Backlogs and Fax Machines

Surgeries are backlogged. What are referrals? Can we fix the fax?
Show Notes
Our first full episode of "Fixing Faxes".

There is a backlog of surgeries due to COVID-19, how is Canada going to deal with those. How do referrals work in the first place and how will Clinnect help? Do we need faxes?

Fact Checks
In the opening Angela mentions being at home with her children for 73 days, that was incorrect it was actually 74 days according to her calendar.

Here is the CMAJ article that Angela refers to.

The "large" number Angela refers to is around 100,000 surgeries across Canada canceled or postponed due to COVID as of April 25, 2020.

To really hit home on the fact that our reliance on fax machines in Canadian healthcare is antiquated and not secure; here is an opinion piece published by the College of Physicians and Surgeons of Alberta that we could not stop saying "exactly" throughout. The physician, Dr. Sandy J. Murray (twitter: @Diver_Doc) also talks about the theatrics of Canadian healthcare and how we pride ourselves on innovation yet rely on a foundation of fax machines. We think Dr. Sandy J. Murray needs to take a look at Clinnect ;) and we agree: "Axe the fax. Let’s make this change together."

Resources on the issues of patient referrals:

There is a lot of information for physicians and care providers to sift through when managing referrals, at Clinnect we believe that physicians and care providers should do what they do best and we make it easy for them to follow best practices and policy by ingraining it into the product. Simple. Central. Secure.

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Produced and Hosted by Jonathan Bowers and Angela Hapke
Music by Andrew Codeman (CC BY 3.0)


