Myhre

Communication between care providers is at the heart of the referral process. I think my discipline has been a partner in creating this issue as there are those that do not even complete basic information for consideration by the consultant. Whenever I reflect on the process of referral as a family doc, I specifically consider what the consultant (regardless of discipline and including D.I.) needs to see. However, and regardless of the adequate referral, my experience is that the administrative triage, not the MD communication, is the major obstacle for good care. Randomly throwing the patient down the triage algorithm… Read more »

Olga de Sanctis BSc MD CCFP

Reading the above dialogue reveals important issues with referring physicians and consultants. I understand the medical health system is over burdened. I have been in family practice for 26 years and it is my experience it is getting more difficult to refer patients to certain specialties. In particular it is quite frustrating referring to orthopedic surgeons. Frequently the response back by fax is ” referral denied” ,… No explanation and no alternate recommendations. The patient is left hanging and our staff are left calling around frequently with no luck. I have given up referring to psychiatrists and over the years… Read more »

Christine Renz

I am happy to see these changes (or something similar) implemented. I have had patients wait months to even hear if they got an appointment. It often leaves me wondering if the referral was even received. I also don’t think specialists should be allowed to refuse referrals for any reason except perhaps that they are so busy they can’t provide care in a timely manner. In that case, while not expected, it would be great if specialists would take the initiative to forward on referrals to a colleague, especially ones in the same office, and give the referring doctor the… Read more »

Das Madhavan

Definitely a valuable step towards better patient care, of course. This is a chronic flaw in patient care and ashamedly unsolved problem in Alberta. I read all the comments and appreciate docs taking time out for active solution-seeking focus. From my experience the following are the areas of concern: 1. None of the referrals to ER will get a reply, except 1 % or so. In our clinic we can confidently manage quite sick patients – if we are to send someone to ER, it will be due to some serious concern. 2. The communication from the ER mostly identifies… Read more »

Theresa McCallum

I agree with the concerns expressed by Dr. Haussmann. I am a solo practice specialist. I have one employee. I triage every referral phone, mail, fax, or email from in and out of province health care providers. I am always overwhelmed by referrals. From September 28,29,30 I received 47 (oops, there’s another folder) 54 referrals. At least 30% are either illegible, do not ask a specific question to be answered, or they state “significant lab work and imaging results can be found on Net Care”. I typically try to power through everything each night and that means no sleep until… Read more »

Dr. Michael Caffaro

Thank you for commenting, Theresa. First of all, it is appreciated that you triage the referrals coming in to your office. Secondly, the College (and I believe patients) would not expect you to make a call on referral appropriateness on incomplete information. The illegible/incomplete referral should go back to the referring MD noting deficiencies and expectations. The clock does NOT start until that referral is in your hands and contains the reasonable clinical information needed to accept or reject the referral. A comment about ‘’…results can be found on Netcare’ is in order. It has not yet been mandated that… Read more »

Troy Pederson

There is an important element of accountability in the referral dynamic that needs to be tackled if we really want to see change that benefits the patients within the system, not just the patient who requires the consult. In this proposal we are applying a time metric across the board. The timelines can be debated, but these are at least a reasonable starting point for building a standard of care. The metric that we are missing is evaluation of the whole consultation process. The referral-consultation process has become bloated in many ways to the detriment of the patients that most… Read more »

Dr. Michael Caffaro

Troy, thank you for commenting. The College cannot directly impact the financial processes that can give rise to inappropriate referrals followed by wasteful consultations – other parties need to act on this activity. I would hope that a renewed interest in/scrutiny of this process would at least encourage both referral and consultant physicians to hold themselves and each other accountable as to the need for and quality of the patient consult. The valuation of this process is admittedly (at the College) seen through a professional, not a financial, lens. I would expect that our patients and the public would have… Read more »

