Jonathan shares a personal experience regarding a specialist referral, it provides an opportunity to refresh on what referrals are. In this episode Jonathan and Angela refer to the Medical Post, September 2020 issue
. Topics span personal experience, referral etiquette, lost referrals, and what is really expected of the patient in the process. Find Us Online
Produced by Jonathan Bowers and Angela Hapke
] but your, desk moves up and down. Is that an issue?
] But Nope, no, no, it's not because I'm Mount to everything to the desk. Not, not to like to the wall or anything.
] got it. So it moves with it. Okay, that makes
check this out. this is sometimes how I come into meetings
welcome to the meeting.
] this is so weird. Your head's just slowly rising up from the bottom of the screen.
] yeah, just appear. I just,
] Well, you don't, you don't appearance. Like if you were in PowerPoint, it would be the slowest, The slowest, like fly in
] yeah. I fly it from the bottom. Yeah. Real slow.
] shout out to Justin Jackson and, John Buddha at Transistor FM.
You're listening to Fixing Faxes, a podcast on the journey of building a digital health startup with your hosts, myself, Angela Hapke.
And I'm Jonathan Bowers. I just got back from taking Zack to an eye specialist, a referral that we had from our GP or family doctor. I'm not sure what the distinction is between a GP and a family doctor.
] There is a very clear distinction between, GPs and family care providers. But that is a topic for another time.
Getting a Referral to a Specialist
] Okay. anyways, so, Zach, had a bit of a traumatic birth and suffered some nerve damage to his eyes. And so for the first the many months of his existence his eye didn't open quite correctly and that was concerning. and so we got referred to a specialist. Now the specialist did not let us know that they would much rather us go to a different specialist because that specialist is capable of doing the actual surgery that might be necessary. Didn't phone us, didn't find the GP. So we just phoned them many, many months later asking what's the status of this? And they said, Oh, it needs to go to a different specialist. And so we then had to go back to the GP. The GP, sent the referral to the new specialist and, anyways, it was kind of a pain in the butt. And the only reason why he caught it was because Julie phoned the specialist's office and said, I thought I would have heard from you by now and nothing. Nothing happened. anyways, like medically everything's fine. His vision is perfect. I mean not perfect. It's it's good. he has, he has, what's called a Horner's I'm saying this right Horner's syndrome, which, apparently causes people to sweat differently.
] Um, but yeah, I don't really know much about it. Either. A friend, a friend of ours has it. and as an adult, like we, we had no idea. but anyways, yeah, the, the eyelid, has recovered well. It's, it's very difficult to see that one eye lid doesn't open quite as much as the other. It's more apparent when we look at him in a mirror because it's it's, the assymetry is wrong.
Um, and his pupil, his pupil is performing well. There's no, there's no damage in the back. He's not going to need glasses. So we're pretty excited, but it made me think of this whole Clinnect journey and referrals and having to manage, having to manage it ourselves to some
degree, to make sure that it was happening.
] as a father or a parent of a patient, this is a tough one. So you, so your primary care provider sent a referral, they sent a referral to a specialist that, it was probably from the primary care provider's perspective, an appropriate specialist to send it to.
] and it is, it is actually, so we went to the, to the, to the specialist that can do the surgeries. We've gone to see them twice. And then at the end, he's like, there's no need for surgery. Let's send you back to the original specialist because that's a much easier drive. And so then we'd been going and everyone's been great.
It's just the, just the logistics piece that has sucked. So everyone made the right, like it was, yeah, it was the right referral to make.
] Yep. It was so their primary care provider made, from their judgment, the best call to a specialist that they could have made. Yeah. That communication though, from when that specialist received that referral and saw that referral as, possibly appropriate but given the, the, the circumstances with Zach, I'm thinking that maybe there would a surgery would be needed, that that referral then should have been either forwarded to the surgeon with the indication back to your primary care provider that this referral has been forwarded to the surgeon, or that specialist should have.
Gone back to your primary care provider and said, actually in review of this patient, we think they're better off to be seen by a surgeon first just to maybe rule that out. Which was eventually what happened. Yikes. And how long, how long did you wait?
] Oh, I don't remember. It was, I want to say a month or two.
] So we're talking about and how old is Zach?
] How old was he? Oh my goodness. Oh,
] would have been only,
] One thing I've learned is that having a child, you don't remember anything about anything?
] that's true. Welcome. Welcome. Welcome to Parenthood.
] he was quite, I mean, he was quite young when we took him the first time.
