The Curious Case of ConsultLoop: Promise and Failure in Canadian Healthcare
This is a hard piece to write. After nearly 4 years of sweat, personal sacrifice and financial investment, ConsultLoop is closed for business. Taking a step back, it’s another small business that tried but didn’t succeed. It’s ok, it happens and we do our best to move on, taking the lessons learned with us into the next chapter. However, this feels different. In many ways, ConsultLoop achieved more than we had ever imagined, but failed more spectacularly than we could have expected. If digital health, patient experience, provider burnout, system change, and small business interests you at all, I suggest you read on. This is a lesson in barriers to improvement and all that stands in the way of ambitious, quality care.
ConsultLoop was founded by myself and two partners, also family physicians and dear friends. We were new in practice and were frustrated by the constant lost referrals and the lack of information we had on which specialists would be best for our patients. We saw the harm done to our patients from the referral process, and set out to improve it. It should be easy — 21% of referrals get lost, we have no insight into wait times, and can’t find out if a specialist is appropriate or not for a patient unless we can reach their office or get a rejection letter weeks later. The status quo is unacceptable, and so we brainstormed and came up with the idea for ConsultLoop — an e-referral platform with a directory of specialists showing wait times and descriptions of their scope of practice. We got our design thinking work boots on and iterated a lot along the way.
As an e-referral platform, it did a few key things. It allowed any clinic to see the referrals sent out, their status, and whether the patient has confirmed their appointment time or not. It involved patients with emails and text messages so they could always check the status of their referral, look up key information like the appointment time and address, and indicate preferred days of the week for their appointment. Our directory grew to 5,500 specialists in Ontario, and this made it possible for clinics to find the right specialist for their patient, with a wait time that made sense for that patient. Our data was based off of real referrals and so it was unprecedented in Ontario. We published a report about it, too.
There are three key things we did as well. We made sure that the doctor or NP making the referral has zero change to their workflow — all the change was on the front desk admin staff. We also made sure that a referring clinic could use ConsultLoop for every single referral, even if the specialist was not receiving referrals in ConsultLoop. Finally, we ensured that every patient could benefit, no matter if they had OHIP or not, or email/text capabilities. Finding the right provider, navigating wait times and ensuring the referral isn’t lost has value even without digital connection.
With all this, how did we do? We managed over 28,000 referrals. Over 200 doctors and NPs made referrals on our platform. We had over 80 clinics signed up to receive electronic referrals. We captured wait times and response times that have never been available to patients and clinicians (let alone researchers and administrators) in Ontario. We were adored by customers for our customer service and respectful business practices. And patients, they gave amazing feedback on our process in our recurring post-appointment surveys. As for efficiency, about 70% of patients could get to their appointment without a phone call if they were registered with an email or cell phone. We did this all as a self-funded company, with an ongoing operating cost of roughly $5,000 a month — peanuts by health care spending standards. We were lean, we were nimble, and we were clever. But we are closing. What happened?
Here are key areas that affected us and our chances of succeeding. Did we make missteps in hiring, chasing enterprise/hospital contracts, and other internal mistakes? Sure we did! But those were minor in comparison.
Finding a Payer
We made minor modifications to pricing, but essentially this cost $50–100/month per doctor depending on whether or not you wanted us to follow up on referrals specialists didn’t respond to. Doctors rightfully were weary of paying for more services that they felt their EMR and staff should be doing. Patients should not pay for something like this. The government would be a natural payer but we failed to get their interest and even a couple of doctors approached their LHINs and were told flatly — “no” without so much as a demo or conversation. In one case, a hospital requested to meet with us because our functionality filled a hole (engaging patients and referring doctors) in a $100,000 a year software that the LHIN was paying for. This is where we realized that without political capital to secure government attention and therefore sustained funding, we had no future in Ontario.
Management Capacity
Most clinics are not set up to make meaningful, thoughtful change in digital health. Staff are generally under-trained in basic computer skills, and there’s often no authority to coordinate change and ensure there is buy-in. Digital health will only go as far as over-worked, under-paid front desk staff will take it. We don’t equip these hard-working and well-meaning people with the right environment to succeed here, and we will struggle with all improvement efforts until we figure that out. For most clinics, docs would hear a 5 minute pitch, say “Great, go talk to my front desk staff” and that would be the end of physician involvement. This is not the way to ensure success, and the lack of meaningful upside or carrots made it hard to keep a non-communicating team engaged through a period of change.