Troy Pederson

Michael, my comments certainly fall short of a solution but I think your reply helps to frame one of the biggest challenges we face as physicians with respect to reconstruction of our profession. The CPSA advocates for standards of professionalism however neither has the resources nor mandate to call to task fundamental issues reflecting lack of professionalism that we see daily in clinical practice. Clearly the most recognizable role for the CPSA we all rally around is the penalization of egregious behaviours of sexual misconduct or gross malpractice. However the major cause of erosion of physician performance comes more through… Read more »

mitch lavoie

The supply and demand model will always apply. These new Requirements will motivate consultants who already have large wait lists and busy practices to further limit their availability in order to avoid sanction by the CPSA for contravention of the unrealistic timelines in the Requirements. Presumably a practice which is closed to new referrals need not respond to a request for referral. For the most part a consultant’s workload, especially for surgeons, is determined by access to limited resources, not by demand. Through my three decades plus in practice I have noted an ever decreasing threshold for referral combined with… Read more »

James MacKenzie

I am a Specialist and it has been my practice to review all of my referrals myself. This allows me to accept the referrals that are within my scope of practice and to redirect or reject referrals that are clearly not appropriate for me. It also allows me to prioritize the referrals based on medical need. The time frame ( 14 days ) for acknowledging a referral has been accepted means that the physician themselves cannot be the one reviewing the referral. If I take a 2 week vacation, the new referrals that I will review on my return are… Read more »

Dr. Michael Caffaro

Thank you, Jim, for your comments. Please also see my reply to Theresa McCallum – I believe it is possible to allow you to be away from the office and not necessarily delegate your appropriate (and appreciated) triaging of consult requests to another (non-clinician) party.

Munaa Khaliq-Kareemi

I had the opportunity to be present at rep forum when the case that has prompted these rules from the college was presented with an “autopsy of timelines” and subsequently discussed. Unfortunately the family of the patient was present and has subsequently interjected themselves at many levels of the health care system. This does not allow frank discussion of the circumstances. I have great respect for this family involving themselves to improve our delivery of health care. But let’s be frank. In this time the college has enforced a set of rules that clearly points the finger at short-comings on… Read more »

Dr. Michael Caffaro

Munaa, thank you for noting that the new Standard tried to particularly lay out the expectations of BOTH referral practitioner and the consultant – telephoning the colleague for the urgent referral rather than faxing, sticking to s single consultant for referral rather than sending out multiple referrals to specialists in an area to generate ‘hits’ and being clear what exactly the referral is for (your ‘clear question’ comment). On the latter point especially, the coming Advice to the Profession document will once again highlight the multiple resources (CMA, CMPA and CFPC to name a few) that already exist and are… Read more »

A.H. McKenzie

e-Referral what is happening with this initiative? apparently the government has spent $ millions developing whatever it is, yet the physicians and patients of Alberta have nothing to show for it except another “pilot” project entombed in Netcare. the department of health says they have a software plug-in that EMR vendors can use to integrate the e Referral app directly into their systems to create and transmit referral data electronically, but there is no demand for it. where is the leadership of our profession in bringing some sanity to the patchwork of more than a dozen EMR systems being used… Read more »

richard hackett

one growing concern over 25 years in rural practice is with referral to ‘service arrangements’, which act as a cover for specialists in many fields. There may be a clinic referral form which my office and I endeavour to find and complete, but essentially the referral is in the form of a fax (and we keep copies of all the transmission details in our EMR). What follows after that is a phone dialog which at worst involves the receptionist in the specialist service and the patient’s driver or parent, who are two very poorly informed persons about the reason for… Read more »

Richard schuld

I’d like to see the full discussion, but can’t read it on my device sequentially as the subsequent emails gradually move out of the reading zone. ?any suggestion to fix this?

Christin Hilbert

I am happy that these standards have been formalized. Recently, we requested a consult letter on a patient’s first visit with a gynecologist, whose receptionist told us “she doesn’t do consult letters”. Obviously, that’s unbelievable. I would like to say that the tool of Netcare is woefully underutilized. I think that I should be able to say to a consultant – please check Netcare for this lab and this Di. I think as a referring Dr I should specify WHAT to look for on Netcare, to simplify the process – but I am shocked how few specialists actually look on… Read more »

Dr. Michael Caffaro

Thank you, Christin. I hope that you will take the time to inform your consultants that consult letters are part of the expectation of the process – the reminder may be enough to jolt them back to the requirement. Accessing Netcare (and fully EMR adoption) has not been mandated of Alberta’s physicians. It is therefore inappropriate for any referral/consultant physician to direct the other to ‘look it up on Netcare’. The expectation of the Standard is that the required information accompanies the communication between the referral MD and the consultant. I do believe that looking at the appropriate database for… Read more »