] Yeah. Oh yeah, baby. I mean, he's not even two now. He's, he's under two and this has, we've done this for, we've gone five times, I think, to the, to the different specialists. and each with like several months in between, so
] Which that part is pretty typical, right. That, that follow up piece. but that initial piece had you guys not phoned, what do you think would have happened?
] Honestly, I'm not sure. I think it would have just, I think it would have just gone on forever and we would have eventually phoned and been like, what the heck? Like I thought we were supposed to have an appointment.
] right. Or the next time maybe that doc went to the primary care provider on an, like an annual check for something you might've mentioned it. Oh, by the way, we haven't really heard back from that eye specialist yet.
] Yeah, I think, I think the longest it would have taken was, yeah, it would've been three months because it would have been the next checkup which would have, which would have happened three or six months later with our, with our, primary care provider.
] And so then once you, once you got the referral to the right place, and this is with the surgeon, how quickly did you guys, kind of see
] well, the involves some try some driving. So it was sort of a little bit, half on us, half on
them. Um, they were, they were quite busy cause it was at Children's. We had to go to Children's. and the first time was pre COVID. The second time was No, I think the second time was pre COVID as well. They had, but they had a normal, there was a, there was a Norwalk
outbreak or some other outbreak. Uh, yeah. Uh, so we had to be careful. I honestly, I don't remember what the wait was.
] Not that's. Yeah. That's okay. I was just trying to. Trying to draw a line between, you know, when you wait three months to hear back and, on a referral that was supposed to be sent somewhere in that timeframe you don't, you could have possibly already have been seen by the more appropriate, provider.
So, Jonathan, I am sorry that you guys had such a.
] well, the, I mean the nice thing is that there, it was all just looking like there was nothing for us to do. So, he has recovered without any interventions. They just were doing checks.
end result. It would have, it would have ended in the same, in the same place.
] more by luck because, he's, that's the circumstance that he's in.
He doesn't have enough damage that it needs any interventions at all.
] Firsthand experience and that's all because of a referral.
How Referrals Could Have Worked with Clinnect
So let's talk about what would happen if they were using Clinnect.
] yeah, sure. I mean, like that feels a little, it feels a little like let's plug the product. Um, but, but that is what, that is what we're trying to solve.
] I think if there was an easy way to, so, so what I was trying to get is the primary care providers sent it through based on the information. a correct referral. what happened on the other end is because they're a specialist, they have a specialist eye looking at it. they were able to say, Oh, you know, it probably shouldn't go to us.
It should go to someone else. That's where that community that's, that's the particular point where the communication broke down back really? Uh, what typically happens with, you know, the faxed referrals is that the specialist's office then has to phone the primary care provider and say, Exactly what we just talked about.
Yes. This, is a, is a good referral. We've reviewed it. And we think that you should go to Dr. So-and-so, which is down in the lower mainland. And, please resend the referral down there that that's the communication that didn't didn't happen. Because there wasn't a simple way to decline or reject that referral with a reason.
Had there been a really simple way because it probably just got lost in the, in the amount of phone calls that they had to, they had to make. I probably just forgot to. And your primary care provider
] That's the sense that we got, like, it, it moved very quickly once we phoned, but it felt like, it was sitting there, but like under a pile of a bunch of other stuff.
] Under a pile of the, all this is my to-do pile it's. Yeah, exactly. so yeah, that simple, just that simple communication with the rejection or, And there was no way for your primary care provider to have an easy way to follow up on that, to track that referral. was it, was it received, was it accepted?
those are just really two simple things that your primary care provider needs to know that they weren't able to with faxes. You just, you can't check up on this.
I'm not going to plug Clinnect, but
] Clinnect does solve those.
] we can plug Clinnect, like that's I just, I wanted to share that and, and I guess I'm sort of looking at these notes. Sort of wondering like, Hey, like let's talk about this in the context of referrals and maybe it's unrelated.
What Happens to Lost Referrals
] no, I don't think it is because, so let's talk about what could, like, maybe it will kind of segue into what could have happened if it was a lost referral and what is happening to our system with lost referrals. And let's talk about the fact that there is lost referrals. First of all. Like, that Zach's referral wasn't lost, but you didn't know that nobody knew that because there was no action done on it.
And there is this, this, deluge of, of lost referrals that are happening out there? Yes. Fax machines probably work 99% of the time . And so where do these people end up or in your case, let's say you waited.
And it was sitting in, in somebody to do pile and Zack got worse. Right. And so then there's this. So there's a few things that happen from this is either you phone. Like thank goodness Julie did. And, and, but that's on the patient or you end up getting worse and you end up in the emergency department. Now this is a huge issue, with lost referrals ending up in the emergency department, because guess what?