EMR Gatekeepers
We know EMR integration is important. It would reduce some clicks, but at what cost? We had early discussions with two large EMR companies after months of chasing them. They wouldn’t entertain any integration unless we showed enough docs were paying for this. Furthermore, it would be under a model of revenue share (30–40% according to the rumour mill) with us paying for development costs. This is impossible for a small self-funded company, and even then, would not necessarily be the right move. While we were often asked if we integrate with EMRs, the better question is whether EMRs integrate with valuable third-party applications. The paradigm needs to be flipped. Digital health cannot move forward without a simpler way to integrate. Furthermore, integration needs to be unpacked to understand exactly what that means at a cellular level. Our discourse treats it too simply, and our policies have failed spectacularly to set up a thriving, interoperable, competitive digital health sector driven to create value for front-line clinicians and patients. Plainly put, without integration, we were beholden to EMR workflows and how difficult they made it for our customers, costing us business, including our largest client that would have made us profitable.
Accountability and Problem Ownership
We met with many government agencies over the years to talk about what we are doing. The response would either be that this is interesting but not quite their responsibility (including the ministry lead on access to specialty care, so make what you will of that), or that they are planning to do (read: not doing, but planning to do) some aspect of what ConsultLoop offers so cannot work with us. It is a significant problem when you have system-wide challenges that nobody is responsible for. It’s akin to a condo building with a flood in the lobby. Each condo owner feels it’s not their problem, yet they are all suffering for it. Health care of people is too important to be compromised because of management/governance blind spots (no analogue to a condo board) or institutional ego. OHTs may solve part of this problem, but as I’ve written before there is much room for skepticism. It was very hard to solve a problem that everyone encountered in some way but nobody was accountable for it.
Patient Involvement
Patient engagement has been a double-edged sword for us. It has been tremendously valuable in building a better service and imagining what is possible, and it was frankly lots of fun and very meaningful. However, when we met with government agencies, we never felt that patient demands entered the conversation from their side, despite knowing that patients are involved at those agencies. It makes me feel that patient engagement is used for political benefit, but when the rubber meets the road, it’s absent. Yes, this is on those agencies who might screen the film Falling Through the Cracks and say they are committed to improving patient safety yet in the same week tell us this is not a priority and they have no part to play in this. The patient voice needs to be there at the system level, helping to develop primary care, helping to improve the connective tissue of our system. Instead, the movement has been largely been an institution-based or agency-based one, meaning that the problems and solutions proposed are of a given limited scope and rooted in tertiary/quaternary care. Ultimately, this is about decisions. If patients are not part of the key decisions around purchasing at the right levels of scope, then their influence is below its promising potential. In my opinion, we need a robust patient body at the ministry level, and we need patients to participate in purchasing at all levels. Otherwise their good work is downstream from where problems originate.
Doctors
To my peers, I appreciate all of you who were supportive of what we are doing, who shared their stories of struggling to provide good patient care given the set of tools and the workbench provided by the system. However, as a profession, we are so disorganized. What would happen if we collectively solved the problems that each and every primary care clinic encounters each and every day rather than being too small to fix it ourselves? What if we moved away from manual fax and phone work that costs us all so much money and digitized some of it? Could we free up staff time to help our patients that need extra attention, cut overhead, or decrease our hours? What if we exerted real pressure on the EMR companies we send tens of millions of dollars to each year and demanded better support for our clinical care of our dear patients? Our organizations are not ready to tackle issues like this, especially within primary care where there’s a complete lack of capacity for centralized office support.
I mention these six issues because as we embarked on this journey, and took on the risk of a new venture, we expected to find support once we showed that what we built works and provides value. Unfortunately, I feel that these issues were tougher to solve, or didn’t show up when we needed them to. As such, the company is closing, the platform is now off-line, the directory stowed away in a folder in the cloud.
For future digital health endeavours, they will have to meet these same challenges as they go forward. Is it clear who will pay and how they will benefit? Is the change management being pushed with enough political cover? Is there clear accountability in the system for the problem they are trying to solve, so that there is an engaged and interested entity? Are they solving a problem that is resonating with a patient voice that is also heard? Are they getting the support of doctors? Most importantly, will medical politics help them or stack the cards against them?
We did a lot of good, and we accomplished many meaningful things. At the same time, we failed on a lot of counts. When I look back on our journey, I don’t think that the current landscape has the right conditions for success for our type of venture, one that supports the public system and is designed to address equity challenges. Given the chance to try again, I frankly would not. Is that just sour grapes? Perhaps. But I think it’s something that merits a moment of pause — will the good things we ask for come about with the way things are set up? Are there the right conditions for success? Can we expect better things when better things stumble in finding solid ground in our system? For the defenders of our public system, the patients who seek care within it, and those who work in it, this should raise alarm bells. If we cannot improve our system, it will eventually fall out of favour and be politically indefensible. I saw ConsultLoop as a defense of our public system, and it made it very meaningful for me.
I leave this experience with pessimism for the future of healthcare in this province and our country. I hope to be proven wrong, just as my optimism four years ago has been proven wrong beyond the shadow of a doubt. ConsultLoop is no longer in business and we learned a lot. May those lessons cast light where they are most needed.