Angela:  Can I say the f word on.
[00:00:02]Jonathan: You can, but then we have to beep it out or we get flagged as explicit in Apple.
[00:00:06] Angela: Yes. Can we go for the explicit in Apple flag?
[00:00:10] Jonathan: This is an explicit podcast, not for children. I think. I don't know how it works. I have to, I have to explore that a little bit. I've just, I'm just figuring out the recording and production piece. Uh,
[00:00:21] Angela: I love it.
[00:00:22]Jonathan: Hi, I'm Jonathan Bowers. I am a software entrepreneur from Kamloops, and I haven't slept much this week because Zach is experiencing a sleep regression.
[00:00:40]Angela:  Hi. I'm Agela Hapke. I am the CEO of Clinnect a digital health startup in Kamloops, and I sent my children to daycare for the first time in 73 days.
[00:00:56] Jonathan: Oh my goodness.
[00:00:57]How do you feel about that?
[00:01:02] Angela: Um, Jonathan, I have never felt like deeply felt bitter sweet like this week.
[00:01:12] I have spent 73 days seeing them every single day,
[00:01:19]kissing their smushy little faces,
[00:01:22]watching them grow, and I have to now give them away for eight hours a day again.
[00:01:27]Jonathan: Wow.
[00:01:28]Angela: And on the other hand, mama gets to do, whatever mom wants to do for eight hours a day again.
[00:01:38] Jonathan: That's so exciting. I'm so jealous and so scared for you at the same time.
[00:01:42] Angela: That's, this is what I mean by bittersweet. I've never felt the deep visceralness of bittersweet in my life before.
[00:01:49]The Backlog of Surgeries
[00:01:49]Jonathan:  well, this is a podcast about healthcare and healthcare technology. So let's, let's talk about, uh, what's going on in your world right now.
[00:02:02] so interesting things happening right now in the world of surgery. Um, the CMAJ, which is a Canadian Medical Association Journal, just published, um, a article around how they believe that the backlog of surgeries will be not solved. But part one, part of, of a large solution would be central intake for referrals.
[00:02:28] Jonathan: Oh, interesting.
[00:02:30]Angela:  It's being echoed everywhere. And as myself and one of my colleagues talked about, he says, I don't think anybody understands how hard it is. And I was like, I would, uh, I would agree. Um, And it's, it's not the software around it, but it is the cohesiveness of groups to agree to a central intake. And especially especially in the case where there is the perception of surgeries being divvied up.
[00:03:01] Like let's just each take, uh, our equal pieces of the pie and do it that way. And the other person is maybe arguing in the fact that. Well, I can get done way more gallbladders than you can, so maybe I should just take more to them
[00:03:20] It's an interesting one because when we talk about a divvying up just strictly referrals, what you're divvying up there is, um, consultations and potentially procedures down the road. But when we're talking about divvying up procedures.
[00:03:35] There's a much higher price tag attached to those, right? Um, it's also short term thinking,
[00:03:41] Jonathan: In what way?
[00:03:42]Angela: So if you think about the way that connect is built is we're built, um, with the longterm in mind. We are building it so that groups can get to on the same platform, divvy up those referrals in a way that is equitable or purpose, purposefully inequitable. With the idea that you're going to get good data from this, you're going to get accurate go times with your wait times, right? You're going to, um, get a baseline of where you're at when you do equally, based on constraints if you want to equally, level load those referrals, and then maybe six months time, start to taking a look at wait times and going, Oh, well, you know, if we tweaked this here, tweaked this here, then we could do, uh, then we could maybe shorten wait times for everyone for category A or B.
[00:04:38] It's that longer term view that gets you sophisticated data, accurate wait times, um, reports and data to go to governing bodies or sit at tables with and go, Hey, this is, this is the actual stuff. And that takes time. That takes a long time. Whereas what we're talking about with, um, this backlog of surgeries that are waiting, um, due to COVID, you're just looking at like, how many can we get through as quickly as possible in the most equitable way? now, not two years from now, but now.
[00:05:17] Jonathan: But isn't that the same thing that like, if there's a backlog and you're trying to get through them as quickly as possible, is it a different solution than when we're not faced with this, , however many months backlog of, of surgeries.
[00:05:30] Angela: Arguably it is the same solution. The, the difference I think is, um, Clinnect is built in a way that we can do a central intake that also allows patient continuity of care. So meaning I have my surgery done by the same surgeon that I saw in my initial consult.
[00:05:48]This messes all of that up. And that was the differentiator with Clinnect is we actually like for so long, we talk about the fact that, um, in order to have a central intake and do surgeries effectively, um, everybody needs to kind of be put into, to pooled piles along each part of the journey and Clinnect.
[00:06:07] Um, and our philosophy said, we'll hold, hold, hold up a minute. Couldn't we maybe have both.
[00:06:13] Jonathan: Right,
[00:06:14]Angela: and still serve the public in a way that is, um, is appropriate, but you also get to have that continuity of care with the surgeon that you've, started to get to know. And that that's never been really considered.
[00:06:31] The thing is always been that, um. In order to get me through as quickly as possible, I just get to see the next available person, whether that be for a consult or a procedure or et cetera, et cetera. Whereas we said, you know, timeout. If you take a look at the big picture, I think we could do both of those things.
[00:06:47]Jonathan: but right now it seems like the focuses is not so much that continuity of care. It's, it's we'd like, we really need to get through this backlog of, surgeries and you don't, you don't really get to decide. You just like, it needs to get done.