You can get a consult with a specialist in the emergency department that you've probably been waiting for a long time, because either A, your referral was lost or B nobody's communicated, wait times to you, or even an let you understand that they do have that referral and that, you know, you are in a you're on a wait list.
so like, yeah. So even the understanding of, Hey, we got your referral. It's accepted. And, you know, we are just waiting to book you a consult is possibly enough for you to, to, to find the ease, you know, worries. And, and, and, and things like that. But if you don't have that, and you're too scared to phone, Then, then what happens either you end up back in your primary care provider's office with a more acute condition where you ended up in the emergency department and they do, they, they are saying that the patients coming through the emergency department are due to, they have no idea what I was supposed to see a specialist, but I never heard.
] Yeah, that just seems, It's so preventable,
] So preventable, right? So preventable and, uh, a number and let's be very clear. An emergency, visit is a huge, price tag for, for, in, in public health care. Like an emergency room visit comes with a price tag and it is far higher than anything else that we're talking about with consults and things like that because the, the resources in the emergency department are significant compared to anywhere else besides, you know, operating rooms in ICU.
Right. so there's, you know, there's, there's that. That fiscal piece too. And I don't want to, I don't want to drop it down to like money. but by referrals being lost in the system end up to be far more expensive, from a public payer, perspective, then, you know, just actually handling referrals in a transparent and, efficient way. where do these people end up? Well, they end up hopefully in not worse condition and back in their primary care provider's office or phoning or whatever, but in a lot of cases, they'll just give up on the system and head to the emergency department.
Why is it The Patient's Job to Follow Up?
] Yeah. I mean, like, it's just, it feels like there's a lot. It felt like an, one, something that shouldn't have been our job to do, like to have to follow up and make sure that the appointment is getting booked because it involves travel regardless. Right. It was either travel one way or travel another way.
So we just needed to plan for it. And whether it happened that week or two weeks from now, it didn't really matter. We just needed to plan our. Plan our travels and our stay. Cause we knew we were going to have to spend the night. And so like, okay, well we haven't heard let's phone because we trying to book travel and trying to book travel around some other things.
but why, you know, why is that our job to do that?
] And also like, we don't know that that's our job.
] Like no one said, no one said you need to phone and follow up. And even, even when we left the, the most recent appointment. they said, okay. They need to, like the doctor says, yeah, w he's looking really good.
Let's see him at this point. At this time. I can't remember what the time was. And we're like, okay. and then he wrote some things down in the computer and we thought, okay, is that it? Is that what we do? And then we left, we left the room and so we like, okay, well, let's go check with the front.
And so we went to the front and she said, okay, no, you have to go and get re-referred because it's going to be too long. And the doctor, the specialist didn't tell us that. And he also didn't tell us to go check in with the front. So what would have happened if we had just left? Because there's N there was no, like, there was no clear, like next step for us to do, like, what do we do now?
it felt like it was all handled. Like they'll just call us and set up an appointment for the, you know, after the six months or a year. I can't remember, when we're supposed to bring him back, But that's not, that doesn't seem to be what was going to happen. We actually needed to take that back to our GP, to have him do the referral. To, to send a new referral because it expires, I don't understand why would it expire, like, why doesn't it referral expire? And everything's so confusing and why is it our job to do this? Like, why doesn't the system just handle this? Why it's just all in the computer already? Like, why can't you just set a reminder, like I do in my calendar for my dentist appointment to like go and show up at the dentist.
] and I think that's a fair point because we commonly do, compare your experience with, your doctor or your specialist, like a hair appointment or a dental appointment, which seemed to be handled, in, in a way that, like, I know when I leave my dentist, my next appointment is already scheduled for
] Yeah. Yeah, it's already scheduled. And so that's kind of what I was thinking is that they said, we'll see you in roughly a year or whatever the time was. like I get that. You can't pick a date for me right now, but let me know when it is, because I thought that's what was going to happen. But that, that wasn't what was going to happen.
I needed to go and take it to someone else. Then send it back to then book a time like that doesn't make any sense to me.
] right. I, I am unfamiliar with referrals expiring, interesting.
] That's maybe not the word, but like
we had to take it back to the GP to send it back.
] So that's an interesting piece is where is the district? So if, if you were truly discharged from the specialist office, then the discharge report should be sent to your primary care provider to let them know that, we've done this and, please refer, uh, Zach back in six months so we can have another blah, blah, blah.
