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Implementation of a Regional Surgical Access, eBooking & Wait Time Reporting SystemAn eHealth Success Story in Ontario’s Central East LHIN

The Central East LHIN, which has an annual budget of $2.5 billion, is one of 14 Local Health Integration Networks that have been established by the Government of Ontario as community-based organizations to plan, co-ordinate, integrate and fund healthcare services at the local level.

Covering the region between the east end of Toronto and Cobourg to the east, and from Lake Ontario north to Algonquin Park, the Central East LHIN encompasses 11 hospitals and 172 agencies, including community health centres and support services, long-term care facilities and a Community Care Access Centre (CCAC). This is one of the fastest-growing geographic regions in the Province and home to more than 11% of Ontario’s population or roughly 1.4 million people, according to the 2006 Census.

The Challenges

In accordance with its Service Accountability agreement with the Ontario Ministry of Health & Long-Term Care, the Central East (CE) LHIN, like the 13 other LHINs, is obligated to measure and report on its performance in meeting various provincially-imposed Wait Time targets. These are LHIN-wide targets and include Wait Times for diagnostic imaging (e.g., MRI, CT scans), for example, and especially for select surgical procedures, such as Cardiac, Cataract and Hip & Knee Replacement.

“Wait Time” mainly refers to the time between the ‘decision to treat’ (decided by the surgeon) and the ‘date of actual treatment’ (as recorded by the hospital) – in many jurisdictions, this is referred to as “Wait 2”.1 Both parties are obligated by law to submit that data to the Wait Times Information System (WTIS) managed by Cancer Care Ontario (CCO), which was given the mandate by the Ministry to manage the Wait Times program for the Province and to capture and report Wait Times information province-wide. Although Wait Times targets vary by procedure, the target for Hip & Knee Replacement, for example, is 182 days. The LHIN must meet that target within the 90th percentile, meaning that 9 out of every 10 patients needing this procedure must be treated within 182 days.

“To me, this is one of the most comprehensive, coordinated,

region-wide IT implementations that I have ever been a part

of,” insists Barker. “There are other regional things

happening, typically driven by eHealth Ontario, but this has

clearly been one of the bigger successes.”

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Real-Time Data Lacking for Performance Planning

“In Q3, when I was reviewing the LHIN’s performance data, I didn’t like the direction that Wait Times were trending for surgical procedures,” admits Paul Barker, Senior Director, Systems Finance & Performance Measurement, Central East LHIN. “Although we were still ahead of the required targets, I was concerned that based on the path we were on we would no longer be meeting those targets by year end.”

According to Barker, performance monitoring had traditionally been based on looking at retrospective data – where they have been and past performance month-over-month. Believing firmly in the adage “If you don’t know where you’re going, how can you change direction!” Barker felt strongly that in order to know how to change the trajectory of their Wait Times performance, he needed information on where they were going.

“If we know, for example, how many patients are currently on wait lists, what they are waiting for and how long they have been waiting, we can work with the hospitals to shift resources, shift patients and prioritize procedures within clinical practice areas to help us achieve our Wait Times targets,” explains

Barker, adding that when he approached the LHIN’s Wait Times Strategic Planning Group consisting of senior management from the LHIN, the hospitals and CCAC, they simply did not have that information. The hospitals were only seeing such information once patients were actually booked for their procedures by the individual surgeon’s offices throughout the region, and this typically only occurs one to two weeks before the actual procedure.

“I didn’t have this information, the hospitals didn’t have it – it seems that only the individual surgeon’s offices had lists of their wait-listed patients and priorities, but that information wasn’t being rolled up to the hospital or LHIN level in any way,” says Barker, identifying a clear need for access to current wait list data to help with resource planning and Wait Times management.

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Wait Times Data Submission Also Problematic

While the LHIN, on the one hand, was just reaching the point of taking action to address its need for access to real-time patient wait list data, the medical offices representing the roughly 340 surgeons throughout the region, had already been struggling for quite some time with their own challenges related to submitting Wait Times data.

For medical secretaries in those offices who work closely with the hospitals every day to schedule surgical procedures for their patients, submitting Wait Times data had been a labourious, time-consuming process. To meet their reporting obligation, they had to access a WTIS Web site, open a case for each new patient and enter required Wait Times data – specifically the decision-to-treat date and a treatment ‘priority score’ assigned to each patient by the surgeon based on patient condition and diagnosis.

