Commission on the Reform of Ontario's Public Services

Chapter 5: Health
Case Study #1:
A 50-year-old woman has a mammogram. The results go to her family physician, whose office calls and asks her to come in for the next
available appointment, which is a week later. At the appointment, the family physician says the results are positive for cancer and that she
will arrange for a needle aspiration. The family physician has trouble finding a radiologist to do the needle aspiration and it takes three
weeks to have it performed. The radiologist then has difficulty finding the mammogram as it was done somewhere other than in his clinic,
creating further delay. The aspiration shows suspicious cells and the family physician’s office calls the patient back and asks her to make
another appointment to discuss the results. The family physician now wishes to do an MRI, and again there is difficulty getting it done in a
timely fashion. Meanwhile, the patient is becoming frantic and taking a lot of time off work. When the MRI is done, the patient is again
called back to the family physician’s office where the doctor tries to find a breast cancer surgeon to perform a biopsy as her preferred
surgeon is on holiday. Three weeks later, the breast cancer surgeon performs the biopsy, which is found to be negative (i.e., cancer-free).
Case Study #1, What could happen:
After a positive mammogram, the patient is referred electronically as a “Category 1” to a breast assessment centre. The patient goes
online to her own record and links to the centre, where she can find and book an appointment at a time that suits her that is also within
the Category 1 window for diagnosis and treatment. Through this online portal, the patient is also told how to prepare and what to expect
at her appointment. When the patient arrives at the breast assessment centre within the proper time-frame set out by best practice
guidelines, she sees a nurse practitioner expert and has her blood work done, a needle aspiration and an examination by doctor, all in
one appointment. The patient then books her own followup appointment for four days later, which happens to be an early evening
appointment so she can go after work. At the followup appointment, her results are discussed and are also available to the patient online,
with email and text access to a registered nurse. That followup appointment avoids the unnecessary MRI and the patient is booked for
biopsy. Again, the patient can see the results and discuss them immediately by email and phone.
What is most surprising is that both cases could happen in Ontario as it has the resources in
some areas of the province, but lacks the co-ordination. In Case Study #1, the “system” breaks
down, while losing sight of the patient experience as scheduling delays layer on top of one
another. In the alternate outcome scenario, the patient has control of the scheduling and is at
the centre of a standardized process.
We need to see the system proposed in the “what could happen” scenario become the
standard operating procedure for breast cancer diagnosis across the province. Comparable
systems could be developed for a host of conditions, including diabetes, chronic obstructive
pulmonary disease and kidney disease.
Ontario needs to integrate silos and reduce administrative red tape that impedes efficient and
effective service. That said, for the sake of simplicity, we will continue to use the term “system”
for the remainder of this chapter.
153