] and maybe that's what would have happened,
] Yeah. Like why, why is no one telling anyone what the hell is going on?
] why is there no patient communication? Um, standard
] as a good question. I mean, when, so when, so we are in the referral space. We are not, possibly yet in the patient communication space, big patient communication space is, much more littered with groups, companies doing some type of communication because of exactly what you're expressing.
Everybody is not everybody is a primary care provider. Not everybody is a specialist, but at some point in our life, we are all patients or we are supporting patients. So we all understand that to scope of, of the, the journey so much better. It's so disjointed. There is no, one provider for communication to patients, there is, uh, um, kind of a mixed mash of patient communication systems within systems.
And, you're absolutely right. there's no way to easily let patients know, actually that's, that's, that's not correct. There is ways to do this. we just, we have not adopted standards. We have not adopted even really policy policy around this. I don't know.
] And, and your, your story isn't uncommon.
] No. I know. I know. And this is, this is an easy one. Like it's not even a, it's not even a bad
outcome. It's, it's fine.
] It's it is it's okay. And
] It's inconvenient at, at worst,
that's it? And it's not even really that inconvenient. Like we just had to make a couple of phone calls. It just was like, and it wasn't that stressful. I mean, the, the sort of waiting around to know is Zach's eyes going to be
] course. That's the stressful piece. Um, yeah, so yeah, you know, in this case, this is a good outcome case. imagine being in what is potentially a very critical outcome case, and you're having to manage your own communication and your own appointments and your own, essentially your own referrals. I don't know what to say
] I'm not looking for you to say anything. Like I'm not, I'm not looking for you to reassure me. I'm looking for content for the podcast. So
] I know. I know, I know. I find myself a little bit stuck in between because I'm feeling
bad for you.
] don't feel bad for me. Like I'm this is I'm using, like, this feels like something that I can talk about for the
purposes of the podcast. Like I'm not looking for a therapy session here at all, like, or sympathy, honestly. Like I don't need the sympathy. Like, it's not like, it's fine. Like we're, we're doing fine. He's doing fine.
] Did we cover all the things that you want us to talk
] not really, like I thought this was like, so there was this.
so the CanadianHealthcareNetwork.ca
or the, like the medical post that comes out, which I don't, I don't really get to subscribe to because it's like by physicians for physicians.
But anyway, it, their September issue was all about referrals. It was like, like that was the. The, the cover art and everything. so, one of my colleagues had had given it to me and there was this really interesting article about referral etiquette guides.
] Yeah. So I was like, Oh, okay.
So that's interesting. Like, okay, so let's go through that. So I, it had some really interesting pieces. I was also very interested as to where does Clinnect fall in encouraging some of this etiquette. So like just naturally through a product to be encouraged some of this etiquette or not.
So there was very specific and etiquette for referring physicians and then for receiving physician. So there's like th th for referring physicians. So your primary care provider, the number one thing was give us a specific reason for the request.
What do you want to know? So I thought that was pretty obvious, but I having, having worked, you know, in, in a specialist offices and helping them out, you would think this is obvious sometimes this does not like the patient referral does not actually come with a specific
] Really. So it's just like, here's a scan and
] yeah, well, it's more like I have a really lovely, elderly lady with this. Oh, Okay. what would you like to know about that? And so then this actually gets to, there's another there's another recommendation is, your expectation, is this re to request an assessment or advice? So kind of the idea of what question do you want answered with this? So like almost phrasing the referral as a question, which I thought was really, really fascinating anyway.
Number two was, relevant patient history, patient concerns, medication and exam findings. Once is that once again, things that you would think would be, but not always, accurate contact information
] Okay, that seems fairly
] number four was patient age, gender, and any language barriers. So I thought that was interesting.
And, That number six was, do not send unrelated medical information or the patient's complete history because I've seen some of those and they can be like 50 pages long. So, yeah.
] right. And so then, okay then for consulting physicians or specialists, uh, what did they say if you accept the referral?
Let us know,
] right. Decline or accept. Oh, simple things. Right. And then it was also, if you decline the referral, let us know. and also with that one, it was, please help us out by understanding why. So, so once again, Clinnect automates that etiquette, which I thought was, was, really good. communicating wait times.
So just like, like you had talked about the simple idea of how do we just got a phone call, A letting us so that they accepted it. B letting us know that maybe they didn't have an exact wait time, but just even an approximate, you know, you'll be getting a call in three months. Jonathan. Don't worry. We got your referral.