“This was an added burden to their workload that produced little or no apparent benefit for the office,” claims Karol Eskedjian, Project Manager, Lakeridge Health. “It didn’t help them run the office or manage their patient wait lists any better, so there was little incentive for timely or accurate WTIS submissions.”

In addition, medical secretaries and physicians typically did not have an automated system for managing their list of waiting patients, which made tracking each patient relative to the appropriate provincial Wait Times target very difficult.

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Surgical Booking Process Clearly Sub-Optimal

WTIS submission was not the only labourious process in the surgeons’ offices at the time. The booking process for surgical procedures was also highly manual and inefficient, as it was for hospitals throughout the LHIN as well. This was largely due to poor access to wait list and scheduling data and the repeated handling of large amounts of paper patient files.

To book a surgical slot, medical secretaries would fax or send the patient’s file to the surgical booking clerk in the particular hospital where the surgeon has Operating Room (OR) privileges. After confirming the booking and entering schedule and patient information into a surgical scheduling system, the clerk would pass this paperwork along to numerous other areas of the hospital, such as the Pre-Operative Clinic, for example, where any pre-operative tests or examinations required for the patient could be arranged.

All this passing around of paper between the surgeon’s office and the hospital, and amongst departments within the hospital, was inefficient, manual work that involved too many hands touching the same information and often resulted in mistakes and in paperwork going astray.

“The surgeons’ offices found this process to be very cumbersome, and because they had no visibility into the OR scheduling data, they were continually having to phone the hospitals to get this information and to orchestrate schedule changes or report cancellations,” says Thodoros Topaloglou, CIO for the Rouge Valley Health System, which consists of two hospitals in the CE LHIN.

On the hospital side, the manual process of the booking clerk receiving paper from surgeons’ offices and then entering the data into the OR scheduling system was also not optimal, according to Topaloglou. The hospital, who would not see the patient information until the procedure was actually booked, had no visibility into what was going on in the surgeons’ office, including the patient wait lists – what procedures patients were waiting for, how long they had been waiting and so on.

“From the hospitals’ perspective, this was clearly a dysfunctional process that was creating a lot of waste,” claims Topaloglou, pointing out that the backend workflow inefficiencies were resulting in surgical delays and even cancellations. “There is evidence that if you don’t have a good scheduling process, you miss surgical opportunities, and that’s an expensive waste of valuable OR resources.”

It was clear that the current surgical booking environment throughout the CE LHIN was neither surgeon-office-friendly nor operationally efficient, and several of the hospitals had begun independently to look at electronic systems to enable booking process improvement. Combined with the continued problems associated with the submitting of Wait Times data by surgeons’ offices and hospitals, as well as access to current data for performance planning and Wait Times management at the LHIN level, the CE LHIN clearly needed to make some changes.

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Solution

The LHIN, in conjunction with the hospitals and several surgeon champions, decided to invest in a Web-based technology solution to automate and streamline the surgical booking workflow between medical offices, hospital booking clerks and other hospital departments. The software would have to link the surgeons’ offices to the different OR scheduling systems used in hospitals across the region, such as Picis OR Manager and surgical scheduling modules in both the Meditech and McKesson Hospital Information Systems. The understanding was that the LHIN would pay the capital costs of buying the software licenses and implementing the solution, while the hospitals would bear the ongoing software maintenance costs.

Only Novari Meets Priority Requirements

Based on Ontario public sector procurement guidelines, an RFP was issued by Lakeridge Health on behalf of the LHIN and the other hospitals for what was dubbed Project SUBMIT (Surgical Utilization Booking Management Information Tool).

A selection committee was also formed that, in addition to Eskedjian, who was serving as the LHIN eHealth Project Lead at the time, included a Procurement Manager, a hospital CIO, a hospital Chief of Surgery and the LHIN Director of Finance & Performance Management.

“We included some very specific criteria in the RFP, foremost of which was the need for a software automation solution to help us improve three critical processes,” says Eskedjian, who lists those as Surgical Booking, Wait Times submission to WTIS and the ability to access real-time, standardized wait list data across the region to support LHIN-level Wait Times performance analysis, management and reporting.