Jeff Schaefer

What would help myself and many other consultants is being able to post the fax number that ought to be used for referrals in addition to our ‘business or academic’ fax on the CPSA website. I happen to be associated with a Central Triage System which is excellent (well staffed with nurses that communicate with me whenever needed) but happens to be 5 km away (RRDTC) from my academic office (FMC) where my secretary may be away and university fax is shared by several many physicians. For those around Calgary, I encourage referring physicians to look at http://departmentofmedicine.com/mas/ (Quick Reference… Read more »

Dr. Michael Caffaro

Jeff, thank you, I appreciate your suggestion. As an aside, AHS is looking to capture (optional) all consultant offices and practitioners, whether privileged with AHS or not, within the Alberta Referral Directory. This may be one place where this information can be explicitly laid out.

Scott Lang

As I read the standard and the comments it occurs to me that the focus has been on enhanced communication between referring physicians and consultants. I have also observed that patient-centered care has been identified as important as comments have been centered on ensuring quality. However, I see no mention of how patients will be kept informed. Basically, regardless of the parties involved, this means to me closed-loop communication within a sensitive time-frame. I imagine all physicians understand this so what is really the problem – the challenges that prevent it? If this is not understood then I feel it… Read more »

Dr. Michael Caffaro

Thank you, Scott, for commenting. You have hit the proverbial nail on the head – communication that is meaningful and timely among all parties (referring MD, consultant and patient) is the key. It is the basis upon which mutual respect is recognized and understood – in the completeness of the referral, in the acknowledgement of ability to see the patient or not and the importance of informing the patient of referral acceptance (even if it is some distance in the future). Other stakeholders have weighed in during the consultation process . For example, I know that there is AHS interest… Read more »

Shirley Traynor

I am concerned about #9. I do refer to ER, always with a letter in hand and a fax to the ER physician in the appropriate facility also. But if I now have to talk directly to the ER physician each time ,it will occupy a lot more of their time. In the last few years , ER physicians refuse to take our calls in my experience. Surely a detailed letter is sufficient, unless life threatening or very urgent, in which case I phone RAAPID. Or do I need to call RAAPID every timeI refer?

Dr. Michael Caffaro

Thank you for your comment, Shirley. On the specific issue of ER referral for community based physicians, the feedback in my experience has been a phone call ahead is expected and appreciated. If a prospective ER consultant refuses to take a phone call (and therefore the referral of what you think is an urgent case requiring ER attendance) then 1) you should consider a conversation with that department/MD as to each other’s expectations are, and 2) look to another ER. If an ER MD indicated to you that they/their department are fine with a patient and letter just showing up… Read more »

Greg Kozak

I would like to express my concern regarding the timeline presented for accepting referrals presented in this new standard. Although my office while open responds to all referrals within 1-2 days while the office is open (and if the referring office actually phones my office will set up referral that day), I am concerned about holiday schedules. If myself and my one staff take 1 week off we will be not able to keep up with this new standard. In a time of physician burn out I feel this is an unreasonable burden to not be able to take a… Read more »

Michael Caffaro

Thank you for your comments, Dr. Kozak. First of all, there will be an Advice to the Profession document to accompany the standard when it goes live in January 2017. This should clarify (amongst other things) the College’s expectation that for urgent matters, the referring physician is expected to pick up the telephone and call a consultant to arrange that referral. College Council has taken the line that it is the responsibility of the consultant’s office to ensure their referral physician base know how to access the office and the referral procedure. On a practical level, I would expect the… Read more »

Greg Kozak

Thank you for your response. I truly appreciate the intent of this standard. Your response was quite helpful. The only concern I would say as a consultant who has advised the referring physicians we prefer to take consultations by phone so we can expedite the referral this is very commonly ignored. Referring physicians do not even try to phone. They just fax and that ends their feelings of responsibility.

