Background, Conceptual Framework and Early Successes SEPTEMBER 9, - - PowerPoint PPT Presentation

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Background, Conceptual Framework and Early Successes SEPTEMBER 9, - - PowerPoint PPT Presentation

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eConsultation Technical Assistance Webinar #1: Background, Conceptual Framework and Early Successes SEPTEMBER 9, 2015 WEBINAR #1 Agenda Introductions of grantees Overview of program and foundation goals 1 Background and rationale

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eConsultation Technical Assistance Webinar #1: Background, Conceptual Framework and Early Successes

SEPTEMBER 9, 2015 WEBINAR #1

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Agenda

1

  • Introductions of grantees
  • Overview of program and foundation goals

2

  • Background and rationale for eConsultation
  • Conceptual framework: an ideal state

3

  • Grantee highlights – specialist, PCP and heath plan

engagement

  • Evaluation metrics
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From the Foundation

 Introduction of grantees and program  Program vision and objectives

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Why eConsult?

  • Specialty care access is persistent challenge for the safety net
  • Primary barrier ($/reimbursement) overcome with ACA, but also

results in increased demand for specialty care access

  • eConsult improves access, but does so by better aligning

appropriate demand with supply

  • eConsult shows promise for achieving Triple Aim outcomes:

improves patient experience and population health, reduces cost

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Spreading Adoption of eConsult in California Safety Net

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early adopters (2) ready implementers (3) feasibility assessors (3) prospective new partners (4) readiness and capacity to implement eConsult

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eConsult Spread Strategy

51%

innovating with relationships catalyzing policy in midst of practice transformation leveraging technology shared measurement

BluePath Health & Center for Connected Health Policy Community Partners, UCSF/SFGH & LADHS

BSCF grant $ and wisdom from expert stakeholder convening (August 2014)

YOU! Leadership, commitment and local partnerships

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Background and eConsult in Context

THE PRIMARY CARE- SPECIALTY CARE INTERFACE AND EREFERRAL

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The Problem at SFGH

 Lengthy wait times for in-person specialty care appointments  Inefficient initial specialty care appointments

 Referral to the wrong specialty  Incomplete workup  Unclear referral question  Unnecessary referrals/specialty care visits

 Inequitable triage (first-come, first-served)  Primary care and specialty care delivery is segregated

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Yeuen Kim, Alice Hm Chen, Ellen Keith, Hal F. Yee, Jr, Margot B. Kushel, Not Perfect, but Better: Primary Care Providers’ Experiences with Electronic Referrals in a Safety Net Health System J Gen Intern

  • Med. 2009 May; 24(5): 614–619. Published online 2009 March 24

An Innovative Solution: SFGH eReferral Program

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Framework Shift

MEDICAL HOME Paradigm shift from focus on “access to specialty visits to access to specialty expertise”

Alice Hm Chen, M.D., M.P.H., Elizabeth J. Murphy, M.D., D.Phil., and Hal F. Yee, Jr., M.D., Ph.D. NEJM. 2013; 368:2450-2453.

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An Innovative Solution: SFGH eReferral

Internal Data from Alice Hm Chen

25 50 75 100 125 150 175 200 225 3 6 9 12

Wait Time for New Pa ent Appointment (days) Months since Ini a on

  • f

E-referral

Endocrinology Rheumatology Pulmonary Cardiology Nephrology

Decreased wait times PCP satisfaction

Kim Y, Chen AH, Keith E, Yee HF, Kushel MB. Journal of General Internal Medicine 2009; 24(5):614-619.

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Impact Overview

Primary Care

  • Reduced wait times
  • Quick access to specialist

expertise

  • Primary – specialty dialogue is

recorded in real time in EMR

  • Case-based “CME”
  • Virtual co-management keeps

patients in PCMH, reduces need for external care coordination

  • More “balls” in PCP court

Specialty Care

  • Reduced wait times
  • Avoidance of incorrect referrals
  • Ability to clinically triage
  • Improved clarity of consultative

question

  • Increased efficiency of in-person

visits

  • Formalization of curbsides
  • Opportunities to educate, learn
  • Increased “case-mix” in clinics
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Other eCR Programs

Hawaii Medical Service Association University of Mass. Memorial Medical Center Massachusetts General Hospital UAB Hospital Brigham and Women’s Hospital Community Clinics, Inc. (CT) Cook County HHS Univ of Oklahoma Mayo Clinic UCSD UCSF UCLA LADHS Ventura County ACCESS Orange County Univ of Iowa Univ of Wisc Univ of Virginia Dartmouth-Hitchcock Kaiser Permanente Veterans Administration