[00:07:03] Angela: That's exactly it. That's, that's the thinking right now is that it? And there is, there is definitely research that says, um, that patients prefer to get their surgeries done quicker. If it. It means that even if it means that they have to see somebody that's different
[00:07:23]Jonathan:  I'd rather have my surgery now than 10 years from now,
[00:07:26]Angela: and I think, you know, the, what we were trying to say is the question's phrased incorrectly. Um, if, if the question is. Um, would you take a different surgeon than you had your initial consult with to do your surgery? If it meant you could have it faster? Well, that just incites a yes. Right.
[00:07:45] Whereas if the other question, if the two questions were, if you could have your surgery done at the same time, um, would you prefer the surgeon that you've already met and built a relationship with or a new surgeon that's like, that's the question that Clinnect is asking. Which incites a different response, but it takes time to do that. it takes time to understand your baseline data and wait times and then tweak, with good data, making informed decisions versus, the short term thinking where it's like, okay, we just got to get through these surgeries now , I would like to see a bit of both. I'd like to see a mix where, maybe we do that for the short term is we just try and make the most efficient, meaningful, safe way to do this as possible right now. But down the road, don't forget about the long, the longterm
[00:08:41]What is a Referral?
[00:08:41]Jonathan: You've talked a lot about what Clinnect and referrals and all of these things. there's some context that I think people won't have. can you describe what the, like how do referrals work at a really basic level?
[00:08:56] what is a referral? What, what happens
[00:08:58] Angela: Um, I think it's a referral is something that most people are familiar with, whether they kind of know it or not. So every time you go to your primary care provider, um, so that includes general practitioners, family practitioners, nurse practitioners, um, all, all of these, health care providers that can make referrals to specialists.
[00:09:20]So let's say it's a family doctor. You go to your family doctor and you have abdominal pain and your family doctor says, okay. it's bad enough that he's concerned that it might be a gallbladder or something like that.
[00:09:35] So I'm going to send you off to a general surgeon. So at this point, your family doctor is , okay, who's the general surgeons in town? Who does gallbladders. are they all working full time right now? is any of them away on holiday and and and. So all of these questions, so then your, uh, family doctor sends, builds a referral, sends it off in their, um, typically their they make a referral in their EMR,
[00:10:06] Jonathan: What's an EMR.
[00:10:07] Angela: So it's a software that they use to manage your medical records. So an EMR is electronic medical record system. They type up a letter, they put any pertinent information, maybe your medical histories of medications that you're on, things like that.
[00:10:21]They put together a little package that either gets printed off and faxed to this. General surgeon that they've guessed is around and guessed that does, um, gallbladders at this point, your family doctor is hoping that they received it.
[00:10:37] You're not a hundred percent sure because they don't get a confirmation. They also don't know how long the wait time is. They have no idea. the receiving surgeons end either receives this on a fax machine, like a physical copy on a fax machine or their virtual fax machine, which is hopefully linked to their EMR where they receive it, they put it, they put it into their EMR.
[00:10:58] So now you have a patient record on their end. Um, they typically don't send a confirmation back. You are now waiting. You don't have a clue how long you're supposed to be waiting because nobody's given you an estimated waiting time and you have no idea if they actually received it or not. That's typically how a referral goes.
[00:11:17] Jonathan: So in a worst case, you go see your family physician for some concern, and he guesses at who to send it to faxes it, doesn't know if it actually was received on that end. Um, and you never have any insight into that entire process. Possibly never get seen because it was not actually delivered to anyone.
[00:11:38] Angela: Worst case scenario. Yeah. Yeah. And there's many, many scenarios that go along with that. Um, meaning the referral could've gone to a specialist that doesn't practice anymore. The referral could've gone to a specialist that doesn't do, uh, gallbladders and maybe didn't, didn't send it back to that primary care provider.
[00:11:57] Um, best case scenario, they send it off to the specialist. The specialist receives it. Um, maybe their MOA gives the primary care providers MOA, a quick call to say, Hey, we got this, uh, we got this referral. Um, my guess is, you know, it'll be about a two month wait time. Um, but, uh, we'll, we'll contact the patient directly and in two months you're contacted.
[00:12:23] Usually by phone. So hopefully you have to your phone because they're phoning with an appointment for you. And if you didn't answer, then that, then they're going to the next one on the list and they're getting
[00:12:34] that appointment. And then they get you, they get you on the phone and they say, Jonathan, can you come in at two o'clock on Tuesday?
[00:12:40] And you actually can go in and two o'clock on Tuesday and you get seen.
[00:12:43] So Clinnect now is an attempt to try and fix some of those pains.
[00:12:50] Yeah. We are taking on the army of fax machines that are in all the physician offices all over. That's who we're taking on.
[00:13:00]Jonathan: Oh, fax machines. , I worked. For an organization that was kind of old in their ways. . Uh, it frustrated me to no end that the thing that we would do as a practice to put information on, on the web, in a digital form was, so we started by typing it up in a word document. digitally,
[00:13:20] Angela: Okay.
[00:13:22] Jonathan: print it, scan it, and then put the PDF of the scan up on the website.
