Quebec to launch centralized ereferral service

MONTREAL – The government of Quebec is preparing to launch a centralized system for referring patients to specialists, starting in the Montreal area on October 31.

The new system is supposed to improve efficiencies within the existing pool of doctors and GPs will still be free to refer patients to a specific specialist, although the referral must go through the Centre de répartition des demandes de services (CRDS), the regional dispatch centres for all referrals.

But since the system is brand new and its mechanisms are still not fully understood, doubts persist about how those issues will be handled in practice.

The Montreal Gazette reports that some doctors are worried the new system may limit their options or clog the system with inappropriate referrals.

“I’m always afraid when I hear about centralization; it’s risky,” Paul Brunet, president of the Conseil pour la protection des maladies told The Gazette. “We’re not producing more doctors, we’re just trying to be more efficient and that is a challenge. Sometimes we find we were better off decentralized.”

But the associations representing medical specialists and GPs hail the new system – called Accès priorisé aux services spécialisés (APSS) – as a welcome improvement.

“The idea is to give priority access to those who really need it,” said Diane Francoeur (pictured), president of the Quebec Federation of Medical Specialists (QFMS). “Any specialists who are not happy about it simply haven’t read it yet.”

The federation negotiated the mechanics of the new APSS system with the health ministry last November, following the adoption of Bill 20, the health reorganization law.

The guidelines specify a patient must have access to specialized services within the waiting period established for their medical condition, and that all family physicians and medical specialists must use the APSS system.

The federation representing GPs in Quebec (FMOQ) was also positive about the new system. It can be very labour intensive for GPs to track down an available specialist, said spokesperson Jean-Pierre Dion.

“They have to be like fighters, making numerous calls to offices and hospital technicians to get an appointment,” he said. “We believe it will be less work for GPs. But we will have to see if it really is an improvement in terms of access.”

Émilie Lavoie, a spokesperson for health and social services, said the goal is to give all patients equitable access to specialized services with a deadline that is determined by their clinical condition.

The system is set to debut in Montreal for the nine most requested specialties: cardiology; gastroenterology; neurology; nephrology; pediatrics; ophthalmology; ear, nose and throat; orthopedics and urology.

Each specialty was involved in creating a referral form, which will indicate the patient’s identity, pertinent clinical information, the reason for the consultation and whether the referral is general or directed to a particular specialist or institution.

Phase 2 of the system, for which referral forms are being drawn up, will include the fields of dermatology, endocrinology, pulmonology, rheumatology, hematology-oncology, microbiology, psychiatry, general surgery, gynecology and internal medicine.

The referring physician will set the level of clinical priority, which establishes the maximum waiting time: up to three days, 10 days, one month, three months or 12 months.

Requests for specialized services will be made online or by fax to the CRDS, which will send a confirmation notice to the doctor. They will be processed according to clinical priority, as determined by the referring physician, and patients will be referred to specialists as close as possible to home.

The CRDS will call the patient within 72 hours to confirm the request and will call back with an appointment.

Notification will be sent to the referring physician, who will receive the results from the specialist.

“The concern is that it’s not going to be well managed, especially for the subspecialties, and there will be too many inappropriate referrals,” said one Montreal ophthalmologist who didn’t want to be named. An inappropriate referral may be too vague or not specific to a particular doctor’s expertise.

“The worry is that there will be inappropriate referrals that will get seen quickly when more serious problems won’t get seen.”

There are also concerns about who will be screening the consults, in a system that will work like a central triage for the whole island of Montreal. There will be about 20 people working at the centre, according to Lavoie.

When the deal was brokered, specialists agreed to reserve appointment times for patients referred by GPs. Specialists have until January 2018 to improve the timeliness of patient care or else the financial penalties in Bill 20 will come into effect.

But the ophthalmologist worried that it’s “physically not possible for a doctor to see all the consults they get” now, and it starts to “get scary” when pay will get docked for not seeing what might be inappropriate referrals.

“Even if I worked 24 hours a day, I could not meet the demand. I want to be able to see patients who really need me,” said the doctor. “That’s why as a sub-specialist I mostly try to see referrals from optometrists and general ophthalmologists, which have been properly screened.”

GPs have their concerns, too, and seem uncertain about how the new system will work. Some said they find it troubling that a bureaucrat will decide where patients should be routed.

GPs often choose specialists based on previous relationships, the quality of a specialist’s reports or hospital affiliations.

“It’s not just about an available body,” said one doctor, adding that as long as the direct referrals still work well, there shouldn’t be a problem.

Ronald Ludman, a family physician who practises in Westmount, said he doesn’t yet know all the details of the new central referral system, but he worries that if this is the only way a GP can access a consultation, it would make the system unnecessarily bureaucratic and threaten some long-standing relationships among doctors.

“It could be very convenient,” he said. “But it would be wrong to break the many existing links between general practitioners and specialists that work well.”

Francoeur said patients always have the right to choose their doctors and “we will always protect that right.” As a clinical practitioner, she said she understands well that doctors sometimes like to work with a particular specialist for a variety of reasons. However, she also cautioned that in an urgent case, a patient may have to forgo choosing a specialist in order to be seen quickly.

A pilot project of a CRDS launched about a year ago for the West Island has been working well, according to one family physician.

“Patients are seen in a timely fashion and it relieves us (GPs) of a burden,” said Orly Hermon, a family doctor in Pierrefonds, adding that it can require many calls to nail down an appointment with a specialist for a patient, so this “is a big relief for me.”

She said doctors have been able to name a preferred specialist or institution, but there is some trepidation about how that will work once the program expands next month and all requests have to go through the CRDS.

“It seems like a better service for the public, and my colleagues feel the same way,” she said.