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Definitions

Integrated eCR = electronic consultation and referral system eConsult eReferral

  • Technology enabled
  • Expectation that patient will be

seen by specialist

  • Efficient for referral

management/tracking and review by specialist

  • Technology enabled
  • Request for a patient’s condition

and treatment to be evaluated by a specialist; does not carry the expectation that a specialist will see the patient

  • Bi-directional communication
  • Single portal of entry for referring providers; do not require providers to distinguish referrals

from consultations

  • All submissions are reviewed by a specialist
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Electronic Referrals

Operational efficiency

Tracking

Legibility

Clinical efficiency

Redirection

Triage

Preconsultative diagnostic evaluation

Electronic Consults

Drivers of Implementation

 Access to specialty care  Supply/demand mismatch  Long wait times  Decrease leakage  Formalize “curbsides”  Improve communication  Enhance PCP capacity

Integrated eCRs: more culture change; population approach

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Facilitators

 Engaged leadership  Established relationships

between PCPs, specialists

 Intuitive technology  Attention to workflow  Dedicated project

management team

 Funding mechanism

Barriers

 Clinician resistance

 PCP workload  PCP workflow  Specialist reviewer workload

 Lack of integration with EHR  Liability concerns  Lack of systems support  Lack of reimbursement

Facilitators and Barriers

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The Ideal State

A CONCEPTUAL FRAMEWORK

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Innovations for Access - Considerations

  • System Goals – What are You Trying Accomplish?

– Increasing Access to Specialty Care Services – Building PCP Case Management Capacity – Decreasing Inappropriate Referrals – Expediting Scheduling Processes – Increasing Communications

  • System Users – Who will Be Communicating?

– Provider-to-Provider (PCP/specialist) – Primary Care Org / Specialist Org – Patient-to-Provider

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Innovations for Access – “Players”

  • Primary Care Providers

– Geographic Service Area – Current Access and Referral Patterns

  • Specialty Reviewers

– Specialty Expertise, Areas of Focus – Focus for Specialists Engagement (the “Why”, the “What You Want from Them”: training, consultation, case management support

  • Gatekeeper/system owner

– Manage System Needs – technical capabilities: image capture, secured communication, video, archiving

  • Health Plan

– Metrics for Success: reduce unnecessary referrals, increase access, build PCP capacity, etc.

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eConsult

  • Considerations

– Secured email, closed system – Provider-to-Specialist consultation – Presentation of materials/tests/history for review – Creates dialogue for next steps in care/case management

  • E.g.: Top specialties applicable, including:

– Dermatology – Endocrinology – Gastroenterology – Cardiology – Urology

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eConsult

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eReferral

  • Considerations

– Expedited scheduling/authorization processes to get the patient to an in-person specialty appointment – Software, web or email based system – links to separate

  • rganizational scheduling processes and systems

– Stages referral requests through authorization processes – May include history, labs, pertinent information for referral

  • Examples: All applicable specialties
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eReferral

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TeleHealth

  • Considerations

– Case review/Training opportunities for Primary Care Providers – Software, video-based systems to address timing, scheduling, and geography barriers to trainings – Presentation of content, case-based review – can be retrieved at different times.

  • Examples:

– Web-based trainings – Project ECHO – Case Reviews

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TeleHealth

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Grantee Experiences

SUCCESSES, BARRIERS AND LESSONS LEARNED

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Santa Clara County

Engaging specialists for success

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Alameda Health System

Building internal PCP champions

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Clinical Work Groups

 Endocrinology, Cardiology, Urology  Next: GI/Hepatology, Neurology  Specialists +/- Nursing, PCPs x 3 orgs, Admin Support  Monthly Meetings

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Workflow in EHR

 Built customized pathway in Nextgen (AEHR)  Communication in Nextgen only

 All AHS PCPs use Nextgen

 Future issues

 Specialists onto Nextgen  Community Clinics  Scanning

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Community Clinics Health Network of San Diego

Strategies for health plan engagement

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A Framework for Evaluation

A HIGH LEVEL OVERVIEW

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Evaluation: Quadruple Aim

  • Population Health and Clinical performance
  • Population directly and indirectly served by eConsult
  • Effectiveness of eConsult process
  • Provider adoption
  • Efficiency of in-person visits
  • Patient safety
  • Access to specialty care
  • Patient Experience
  • Financial
  • Start-up and ongoing costs
  • Utilization
  • System efficiency
  • Provider and care team experience
  • PCP and specialist satisfaction
  • Staff satisfaction
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Evaluation Metrics

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Discussion!

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Next Steps

 Continued support  Sharing information  Next Webinars