ADR 0005: Access Burden Estimator Design¶

Status¶

Accepted

Date¶

February 4, 2026

Context¶

Healthcare access involves more than just clinical wait times. Financial barriers—including transportation costs and parking fees—can significantly impact patients' ability to access emergency care, particularly for lower-income populations. However, these costs are typically invisible in wait time applications.

Problem Statement¶

1. Hidden Costs: Patients comparing hospital options rarely consider the financial burden of accessing care
2. Access Disparities: Lower-income patients may face significant financial barriers that influence their healthcare decisions
3. Policy Blindness: Healthcare policymakers lack visible data on logistical access barriers
4. Risk of Misuse: Displaying costs could discourage patients from seeking necessary emergency care

User Stories¶

• As a patient, I want to understand the financial burden of traveling to different hospitals so I can plan accordingly
• As a policymaker, I want to see logistical access costs made visible so I can address systemic barriers
• As a healthcare advocate, I want to highlight hidden financial barriers without discouraging emergency care

Decision¶

We will implement an Access Burden Estimator component that:

1. Calculates Total Access Cost¶

Formula:

Total Access Burden = (Round Trip Distance × Fuel Consumption × Gas Price) + Parking Estimate

Components: - Distance: Already calculated from user location to hospital (Haversine formula) - Fuel Cost: Based on provincial gas prices and 10L/100km average consumption - Parking: Estimated range by hospital type (urban/suburban/rural)

2. Displays Cost as a Range¶

Show $min - $max to acknowledge uncertainty in parking costs, not a false-precision single number.

3. Remains Collapsed by Default¶

The component starts collapsed to avoid overwhelming users or creating decision paralysis. Users must actively choose to view the estimate.

4. Includes Prominent Disclaimers¶

Always-visible banner:

"Planning tool only. Never delay emergency care for cost. Call 911 for emergencies."

Expanded view includes: - Methodology explanation (fuel consumption rate, gas price) - Hospital type clarification (urban/suburban/rural) - Rationale statement: "Why show this?"

Implementation Details¶

Provincial Gas Prices (CAD/L)¶

Based on Natural Resources Canada data (updated periodically):

Parking Estimates (CAD)¶

Fuel Consumption¶

• Rate: 10L/100km (industry standard for average passenger vehicle)
• Sources: Natural Resources Canada, Canadian Automobile Association

Calculation Example¶

Scenario: 20km to urban hospital in Ontario

Round trip: 20km × 2 = 40km
Fuel: 40km × (10L/100km) × $1.55/L = $6.20
Parking: $15-$25
Total: $21-$31

Consequences¶

Positive¶

1. Transparency: Makes invisible financial barriers visible
2. Advocacy: Demonstrates "Health Advocate" CanMEDS competency
3. Differentiation: No other ER wait time app includes this feature
4. Policy Impact: Provides data for access barrier discussions
5. Trust: Shows awareness that healthcare access involves more than clinical factors

Negative (Risks)¶

1. Misuse: Could discourage patients from seeking necessary care
2. Oversimplification: Doesn't account for public transit, insurance, lost wages
3. Maintenance: Gas prices need periodic updates
4. Liability: Could be seen as providing financial advice

Mitigations¶

Alternatives Considered¶

Alternative 1: Don't Show Costs At All¶

Pros: - No risk of discouraging care - Simpler implementation

Cons: - Misses opportunity to highlight access barriers - Fails to demonstrate "Health Advocate" competency - Perpetuates invisibility of financial barriers

Verdict: Rejected. The educational and advocacy value outweighs the risks when properly disclaimed.

Alternative 2: Include Lost Wages / Time Cost¶

Calculation:

Time Cost = (Travel Time + Wait Time) × Hourly Wage

Pros: - More comprehensive cost estimate - Highlights opportunity cost

Cons: - Highly sensitive: Implies dollar value on time - Ethically problematic: Could encourage "worth it" calculations for emergency care - Data limitations: Don't have reliable wage data - Offensive framing: Suggests emergencies should be financially justified

Verdict: Rejected. Too sensitive and ethically problematic. The component should highlight logistical barriers, not encourage cost-benefit analysis of emergency care.