Tight timelines imposed on the project created additional product selection criteria for the RFP. According to Eskedjian, a certain portion of the project had to be implemented by the rapidly approaching fiscal year end in order for the LHIN to take advantage of funds earmarked to help meet its Wait Times targets. This meant that only an existing commercial-off-the-shelf (COTS) product could be selected.

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“In addition, the chosen vendor and the vendor’s product also had to have already been approved by CCO for submitting data to WTIS – we simply didn’t have time to go through the whole WTIS approval process either,” stresses Eskedjian.

Based on an evaluation of the RFP responses, the selection committee chose the Novari Access to Care with Smart Wait system as the technology platform for Project SUBMIT.

“We found Novari to be more advanced in terms of remote surgical booking process than other solutions we looked at; however, not just from the perspective of the surgeon office-hospital front end, but rather the entire workflow throughout the hospital,” says Topaloglou, the CIO member of the selection committee.

As part of the selection process and her Project Manager role, Karol Eskedjian visited several existing Novari customer sites and spent time with surgeons and with users from the hospitals and the physicians’ offices there to understand what lessons they had learned from their own Novari implementations.

“We had a very short timeframe, so we wanted to accelerate the project, while minimizing the risk; and since Novari had been used successfully for multi-site deployments previously, although not on this scale, it was really the obvious choice for this LHIN,” she reports.

The proposed Novari solution offered the Central East region three much-needed functional capabilities – wait list management, electronic booking and automated provincial Wait Times reporting. Novari already existed and had proven successful in other customer locations within Ontario and in other jurisdictions, so it was ready to go; and since it was live in other facilities and submitting data to WTIS, only minimal additional CCO approval was necessary. The flexibility of the Novari solution would also enable it to be configured for each individual hospital’s unique workflows, which also vary from service to service within each hospital.

“In short, Novari was the only existing, field-proven solution that met our priority requirements,” explains Eskedjian, who concludes her comments about the committee’s choice by adding that, “It also doesn’t hurt that Novari is a Canadian company – they know the Canadian health system and, as a smaller firm, they have been more cooperative and more willing to share information and plans than I’ve seen with many larger and international vendors I’ve dealt with in the past.”

Management of patients on the wait list is quick and simple – order or filter the

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Further substantiating the committee’s choice, Paul Barker adds that, “When we looked at what Novari could do for us, we recognized two opportunities beyond just solving the initial problem, the first of which was the huge value in not stopping with just Wait Times surgical procedures, but rather automating the bookings for all surgical practices.”

According to Barker, this would drive significant efficiencies across all the hospitals, producing savings in manual, paper-intensive, highly error-prone booking processes and even improving patient outcomes by reducing errors that could potentially impact patient care. The other opportunity Barker cites is to optimize the utilization of a very expensive resource – the Operating Room – by not wasting OR time blocks because pre-operative work has not been performed, for example, causing surgery cancellations, often with too little time left to book-in alternate patients.

Organize and transmit your OR booking requests electronically

including scanned History & Physical and Consent forms.

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Phased Approach Meets Aggressive Timing Challenges

With the urgent need to have the software installed and at least a representative sample of surgeons’ offices using the system by the end of the current fiscal year, a two-phased approach to the Novari implementation was adopted.

Phase 1 covered the installation of the single, centralized Novari application at Lakeridge Health and full adoption of the use of Novari by seven – Rouge Valley Health (2), Scarborough Hospital (2), Lakeridge Health (3) – of the CE LHIN’s 11 hospital sites as well as by affiliated surgeons’ offices. There are 68 such surgeons’ offices for Rouge Valley, for example, including those of Dr. Jonathan Hummel and Dr. Peter Hayashida, Chiefs of Surgery for the Centenary and Ajax-Pickering hospital sites respectively. They were the first users of the new Novari system, and remained strong champions throughout the project.

The first phase, especially the direct involvement by Hummel and Hayashida, built credibility and confidence in the project and helped pave the way for broad adoption and acceptance of the Novari solution during subsequent phases of the deployment.

“What really made all the difference was that the two Chiefs were involved from the get-go, even in the very early meetings with Novari,” says Renate Ilse, Program Director, Surgery, Endoscopy and Central Processing, Rouge Valley Health System, who was heading-up the Novari implementation at Rouge Valley. “Because they really believed the information would ultimately help patients by helping physicians and hospitals manage things better, they remained strong champions throughout, serving as role models for the rest of the surgeon community.”