Michael Caffaro

Well now, this office might see that as a problem if there has been clear direction on the method by which referrals are accepted, and your office staff is available in a consistent fashion via telephone on a daily basis. I will put out there my own bias: The advantage I found with facsimile referrals is I could see easily what work the referring doctor done before asking me to see the patient, and as importantly what work they had not done. In your case, if you do not take facsimile referrals/only accept consultation requests via telephone call, then I… Read more »

Greg Kozak

We have informed offices that we prefer to take phone consultations followed by fax. This allows us to triage and sort out if they need something else done prior to the referral and give a referral date over the phone. It also allows up to sort out whether the referral is appropriate for my office or would be more appropriate to be referred to another subspecialist in Urology. We continue to take fax referrals despite sending back faxes that we would prefer phone calls to book consults mainly because some offices still do not phone and I feel an ethical… Read more »

Michael Caffaro

All good points. I think it is important to stress that the Standard itself will not be revised – the Advice document is being written (and can be rewritten on an ongoing basis as needed). The College will absolutely stress that urgent consults are urgent, and that therefore direct contact (a phone call) is mandated, not an “urgent” fax unless in a follow-up to a phone call. In considering complaints that may arise from this standard, as Complaints Director I have the ability to bring my experience on both sides of the referral consultation process and the feedback from regulated… Read more »

Greg Kozak

I have 2 final comments. This new standard should be applied in both directions. It was raised at the AMA that specialists are unable to get patients without a family physician into a family practice. It is unreasonable that family physicians close their practices and do not accept new patients. If a specialist refers an unassigned patient they receive from ER the family physician’s office should be held to the same standard. The second point I would like to make is that you referred to the fact that there was no pushback during the consultation process from specialists. Correct me… Read more »

Michael Caffaro

Thanks for the further feedback. I do not disagree with your first point. The way to crack that one open may not necessarily be through this Standard (or through any single Standard), but I do not disagree that a community of primary care practitioners (just like a community of consultants) has a collective responsibility to care for people. The concern with consultation in the summer has been noted. Ed. Note: The formal consultation period for the Referral Consultation amendment was April 6 – June 7, 2016. Email notification was sent to all members on April 6, 2016, with reminder notices… Read more »

Jessica Haussmann

I completely agree with Greg Kozak. The timelines is too tight. The fact that the CPSA did not get any push back from the consultant community is more likely a reflection of our lack of knowledge about the timelines and the process that was being undertaken to create the new standard, as opposed to agreement that the timelines are reasonable. I have yet to speak to any consultant, and I have spoken to many of my colleagues about this, who feel that they will be able to meet this timeline. To suggest that I can simply let my referral base… Read more »

Jessica Haussmann

As a specialist in solo private practice I don’t believe the timelines are realistic or practical. I see the need to ensure that the referring physician hears from the consultant in a timely fashion, however I feel a 4 week window is more realistic. If a patient needs to be seen within that 4 weeks window, the referring physician should call the consultant directly. The proposed timelines will not allow my secretary to take time off and that just does not make sense. We all need time to unplug from our work lives to ensure we stay healthy ourselves. I… Read more »

Caitlin

I agree!

John Fernandes

A referral request is, in essence, a medical procedure. As such, it must be completed with care, excellence and completeness. Receiving a referral is also a medical procedure that comes with enormous privilege. Both parties in the referral generation and receiving process have a responsibility to the patient that their part of that medical procedure (the referral) is completed with excellence and attention to detail in all aspects of the process. Close and involved supervision of staff that are involved in the administration of this process is critical to its success. New assertions of the professional standards around this issue… Read more »

Noel Hershfield

It is not good medical practice to refuse a consult, and then send a reply suggesting various therapies. This practice should be stopped!

G. E. (John) Coppola

In my 34 year career having sat on the referring end of the process and in the last 4 years on the receiving consultative end I have come to understand the challenges faced on both sides. While the new standard may seem to add complexity and work to the referral consultation process this is the reality of doing our jobs – it is not simple and easy. Referring physicians (and their staff) need to give some thought to the generation of the request, ask specific questions, provide relevant information and exclude irrelevant information and diagnostics. Consultants receiving referrals (and their… Read more »

Jeremy Reed

This truly is one of the, if the the, best initiative I’ve seen in the 10 years I’ve been in practice. This will fill massive voids between primary care and specialists, avoid tension (and myths, sometimes) between colleagues, avoid unnecessary testing, and really make a world of difference for the patients. Absolutely excellent. -Jeremy.