[00:13:30] That's how information was communicated, started digital. It was converted into something analog, then back into digital, but a much worse version, the original and put it up on the, on the web, and it was, it just, it just boggled my mind that this was, this was something that people thought was the right thing to do.
[00:13:54]What is Clinnect
[00:13:54] So tell me about Clinnect. What is Clinnect now?
[00:13:57] Angela: Clinnect is a drastically different way of making a referral. It's all online. It is tracked. There's an audit log around it so everybody knows when that referral was sent, everybody knows when it was received, accepted.
[00:14:14]It's encrypted in a way that is, forward thinking and exciting. It's not a, not a fax machine or a piece of paper sitting on a fax machine, that's for sure. And it allows the really exciting part for physicians on both the referring and receiving end. Is that the primary care provider doesn't need to make all those guesses that I talked about.
[00:14:39] They can just say, Hey, Jonathan has what I think is a gallbladder issue. I think it's urgent. And it automatically lets that doctor know who is available and who can take gallbladders.
[00:14:53] And then from the specialist perspective, they get appropriate referrals, uh, timely. They're tracked, And, it allows the specialists to share those referrals and when the group of, uh, specialists in that area, so it's pretty exciting.
[00:15:10] Jonathan: It is exciting. Lindsay shared Oh, a Maclean's article about how we rely on fax machines to send all this data around and how it's just, it's just not working. So it seems like, it seems like COVID has come in and the light has been shown and how broken the fax machine is for this kind of thing. For anything like fax machines, we don't meet them anymore.
[00:15:35]We Don't Need Faxes Anymore
[00:15:35] Angela: We don't need them anymore. Um, healthcare in Canada is built on. Foundations of things like fax machines I recently heard somebody say that healthcare in Canada is theatrical in the fact that we do showcase people doing remote surgeries with VR goggles and this amazing, high tech approach to all these, you know, sophisticated, um, methods and things like that.
[00:16:08] Whereas at the end of the day, we still send referrals by fax machines. What we're doing with Clinnect is the really UN-sexy work of healthcare. We are not creating virtual goggles for somebody to do surgeries in remote parts of Canada because that's great, but we need to fix the foundation of even the way that we send referrals first.
[00:16:39] Jonathan: I was talking with, my brother in law is a, uh, family physician and he, he had a quote unquote walk in phone call. And he said, if he had come into the clinic, um, he would have spent like two hours waiting around in the, in the waiting room until he got to see him. you didn't have to take time off work. And then, um. My brother and I just phoned them up and said, yeah, you know, saw him it took them, you know, less than 10 minutes, and it was just such a better experience for everyone.
[00:17:05] Angela: We have, we actually have a lot of our, like our surgeons are just doing phone consults right now and that's surgeons. With an initial consult, right. They're getting the information that they do need. So, yeah, so you're right, it can, it can be just a phone call sometimes too.
[00:17:21] Jonathan: take me back to your, the first thing you said, so, so Canadian medical association journal published an article that is advocating for a central intake.
[00:17:33] Angela: That is, well, I mean, as a journal article, I don't think they're advocating per se, but what they are doing was, showing the benefit of a central intake on the access of surgery post COVID?
[00:17:50] Yeah.
[00:17:51] because, um, during COVID we have just, we, we stopped elective surgeries, almost altogether.
[00:17:57] And there are some big numbers being, um, used around how many surgeries were canceled and how many surgeries, have been, missed during this time.
[00:18:09]Jonathan: so those surgeries were scheduled, right? So they, that referral has already happened.
[00:18:14] Um, this, the specialist already has that. So what, what happens now? Like what's the, what's the process does that, does that get, like, does it have to be referred or does the,
[00:18:25] Angela: Yeah. So this is where, and this is where I'm trying to figure out, like is there a reshuffle of them? Right? So this and when they talk about Clinnect being long term, that's where this comes in. Clinnect is longterm because it starts from the need of a referral first through to the referral actually being sent.
[00:18:44] Whereas these are typically referrals that have already been sent and potentially already been initial consulted on, um, maybe multiple times. Um, they're already at the place where we know they need a procedure. So is there a way to, in the short term, reshuffled these through a central intake that takes into account necessary items to reshuffle, not items, but constraints to reshuffle. Let's call them surgical referrals. In a way that, you know, reshuffles them based on their category, their urgency and the availability of the surgeons themselves because that may have changed.
[00:19:28]And you can imagine to some of these people like they, like we didn't, we didn't hit pause on their symptoms.
[00:19:34] So some of these people may have been like kind of in the semi-urgent category, have now bumped up to urgent, bumped up in urgency because their symptoms are now worse.
[00:19:44]So they do they do need a very quick, efficient, uh, system to take a look at those changes and then reallocate them. Potentially reallocate them. Meaning it could go back to the same, same surgeon that was supposed to do it, or it could go to another one now.
[00:20:08] Jonathan: Do you think you would see some of those referrals start to move around the province and like is that, whose job is that? Like whose job is that to review what has changed? Is that the surgeons or the specialist's job is that the family physician's job? It certainly is not the patient's job. I don't think.
[00:20:26] Angela: I don't think so. I mean, that's all part of it too. Uh, whose job is it right now? So the patient is in the care still of the surgeon or the specialist. And in this case, we're talking surgery, so I can use the word surgeon. Um, and so it really is on them to kind of monitor as to where, where they're at.
