A little engineering, a lot of customer service: What it will take to fix COVID-19 test lineups

Kate Gordon's five-year-old daughter, Rosie, had only been in her Toronto kindergarten class for one day before her little sister sprouted a runny nose. That meant neither Rosie nor Stella, who attends a Montessori preschool, could return to class until Stella, 3, had tested negative for COVID-19.

So the next morning, the family headed to the nearest COVID-19 testing site, located at St. Joseph's Health Centre, in the city's west end.

"By the time we got there at 8:45, the lineup was around the building," said Gordon, whose husband was able to pick the girls up while she held their place during the three-hour wait.

Only Stella required a test, though Gordon decided to get herself swabbed for good measure while they were there. But that's when her family's real trouble started. 

Gordon got her own test results 36 hours later using MyChart, an online tool adopted by some hospitals, including St. Joseph's. "But the problem is you have to be 14 and over to use it. I could use it for myself, but for Stella I had to check this government website," she said.

Three days went by without results for Stella and no school for either girl, until, in frustration, Gordon posted on a local Facebook group about her experience and received a private message from another mom with a phone number and email address for the hospital's release-of-information department.

After a series of emails and form submissions, Gordon got Stella's negative results the fifth day, and after six days out of school, the girls were able to return to class.

Stories like Gordon's have both physicians and people from the business world wondering why Canada can't come up with a better and more consistent user experience when it comes to COVID-19 testing.

"It's actually kind of embarrassing that in 2020, this is the best response that we have," said Dr. Louis Francescutti, an emergency room physician, preventative medicine specialist and professor at the University of Alberta's School of Public Health in Edmonton.

Gordon is careful to clarify that she has no beef with the staff working the front lines at testing centres and laboratories. The people she dealt with "were lovely," she said. "I really feel for these people who work there. They are working their butts off."

But she said she worries about how people with less privilege are supposed to cope with kids out of school and long waits for tests that could put their employment at risk. "I don't know how they're going to survive."

Unified approach needed

As cases surge in Canada's most populous areas, the process of getting a test ranges from the seamless (pre-booked appointments that get recipients in and out in minutes) to the seriously frustrating (trying your luck in an hours-long lineup that could hit capacity before you get to the front).

Every day last week, for example, people were getting turned away mid-morning at a drop-in COVID-19 assessment centre in Brockville, Ont., because — with people coming from all over the region — it had already maxed out the number of people it could see that day.

In contrast, people like Denise MacIntyre in Calgary — who gets tested every few weeks so she can visit a friend at a long-term care home where she also volunteers — said she has no trouble getting an appointment at her local pharmacy. "I just call and they'll tell you if they have time today or tomorrow."

Results have never taken any longer than 48 hours, MacIntyre said.

It shouldn't be so inconsistent, Francescutti said, adding that it doesn't make sense that people should line up for hours given that the swab itself takes less than a minute.

"If I want to get my Apple product repaired, I just go online, sign into a genius bar and pick a store near to me that has the service. And then I go to the store, I get served and I leave. Most people have access to technology that would allow them to pre-book."

Of course, more vulnerable groups, such as seniors and people experiencing homelessness, would require help accessing testing "in the field," he said, but there's no reason technology couldn't solve much of the problem, particularly if applied everywhere in the country.

"We've got 10 provinces and three territories ... that are all doing it individually. We need to have more unison and we need to have best practices once they've been shown to work in different areas, replicated and amplified as quick as we possibly can." 

Mobile app could improve process

Marc LeCuyer, general manager of ServiceNow Canada, a software company that specializes in digital workflow, said a mobile app for booking appointments could solve the problem of long lines at many testing sites.

Given that most people are accustomed to using mobile apps to access all manner of things they want or need — from Facebook pictures of their nephew to their favourite curry chicken — mobile is the sensible delivery system, LeCuyer said.

It also enables operators to capture user experiences and adapt accordingly, he said.

We need to put ourselves in the shoes of the customer, the citizen, and understand their expectations — I show up at a testing centre, I get my test and I get my results in a timely manner.- Marc LeCuyer, general manager, ServiceNow Canada

"We need to put ourselves in the shoes of the customer, the citizen, and understand their expectations — I show up at a testing centre, I get my test and I get my results in a timely manner," he said. 

LeCuyer said expecting people to wait in line for hours not knowing if they'll even get a COVID-19 test that day is a little like running an airport without a reservation system.

"Can you imagine if the airline just said flights are going out every hour on the hour to these locations; just show up and we'll get you on a flight?"

LeCuyer said he feels for the public-sector employees who are trying to navigate this complex situation within the confines of an unwieldy public health system, but a tool that overlays the 10 provincial and three territorial jurisdictions would eliminate a lot of the frustration and confusion. 

"At the end of the day, everything is possible. We just have to get past the barriers."

Lauren Cipriano, an associate professor in management science at the Ivey Business School at Western University in London, Ont., who also works in the department of epidemiology and biostatistics, said average wait times can be mathematically predicted any time increasing demand is expected. 

Ensuring there's enough service capacity all the way through the process, from getting the swab to getting results, is critical. "We need those COVID results so people can act on the information, isolate and not infect others," she said.

"If waiting times are longer or — as we get into cooler weather — conditions are poor, people aren't going to go."

Lack of public health-care delivery

Complicating testing processes is our lack of truly public health-care delivery, said Dr. Michael Rachlis, a private consultant in health policy analysis and adjunct professor at the University of Toronto's Dalla Lana School of Public Health.

"There's no system of primary care like they have in other countries, where there's a health centre in your neighbourhood that sees everybody who needs to be seen, and if we're going to run a testing program or vaccine program, that's where it happens."

Instead, family practice clinics are small businesses, and only a few parts of Canada have regional health authorities with clinics that oversee how some public health initiatives are delivered.

Jeff Lozon, a former deputy health minister in Ontario who was also president of St. Michael's Hospital in Toronto, said that's poorly understood.

"Canadians generally think that their health-care system is a command and control, so the minister of health says something and they have control of that. But in point of fact, the health-care system is much more distributed. It's much less hierarchical than you think."

Michael Carter, an industrial and systems engineer who specializes in making health-care delivery run smoothly, has been advising on COVID-19 testing.

He suggests that in jurisdictions that continue to make tests available to everyone, it would be more efficient, where possible, to have different sites for those with symptoms and those without. That way testing staff don't waste time asking the asymptomatic people — often the majority in line — the same list of questions about how they feel, said Carter, who is also a professor of industrial engineering at the University of Toronto. 

"If we can get asymptomatic people to go to an open space and line up and get through in one minute, you're in business."