Keeping patients from falling through the cracks in Canada's health-care system

One of the greatest shortcomings with healthcare in Canada is that far too many patients fall through cracks in the system. Now, the College of Physicians and Surgeons of Ontario (CPSO) has released its updated policies that it hopes will prevent patients from being harmed.

"Continuity of care" refers to the quality of patient care over time. The American Academy of Family Practice defines it as "the process by which the patient and his/her physician-led care team are cooperatively involved in ongoing health care management toward the shared goal of high quality, cost-effective medical care."

In simple terms, it's the assurance that a requested CT scan or referral to a specialist actually take place. It also means that everyone who plays a role in the patient's care is up to speed.

Hearing about the new CPSO policies made me think of the late Greg Price. In 2012, the 31-year old engineer and pilot died of a pulmonary embolus that occurred following surgery for testicular cancer. To say Price fell through the cracks in Alberta's health-care system is an understatement.

His 407-day journey from first symptoms until his death began during a routine physical for the renewal of his pilot's license. His doctor noticed that Greg had a thickening in his scrotum. That was the first indication that Price had testicular cancer.

It took a year and six weeks from that moment until Price had surgery to remove the cancer. By then it had metastasized to his back. Price died of a blood clot to his lungs that was also misdiagnosed.

A 2013 report by the Health Quality Council of Alberta (HQCA) found Price experienced delays in receiving important tests, difficulties contacting specialists and insufficient communication about appointments. The report said Price was forced to assume a great deal of responsibility in trying to manage his own continuity of care.

Communication with patients 

In 2018, the family of Greg Price produced Falling Through the Cracks: Greg's Story. The short film dramatizes the many occasions when depicts many of the instances that led to delays in Price's diagnosis. It is intended to teach medical students and others and "to inspire positive change and improvement in the health-care system."

The new CPSO Continuity of Care-approved policies  include specific guidelines on:

• Availability and coverage.
• Managing tests.
• Transitions in care.
• Walk-in clinics.

The CPSO said doctors must make themselves available to patients. Phone and voicemail are preferred because this is still the default mode of communication for many patients. The College said doctors are not obliged to provide after-hours coverage but should inform patients of appropriate access points to care. In the case of temporary absences from practice, doctors should take reasonable steps to arrange for coverage.

The CPSO said that when a specialist orders a test, he or she should copy the family doctor on the test requisition to keep the patient's GP in the loop. The college cited urgent policies doctors must follow for critical lab tests and policies radiologists must follow when X-rays show life-threatening findings.

The policy required that specialists acknowledge referrals within 14 days of receiving them and more urgently if necessary. Back in 2012, a Canadian survey suggested that two-thirds of family physicians noted that some kind of communication problem was a main source of frustration for them, such as being informed about the receipt of a referral. The new CPSO policy also called on specialists to track referrals that are urgent.

Prevent breakdowns in care

Most provincial colleges have some continuity of care policies in place. In Alberta, where Price lived, the provincial college has had a detailed continuity of care policy for several years.

Still, the fact that the CPSO has done a detailed revision suggests that prior policy statements were inadequate.

The Ontario college said that technology facilitates continuity of care. A growing number of hospitals have patient portals that enable patients to access test results as soon as they're available.

Virtual visits and Telehealth give patients who live in remote areas more options to receive timely care.

Alberta Netcare eReferral is an online referral form that enables doctors to track electronic referrals in real time as they are submitted, received, triaged and scheduled for an appointment.

At the emergency departments like the one I work in, I am able connect to an online portal that enables me to see all of the lab tests, X-rays and hospital visits the patient has had. That enables me to diagnose patients without wasting time or money on tests that were done recently at another hospital. 

The CPSO policy also stated that patients play an important role in facilitating continuity of care by helping prevent breakdowns in care. The college argued that engaging patients in their care and providing them with the tools they need to navigate the system may help minimize patients falling through the cracks.

As part of that effort, the College released a draft continuity policy and consulted with patients in a way it had seldom done before.

Continuity of care is not solely the doctor's responsibility. It's essential that patients be engaged in finding out about test results and appointments with specialists.

The new policy helps, but major gaps in the system remain. One of the biggest gaps is that information doesn't always follow patients when they transit from one part of the system to another. Far too often, when patients are discharged from hospital, the family doctor isn't kept in the loop.

That kind of problem could be remedied if we had a universal electronic medical record (EMR) that tracks the patient's every encounter with the healthcare system.

The lack of a universal EMR is one reason why the College policy recommends that the patient or caregiver be briefed to smooth out the transition from the hospital to home.

I never had the privilege of meeting Price, though I have met his father David and his sister Teri. They say he  would have wanted his death to result in meaningful improvements to our health-care system.

In my opinion, the CPSO policies and those of Alberta are meaningful steps in the right direction.