This initial phase provided considerable ‘lessons learned’ for the team responsible for Novari deployment, physician and user engagement, and communications within each hospital organization. This team typically consisted of a project manager, an executive sponsor and surgical leadership, someone from IT, and hands-on people involved in the daily workflow, such as a booking clerk, provincial wait times coordinator, pre-op assistant and surgeon’s assistant. The teams benefited from those lessons by having things better figured out, resulting in a smoother Phase 2 – templated process, pre-determined decision points, a support model, roles & responsibilities, communications, etc. This phase involved Novari adoption by the LHIN’s remaining four hospital sites – Peterborough Regional, Lindsay’s Ross Memorial, Campbellford Memorial and Northumberland Hills.

“We had a target process we were working toward that happened to be compatible with what Novari supported; but there were many details that had to be worked out during the implementation, and I’m happy to say that our ‘partnering’ style worked well with Novari and we were able to solve problems collaboratively, not antagonistically,” offers Topaloglou.

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Teamwork Key to Overcoming Integration Challenges

The breadth and complexity of the effort throughout the project drove the need for several sub-projects. One was development of an interface between Novari and the Picis OR Manager surgical scheduling system used in several hospitals so that booking requests originating in surgeons’ offices would automatically flow into the hospital’s surgical booking system. Separate interfaces between Novari and McKesson, GE and QuadraMed applications had already been developed for previous client projects, and, ultimately, an interface to the Meditech ORM application, which is used at two of the LHIN’s hospitals, would also be developed before the project was complete, through collaboration by Novari and Meditech.

“The Novari people went to great lengths to work closely with the SUBMIT team, the hospital teams and the OR system vendor to develop and test the Picis integration – it was a really collaborative effort without which we simply never would have finished that interface,” insists Eskedjian.

To further complicate things, one of the smaller hospitals did not even have a scheduling system, yet still needed to be able to receive booking requests electronically from Novari. The Novari team and their software system was able to meet this unique need.

Eskedjian contends that this same collaborative spirit amongst the SUBMIT partners was

instrumental in the success of other sub-projects. Another such effort involved gaining approval for the “Complex” level of integration with CCO. Unlike the Basic and Standard levels of WTIS integration, in which Wait Times data submission is partially manual, submission is fully electronic in the Complex scenario. Novari automatically opens a patient case in WTIS and feeds in “decision-to-treat date” information and patient priority designations when a surgeon’s office adds a case to their Novari wait list; and the Novari system automatically submits “procedure date” information and closes the patient’s case in WTIS when the procedure is performed. This level of automation can require up to six months of testing and validation by CCO, and since each hospital submits individually to WTIS, validation must be done for each hospital.

“With Novari’s help, we were able to reduce this effort to less than thee months,” exclaims Eskedjian. “And then when CCO subsequently identified new requirements for “Wait 1” data1 to be submitted by all hospitals providing WTIS reporting, Novari was right there again, supporting us by incorporating corresponding changes into their system.”

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Training Key to Successful Change Management

In general, Novari user training followed a ‘train the trainers’ approach, with trainers and super-users first identified at each hospital, followed by the identification of groups of regular users who needed to be trained. The user groups included Wait Times Coordinators, OR Booking Clerks, hospital registration staff and the clerks and nurses involved in the pre-op departments. Of course it also included surgeon’s office staff, who were brought into the hospital for their group training sessions, as well as some actual physicians. Training for the trainers was conducted by Novari people, who then oversaw the initial end-user training sessions in order to support the trainers and provide feedback as required.

“For both hospitals at Rouge Valley, we also used a lot of ‘lunch & learn’ training in addition to the group sessions, some of which Novari guided,” says Renate Ilse. “We also conducted a lot of one-on-one sessions for the medical secretaries by going out to each surgeon’s office.

Training was conducted during the first week of the go-live at each hospital so that the learning would be ‘fresh’ and reinforcement, through actual hands-on use, would occur immediately – users could literally return to their offices after the training sessions and start to use the Novari system right away. Since each group of users works with a different view of the patient booking data in the Novari database, separate training and user documentation was provided for each.

“I’ve done this for a long time, and the Novari support documentation is really superior – the manuals, the training materials, the exercises, the learning tips and more – and if there was anything we needed that wasn’t there, they helped us create it,” says Eskedjian, adding that, “Being able to just make simple enhancements to the Novari training documentation, for example, to meet our needs rather than having to build it from scratch saved us a lot of effort, time and cost.”

