Dr. Christian Veillette holds a tablet featuring Dr. Raja Rampersaud. They have created a mobile app that providers in their program can use to create and manage personalized patient-care programs and track progress.
Frustration and empathy led to the creation of a new shared-care model
In 2013, Taube Zeifman started experiencing mild back pain. She didn't think it was too serious – maybe a herniated disc. But it was uncomfortable enough that she went to her doctor. Not much was done during the visit, other than a referral to a physiotherapist, who gave her several exercises to do. But over the next six months, the pain got worse. "There was pain down my leg. I couldn't stand, and I could only walk slowly," she says.
Taube figured it would take a year to see a back specialist and even longer to get an MRI (magnetic resonance imaging) scan, but her physiotherapist said that she'd only have to wait a few weeks. She was right. Two weeks later, Taube met with Dr. Andrew Bidos (chiropractor) in Dr. Raja Rampersaud's interprofessional spine clinic at Toronto Western Hospital, who determined that an MRI was indeed necessary in her case. Unfortunately, Taube's diagnosis was more than a herniated disc: arthritis, spinal stenosis and spondylolisthesis – all painful back ailments.
Fortunately, Taube was able to see a back specialist quickly and get more information about her ailments. But how was she able to get her appointment so fast when others have to wait months? Her physiotherapist is part of a new program called the Inter-professional Spine Assessment and Education Clinics (ISAEC). Launched in 2013 by Dr. Rampersaud, a Krembil clinician investigator and orthopaedic surgeon at Toronto Western Hospital, ISAEC is an innovative shared-care model that gives patients and other non-specialist medical professionals a better understanding of what they're dealing with. As part of the shared-care commitment between family doctors, physiotherapists, chiropractors and spine specialists, it also gets patients in to see specialists faster than they would otherwise if deemed necessary.
The program, which was seed funded by philanthropy, was born out of five years of research conducted by Dr. Rampersaud and his team. As a spine specialist in Toronto Western Hospital's Arthritis Program, he saw many patients he couldn't help, as only a fraction of those with back pain are eligible for surgery. It was frustrating for him to tell people – many of whom had waited a year for an appointment – that he couldn't help them. And, needless to say, it was frustrating for those patients.
Rather than continue with the status quo, Dr. Rampersaud decided to study the reasons so many patients were being referred to him when there were other, better ways to help people with arthritis-related pain. "I wanted to better understand the barriers people were facing," he says. "I wanted to see how we could do things differently."
One of the problems he found was that people would often get passed around from one provider to the next, until they landed in the right place. A process of elimination is not only poor care, but costly in both time and money for patients and the healthcare system. Many would be given an MRI as a default procedure, which is not only expensive, but other things often show up in these scans that end up being investigated further, even if they don't need to be. "We all have some degree of wear and tear but that does not mean it is the cause of the pain," he says.
Other issues weren't identified early enough because family doctors often don't have adequate back or musculoskeletal (joints, bones and muscles) training. "It's a vicious cycle for patients of 'I'm not getting better, and I'm not getting further tests or treatment,'" he says.
Dr. Rampersaud's research led to the creation of ISAEC. The doctors get information on how to better identify and manage a back problem, and for patients who are not responding to initial management, timely access to a network of providers who specialize in back and arthritis conditions. And the patient is seen quickly. The program mandates that they see an advanced-practice clinician, such as a physiotherapist or chiropractor, within two weeks and a surgical or medical specialist within six weeks.
It also gives people like Taube a clearer picture of what's going on. Her physiotherapist had an idea that Taube might have spinal arthritis, so she was able to give her relevant exercises to ease the pain. Taube was happy to do them because she understood how they could help, and Dr. Rampersaud benefits because he's now seeing the patients he can help. "We can give patients a more comprehensive assessment," he says.
The program, which has been in a pilot phase, was recently given the green light to expand across the province by the Ontario government. Dr. Rampersaud also wants to start looking at patient-care issues around other musculoskeletal conditions. He thinks the ISAEC program can be extended to people experiencing pain in other joints such as the shoulder.
His colleague Dr. Christian Veillette, an orthopaedic surgeon and shoulder specialist at Toronto Western Hospital and a Krembil clinician investigator, started looking at the role of advance-practice clinicians or extended-scope practitioners in his work. Examining shoulder referrals in a more formal fashion, he quickly realized that the same problems existed. "We found that almost 60 per cent of referrals for shoulder conditions have the incorrect diagnosis at the time of referral and a large majority have undergone inappropriate diagnostic imaging," he says. As a result, they have modelled the Extended Scope Practitioner (ESP) Clinics on the core elements of ISAEC.
In the meantime, the Arthritis Program at Toronto Western Hospital continues to innovate. It's testing a mobile app that providers in the program can use to create and manage personalized patient-care plans and, with consent, track a patient's progress. The app, developed by Drs. Veillette and Rampersaud, asks both the provider and the patient to fill out a brief questionnaire with key information. The app then automatically develops a care plan the patient can use.
The app is also a part of the Arthritis Centre for Health Transformation, another program started by Drs. Rampersaud and Veillette. The Centre is working to further advance innovative models of care – looking at how technology, through computer-based learning systems, can be used to provide greater insights about individual patients. The more information they can get before a patient comes in to the hospital (for example, through submitting data from home), the more productive the hospital appointments will be.
"We spend more than 70 per cent of the time collecting information and only the last few minutes of a visit on what we'll do," says Dr. Rampersaud. "With technology, we can spend more time on the things that really matter."
As for Taube, she may need surgery. She's not yet sure whether she wants it, but now, thankfully, she has access to a team of medical professionals. Taube believes that if it weren't for ISAEC, she'd still be waiting to be seen. "I'd still need to be examined, and it could have been another two years before I'd be able to have surgery," she says.