[00:20:49] But as you can imagine, there's no pause on this. It just keeps coming. So now we've put almost the unattainable expectations upon these surgeons to, um, sorry you won't be, doing procedures anymore and yes, your waitlist is building and building and building, but not, you still got to keep it, keep track of all these patients and where they're at.
[00:21:11] I mean, that's insurmountable. So is there, is there a way that we can, quickly and efficiently. Do that as part of the reshuffle.
[00:21:23] I don't know, but it seems plausible.
[00:21:27]Could We Work with Specialist Groups to Address the Backlog
[00:21:27] I would love to work with a group that is so inundated then so up to, they're like eyeballs that they like. They're like, I don't, I don't even know how we're going to restart our surgeries, but are willing to work as a group to do it and have an idea of how they might do, like how they could manually do it, but that would just take too much time and resources.
[00:21:54] I would love to go in with them and say, let's try it. Let's try something and can we build it? Like, could we build something for you? I think that'd be cool.
[00:22:06] Jonathan: I think it'd be cool. I'm so excited about all of the potential that, that this product has, not just for. Like, selfishly, you know, everyone has experienced the, the problem of, of getting a referral to some specialist somewhere and, and just sort of not having any idea of what's going on. Um, so I'm looking forward to just having my problem solved, but, um, it's, it's, it's cool to think that, you know, there's, there's some impact that we can have.
[00:22:37] On, on healthcare on access to healthcare. The thing that everyone points to about Canada, like you have this wonderful healthcare system and it is, it's great in a lot of ways and not so great in, in many other ways. Um, it's just, it feels, it's really exciting to be part of this.
[00:22:58] Angela: You're right in saying that, you know, Canada is often looked at as and held up in the way that our healthcare works and the access, And I'm hesitant to say this, but I think it makes us a bit complacent when we do talk about the forward thinking that we could do around further accessibility and further furthering that, that, um, the health care that we do have is because we do a lot of bat like back back of patting, um, of ourselves.
[00:23:28] That's the word, um, to say like, look at us. We, we do, we do so well.
[00:23:34] Mmm. And it makes us a bit complacent. And I think we could do a hell of a lot better. for not a lot of, massive shifts, but literally just doing what we do 10 times better. yeah, it makes, I'm excited too.
[00:23:50] I think the timing is wild.
[00:23:54] Jonathan: Oh my goodness. you look back to where we were, you know, last year when we were just sort of starting to talk about some of this stuff. And I mean, smart people have predicted that the pandemic is coming, but no one listened to them. But I mean, we certainly did not have any clue that this was going to happen.
[00:24:11]trying not to feel like opportunistic. Um, I mean, I don't feel like we are being opportunistic at all, cause we started this journey a long time ago. Um, but it is, you know, there's a problem and we can help with it.
[00:24:24] And we've got, you know, we've got a kick ass team to, to, to solve this.
[00:24:29] Angela: That's exactly the way I feel about it too. And we're, and here's the best part about it. We're nimble enough to keep, um. Not re not reacting to anything but nimble enough to allow us to do some deep thinking around it and shift. And that's like, that's what I love about, um, where we're at too, is. Is, we're not just this big company that takes forever to maybe like steer the ship slightly one degree to the left, but instead we're like, Oh wow, look at that.
[00:25:05] Let's like, let's, let's incorporate that piece. Or users are saying, please, please, please do this. Okay, let's do it. Let's like, let's make that better. And I think for me, because. The ethos of the company. You have always been grounded in the fact that we are building this for the, for, for the people, for the physicians to use, for, um, not for ourselves.
[00:25:28] Um, but I've never really felt opportunistic about it at all because, um, I am so comfortable in the, the, um, philosophy that we built this on that I, that I feel it's desperately needed. It was needed years ago.
[00:25:48] Jonathan: And, we're being very thoughtful about the approach to things, you know, thinking about, thinking about the privacy, thinking about, um, you know, thinking about it from not just the point of view of the physicians or the specialists or the, medical office assistant, who, who's using the software, but also, you know, what does that look like for the patient longterm?
[00:26:11] Angela: Having worked in healthcare and having been like, just bound, um, from. Making big impacts due to, um, just simply lack of good data, lack of sophisticated data, lack of any type of meaningful information to make decisions on. Um, that's why I'm so excited to move out of the system to a place where I could influence that. In a row, like once again in a really, like, this is unsexy work, but at the end of the day, when I see the impact that, the potential impact, it's, it's overwhelmingly positive. So, and so many different areas for the patient, for the physician, for the, like the, the use of population data for, you know, et cetera, et cetera.
[00:27:06] I just feel like it's not like we, you know, hit really hard in one area, but rather we, we, I think we're gonna hit a few home runs in a few, in a few different arenas here, so that's exciting,
[00:27:20] Jonathan: Home runs in arenas. That's how sports works.
[00:27:23] Angela: Think that's an awful, we're going to take that one out.
[00:27:28] Jonathan: No, I'm going to leave that in. I like, I like mixing metaphors. I'm a big fan
[00:27:33] Angela: so bad As soon as I said it, I was like, Nope, let's rewind that part.
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