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Results

The use of Novari has been fully live across the CE LHIN since the Fall of 2011, and now the only way a physician can book a surgical slot in an operating room at one of the LHIN’s hospital’s is through this tool. Right from the get-go, the Novari project yielded a wide range of benefits for key stakeholders – surgeons’ offices, hospitals, the LHIN and ultimately, patients – related to efficiency, accuracy and timeliness of surgery-related administrative processes across the region.

Automated Wait Times Reporting

Among the most dramatic benefits resulting from the addition of Novari has been the elimination of the need for medical secretaries in the nearly 400 surgeons’ offices throughout the region to submit Wait Times data and patient treatment priority scores to WTIS. This relieves them of a sizeable administrative burden that offered little or no benefit previously. Now, that data is automatically submitted to WTIS by Novari as an integral part of the surgical booking workflow, ensuring that accurate data is submitted on a timely basis. The seven CE LHIN hospitals are all now integrated with WTIS at the “complex” automation level.

“I’ve been told by WTIS Coordinators that because the WTIS data is now standardized, which greatly improves the quality, the number of errors in the data being submitted has been reduced from as many as 30 per day to just 2,” reports Eskedjian, adding that, “Wait Times are also decreasing because the process is now faster and any gaps or delays in the process are much more visible.”

Easily create rooms, days, physicians then drag and drop

individual patients or whole lists into the colour coded grid.

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Remote, Online Bookings

The second of the three top-level, LHIN-wide benefits driven by the new Novari system comes as a result of the introduction of automated, online surgical bookings and Novari’s integration with the region’s existing OR Scheduling applications and Hospital Information Systems. The move to online bookings has contributed substantially to process optimization and increased efficiency across the entire surgical scheduling workflow, from front-end surgeon’s offices, through the surgical booking offices to various backend hospital departments, such as the Pre-Op Clinic and Hospital Registration.

By way of example, Eskedjian cites the huge reduction in paper coming into the ORs as a result of the ability to now transfer scheduling requests and supporting patient information (e.g., consent forms, histories, vitals, physicals) electronically from surgeons’ offices to booking clerks, and amongst departments within the hospitals.

“This has not only reduced the errors previously associated with the booking process, but has also reduced any security or safety risks that may have existed as a result of passing forms and other patient paperwork among numerous people, with some making changes that others didn’t even know about,” says Eskedjian.

Use of online bookings through Novari has also decreased the time and effort required by all parties involved in booking, changing or cancelling surgical procedures. These actions have historically involved multiple back-and-forth faxes and phone call attempts, often for the purpose of soliciting booking information or clarifying patient data. Now, information accompanying online booking requests is tied to the patient’s complete record, so authorized people involved in the process can see everything they need. This has significantly reduced delays resulting from missed communications; and when communications between surgeons’ offices, the OR, Pre-Op and Registration, for example, are in fact needed, Novari’s internal instant messaging feature is proving to be very useful in keeping people connected and information flowing.

Online bookings is also facilitating improved patient list management, which ultimately means better, more timely care being provided to patients.

“This is a major improvement in patient care at Rouge Valley,” declares Dr. Jon Hummel, Chief of Surgery for Rouge Valley’s Centenary site. “By electronically tracking the patient, Novari simplifies booking surgery for the hospital, the surgeon, and most of all, for the patient.”

And according to Dr. Peter Hayashida, Chief of Surgery for the Ajax-Pickering hospital site, “This electronic interface improves our ability to operate on patients quickly and safely. Being able to partner with the other hospitals in the LHIN means we can make this improvement in more places and get better value from the project.”

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Resource Planning & Wait Times Management

At the LHIN level, the Novari implementation achieved a third critical objective of providing access to standardized, current, real-time patient list and Wait Times data that can be quickly and easily aggregated from across the region.

Previously, the LHIN went to each hospital every month and asked for their report data, which was often 30 days old by the time they got it, and then the LHIN had to spend considerable additional time to consolidate and massage the data for regional reporting. Now, however, LHIN staff can simply run reports in Novari that provide real-time patient wait list data. This ‘where are we going’ data – how many are on wait lists, what are they waiting for and how long have they been waiting – can be used to forecast Wait Times results and identify any initiatives that may be required to improve those results, especially by managing the allocation of surgical resources across the region.