Alternative 3: Show Only Distance, Not Cost¶

Pros: - No financial implications - Still shows access burden

Cons: - Misses the point: distance is already shown - Fails to highlight financial barriers specifically

Verdict: Rejected. Distance alone doesn't capture the financial barrier aspect.

Alternative 4: Show Transit Options¶

Pros: - More equitable (benefits non-drivers) - Lower cost alternative

Cons: - API complexity (Google Transit API, etc.) - Data availability varies by region - Maintenance burden

Verdict: Deferred to future enhancement. Focus on driving cost first (majority use case), add transit later if demand exists.

Design Principles Applied¶

1. Transparency Over Optimization¶

Show methodology clearly. Don't hide assumptions. This aligns with the project's core principle of "audit, don't aggregate."

2. Safety First¶

The disclaimer is always visible, not just in expanded state. Never encourage financial considerations to override medical judgment.

3. Range Over Precision¶

Use $21-$31 not $24.57. Acknowledge uncertainty rather than creating false precision.

4. Collapsed by Default¶

Opt-in, not opt-out. Users must actively choose to see this information.

5. Educational, Not Prescriptive¶

The "Why show this?" section explains the feature's purpose: making barriers visible, not guiding decisions.

Technical Implementation¶

Component Structure¶

<AccessBurdenEstimator
  distanceKm={20}        // From calculateDistance()
  province="ON"          // From hospital.province
  hospitalType="urban"   // Could be enhanced with DB field
/>

Integration Points¶

1. ExpandedCardDetails: Shows when user has location and hospital card is expanded
2. Map Popup: (Future) Could show in hospital popup
3. Comparison Modal: (Future) Could compare access burden between hospitals

Test Coverage¶

• 21 unit tests covering:
• Collapsed/expanded states
• Fuel cost calculation (multiple provinces)
• Parking estimates (all hospital types)
• Total cost ranges
• Accessibility (ARIA attributes)
• Edge cases (very short/long distances, unknown provinces)

Success Metrics¶

User Engagement¶

• Track expansion rate: X% of users expand the estimator
• Correlate with distance: Do users farther away expand more often?

Advocacy Impact¶

• Include in medical school applications as "Health Advocate" feature
• Use in discussions about healthcare access barriers
• Potential media coverage: "First ER app to highlight financial barriers"

Stakeholder Feedback¶

• Interview question: "Is the Access Burden Estimator helpful or harmful?"
• Expected answer: Helpful for planning, if properly disclaimed

Future Enhancements¶

Phase 1 Enhancements (If Time Permits)¶

1. Hospital-Specific Parking Data: Replace estimates with actual parking rates
2. Transit Options: Add public transit cost/time comparison
3. Comparison View: Show access burden delta when comparing hospitals

Phase 2 Enhancements (Post-Launch)¶

1. API Integration: Live gas prices from Natural Resources Canada
2. Vehicle Type Selector: Let users specify their fuel consumption rate
3. Accessibility Mode: Include wheelchair-accessible transit options

Out of Scope (Intentionally Not Building)¶

1. Time-value calculations: Never include lost wages or time cost
2. Insurance integration: Don't factor in coverage
3. Financial advice: Don't suggest whether care is "worth it"

Related ADRs¶

• ADR 0002: Metric Ontology - Transparency philosophy
• ADR 0004: Landing Page UX - Collapsed-by-default pattern

References¶

• Gas Prices: Natural Resources Canada Fuel Focus
• Fuel Economy: Natural Resources Canada Vehicle Fuel Consumption Guide
• Parking Rates: Informal survey of major Canadian hospitals
• CanMEDS Framework: Health Advocate role description

Approval¶

Rationale: The Access Burden Estimator demonstrates healthcare systems thinking while maintaining patient safety through prominent disclaimers. It differentiates the project from competitors and showcases the "Health Advocate" CanMEDS competency.

Trade-offs Accepted: We accept the maintenance burden of updating gas prices in exchange for making financial access barriers visible.

Risk Mitigation: The always-visible disclaimer and collapsed-by-default approach minimize the risk of discouraging necessary emergency care.

Last Updated: February 4, 2026