We'll be calling you. Oh, hallelujah. Thank you very much. I can breathe easier. And I don't need to think about this everyday because you did talk about how, this wasn't stressful. It wasn't a big deal. It wasn't hard to call, but my guests. And I'm, I, I don't know Julie very well, but my guess is every single day, this came into her mind at some point or
] yes. Yeah, for sure.
] and maybe yours too, but I, I know what it's like. Um,
] He wasn't inside my body.
] I didn't grow them inside of me.
] Yeah. Right. and then the, the other, the other etiquette was like post appointment or ongoing care. which is yes, like that's, that's good, but that doesn't really have to do with referrals per se. So it was just a fascinating, this etiquette guide where I was like, yeah, so to answer my question that I had thought about before reading there to close, yes, Clinnect certainly encourages all the etiquette plus plus
] I feel like that can be part of the, like part of the marketing material is, is, you know, high class referral etiquette.
] just like top notch referral
] Yeah. We know the difference between your dinner fork and your salad fork and the
] We put them all in the
] and the desserts, but Oh yeah. It's all lined up properly. And the napkins folded exactly how it should be.
Folded into a swan for pete's sake.Angela:
] Yes, exactly. Exactly. So I thought that was really kind of cute. I was like, Oh, I mean, when I have seen referrals and I do understand why this etiquette exists, I would argue that this is bare minimum.
] Yeah. It feels like bare minimum. One of the, the other thing that strikes me is, I understand that this is between professionals, but it feels a little bit like the attitudes that, I feel are imposed on patients too. Like.
] Explain. What do you mean by
] well, so the, the, the etiquette requests too, like, what is the ask? Like when I go to the doctor's office and say, I don't feel well, and they say, what do you want me to do about it?
I don't know, I'm not the damn doctor in this relationship. You tell me what I should do about this.
] yeah. What do I want? I want to feel better. I don't want to feel like this obviously. Like why, why do medical professionals, like, it feels like, like I need to have done all the research and understand everything and they're not really here to help.
They're just here to like, let's. Just tell me what you want me to do and I'll do it. Like, no, that's not what I'm looking for here.
] Right, right. And, um, so that's an interesting thing because, it actually, in this, in this exact same magazine article, there was this one written by a primary care provider that said. that talked about how she has all these patients that come in that are just like, just send a referral to so-and-so for me or to X specials.
So she, on the opposite side of that felt like she was just there as a, like kind of a fax machine,
a referral sender. Like this person didn't really want her investigation. But rather figured that they knew what they wanted and just, and she was, she was like a stepping stone along that. So it's, I, I wonder if there is a bit of a mix of that, where they have, you know, potentially so many people that are coming in going, I want ABC.
And then when they have somebody like yourself that comes in, that goes, I have this concern. I don't know. I'd like you to look into it. They're a bit like, well, Do you like everybody else coming in here asking for a referral to blah, blah, blah.
] I can't, I can't believe that that is what most patients do is they come in and say, I need this, I need this ID desk. Cause I don't think people that I'm willing to put in that much work to understand anything.
] I think they've talked to their friends.
] You have to re yeah, I don't want to get into the, you know, also the, the, the high frequency users of our medical system versus the low-frequency users of our medical system are probably more apt to say, I want to ex my friend. So-and-so had the exact same symptoms as me, and they went to.
Yes. I want to do the same thing, right.
. I just wanted to mention this too. there was this, there was this one doctor who did their master's in referrals, which I thought was really right.
And he did a whole article, and he was asked, you know, about kind of what his, his, his take was on all this, but also asked about, Like, what does, what does change need to look like? And he referred to the quadruple aim, which is to improve the patient experience. Number one,
improve the provider, experience, support the population, by decreasing wait times and provide value for money.
So I thought that was an interesting,
] that sounds exactly what Clinnect is trying to do. The quadruple aim.
] maybe that's why I like this article so much. I think the
] Yeah, it's just, it's just stroking your ego a little bit.
] right, exactly. You got it.
] Thanks for listening to Fixing Faxes, building a digital health startup I'm Jonathan Bowers and my co-host is Angela Hapke. Music by Andrew Codeman. Follow us on Twitter @FixingFaxes. We would love for you to give us a review on Apple podcasts. We've got eight so far. let's get it up to 10. .
Yeah. Uh, Transistor added a, added some features into their podcast dashboard, and you can just press buttons and they just get submitted to all the podcast hosts, including Apple podcasts, which took me days to try and get done. And now you just hit a button. Boom. It's
Good work Transistor.