“We’re now seeing a more clear and accurate picture of what the real Wait Times are and gaining a better understanding of the potential pressures we face at the regional level,” says the LHIN’s Paul Barker. “We can now start having discussions with all stakeholder groups about solutions at a regional level, including a common intake pool or common referral process, for example, or perhaps moving patients ‘around the board’ a lot more to address priority needs and optimize the use of resources.”

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And the List Goes On …

In addition to the three strategic benefits described above, the Novari implementation has delivered a long list of additional benefits to stakeholders, including, for example:

• When surgeons’ offices submit surgical booking requests for previous hospital patients, a live feed from hospital ADT systems into Novari ensures a ‘single source of truth’ for patient demographic data and eliminates potential data re-entry errors; for new patients, Novari triggers a Registration Request that ensures timely registration to meet CCO timing requirements for submission of patient and Wait Times data.

• The various groups having to review their processes as part of the system implementation has been like a quality improvement project and has yielded huge benefits. “When everything’s electronic, it’s very visible, so poor performers stand out – you can’t hide the fact that you’re holding onto data or perhaps incorrectly inputting surgical requests or always doing things at the last minute,” insists Eskedjian, claiming that the process improvement has been very beneficial to the hospitals.

• “Novari has given me a tremendous amount of access to information about what’s going on in the surgeons’ offices, and while some did things better, some definitely did them worse – we found there was a lot of misinformation, a lot of poor work habits and outdated practices,” reports Rouge Valley’s Renate Ilse, who says that when the system identified a problem, they sent people out to the surgeon’s office to coach the medical secretary to better performance through re-education.

• The LHIN found that one reason for bad Wait Times results was that invalid or incorrect data was being submitted. The Novari system is now catching and flagging those errors and forcing users to enter valid data. “These checks and balances are embedded right in the system and into the way data is entered and processed, so in addition to making the data more visible and accessible, Novari is helping us make it more accurate,” explains Paul Barker.

• With Novari, the hospitals and individual clinical programs, such orthopaedic surgery or surgical oncology, for example, now have a decision-support tool that can help them decide whether they need another OR, for example, or whether to re-allocate OR time from one service to another, or whether they need to go to the LHIN and show them they need additional resources to meet their Wait Times goals, and so on.

“To me, this is one of the most comprehensive, coordinated, region-wide IT implementations that I have ever been a part of,” insists Barker. “There are other regional things happening, typically driven by eHealth Ontario, but this has clearly been one of the bigger successes.”

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Driving Efficiency in Other Clinical Areas

“We are only in the early stages of using all this, but the potential is enormous,” says Barker about the initial Novari implementation and about future prospects. “My understanding is that the Ministry is very interested in learning more about this because they are recognizing the potential benefit of a tool that should be deployed far broader than in just one LHIN.”

Within the CE LHIN, plans are taking shape to extend the use of Novari to deliver additional capabilities and efficiencies in other areas. For example, at the request of the LHIN, Novari is already being used to provide online booking capability for more than just major surgeries in the main OR, for which it was originally implemented. These include endoscopies, birthing procedures (e.g., C-sections), eye clinics and more. The tool is also being looked at for online bookings and

as a central intake point for scheduling diagnostic imaging exams, such as MRIs and CT scans, as well as for booking Pre-Operative Clinic appointments.

“Using Novari has helped people overcome inertia and put them squarely on the path to automation, so we are looking at automating other things beyond just OR bookings,” says Renate Ilse.

According to Ilse, she and Dr. Hummel, one of the Rouge Valley Chiefs of Surgery, along with Rouge Valley CIO Thodoros Topaloglou, recently won an “innovation challenge” put on by CCO and have been given funding to develop a decision-support application that advises surgeons’ offices how to best allocate the next available surgical slot to maximize both patient and system needs. Commenting on this opportunity, Topaloglou offers that, “We are only able to do this because of access to Wait Times data, surgical booking data and the OR calendar – data that is all now available through the single Novari system.”

1 “Wait 1” refers to the time between the ‘referral to a specialist’ (typically by a general practitioner or family physician) and the ‘date of actual specialist/surgeon consult’ (as recorded by the surgeon’s office). “Wait 2” refers to the time between the ‘decision to treat’ (decided by the surgeon and patient) and the ‘date of actual treatment’ (as recorded by the hospital).