Transcript TCLHIN Urban Telemedicine Initiative for WMS
TCLHIN Urban Telemedicine Initiative for WMS
AGHPS 3rd Leadership Summit 2013
November 15, 2013
Overview
Context - Urban Telemedicine Initiative Urban Telemedicine Model Development Implementation Journey Highlights MOU Documentation Practice Guideline Evaluation Lessons Learned Critical Success Factors
Telemedicine
Medical support to patients in remote areas History 1900’s - two-way radio connection to Royal Flying Doctor Service of Australia 1950’s to 1990’s – telephone connection to remote areas Late 1990’s - urban telemedicine (Britain, US) via computer 2012 - TC LHIN Urban Telemedicine Initiatives Client and healthcare provider within the same LHIN Mechanism to increase access
Withdrawal Management Services (WMS) In TC LHIN
Hospital-affiliated, situated off site Separate facilities with some integrated practices Non-medical withdrawal system – care by unregulated health care providers Two-way impact on ED patient flow High level of client medical and withdrawal related complexity Patients go to different sites for episodes of care
Drivers for Change
ED visits by mental health and addictions clients increasing steadily in TC LHIN Some sites sending every client to ER for medical clearance prior to accepting – bed held at site Many WMS clients have issues accessing primary care and use ED as a substitute Coroner’s Report
Urban Telemedicine Model Development
Proposal to Charter & Funding – 4 months NP role for model included developing an understanding of: Scope of practice Clinical consultation Medical clearance Primary care focus opportunities Model for sharing resource across sites Telemedicine capabilities
Final Model
Partnership TEGH – Lead Agency St. Joseph’s Health Center UHN Nurse Practitioner (NP) hired and paid by TEGH NP visits a different site daily while supporting others via Telemedicine Utilize clinical expertise to defer people from ED, provide primary care and WMS staff consultation
Milestones
Legend
Planned Actual Apr’12 Jul’12 Oct’12 Jan’13 Apr’13 Jul’13 Oct’13 Jan’14 1 Initial proposal 4 NP hiring 5 MOU development 6 OTN installation 7 OTN training 8 NP site orientation 11 Client care initiated 12 Interim report to LHIN
Memorandum of Understanding (MOU)
Single MOU Sets out expectations and accountabilities including; Role responsibilities of lead and partner hospitals Human resources and practice accountabilities for NP PHIPA Compliance, Privacy and Health Information Custodianship Policy development
Implementation Challenges
Expected
Technology limitations Collaboration across hospitals and sites Client perception of telemedicine Documentation system per site
Actual
NP Hiring – need for seasoned clinician Documentation strategy for accessible record Privacy considerations across sites Practice Guideline development Evaluation Framework
Implementation Challenges
Expected
Technology limitations Collaboration across hospitals and sites Client perception of telemedicine Documentation system per site
Actual
NP Hiring – need for seasoned clinician Documentation strategy for accessible record Privacy considerations across sites Practice Guideline development Evaluation Framework
Documentation
The Situation Paper based, site-specific client care documentation Existing data extraction software (Catalyst) No budget for electronic medical record Ideal System Unique medical record for each client accessible by NP at any site Supported by pharmaceutical data base Integration of diagnostic test results/ reports Means to flow relevant information for handoff PHIPA compliance Capacity for data extraction
The Documentation Journey
The Process Several meetings over 6 months with LHIN representation Goal to balance privacy, IT perspective, user needs and available alternatives Considerations Cost Simplicity vs complexity Approval times for external software vendor Access to client health care information by unregulated staff
Documentation Options
Paper Record
Paper record One copy Resides in WMS paper chart Staff fax to NP as required for referencing care to make clinical decisions WMS Site as custodian
Paper Record with Electronic version
Produced on computer Printed to chart NP keeps documents (ie in Word) for reference on laptop Original in chart WMS Site as custodian
EMR
EMR installed on laptop, server or web based EMR version is original NP progress note printed for WMS chart ? Site access
Catalyst Super user
On Catalyst NP as super-user Partitioned by site visits but contiguous for patient??
Same system as registration TEGH as health records custodian Health record custodian ??
Documentation Decision
Model TEGH as health information (HIC) custodian Separate medical record for each client contiguous if care at more than one site NP provides needed clinical information to WMS staff on “as needed” basis Strategy Electronic medical record Web-based access from all sites to ensure timeliness (Application Service Provider) Relevant notes to paper chart
Practice Guideline Development
Purpose To establish common Urban Telemedicine Initiative practices among sites.
Intent Guideline to be a “living” document, reflecting evolving practice.
Process Involvement of WMS staff, supervisors, managers and directors in development.
Practice Guideline Content
Primary Health Care NP Practice Telemedicine Practice Client Eligibility and Priority Referrals to UTM/NP Consultation and Continuity Location, Frequency and Scheduling Documentation Privacy and Consent Health Information Management Telemedicine Assessments Infection Control Evaluation, Program Development, CQI
Evaluation Design
Conceptual framework Access Integration Patient centered care Safety Development of data elements, definitions, sources, frequency, accountabilities Need for pre-data identified Design of data collection tools and scorecard Reporting accountabilities to LHIN established
Key Findings: Client Care
A challenge to distinguish unique clients and encounters 150
Clinical Encounters -NP
140 138 100 99 50 0 70,0% 60,0% 50,0% 40,0% 30,0% 20,0% 10,0% 0,0% July August
High Risk Clients
September 64,8% 59,7% 37,9% 8,0% 6,0% 4,0% 2,0% 0,0%
ED Diversion Rates
6,9% 5,9% July August 7,2% September 80,0%
Follow-up Care Ratio
60,0% 59,8% 49,6% 40,0% 20,0% 0,0% July August 62,4% September July August September
Key Findings: Client Care
Trending reasons for a visit
10% 9% 16% 6% 59% Substance Abuse Mental Health Issue Medical Issue Medication Issue System Navigation Issue
Key Findings: Patient Satisfaction
Metric
Number of respondents Accessibility of the NP Excellent quality of care Good quality of care Impact on self-management: "a lot" Impact on self-management: "some" Self-estimated diversion Use again ?
Recommend to others?
32
Jul-Sep 2012
96.9%
87.5% 100% 12.5% 90.0% 100% 10.0%
53.1%
100.0% 100.0%
Scorecard
Scorecard
Lessons Learned
Our history of voluntary integration and WMS committee structure supported the process of change.
New uses of telemedicine are challenging due to already existing definitions for type of engagement. Site differences posed both challenge and opportunity.
MOU development can be a lengthy process when combining privacy, human resources and site accountabilities.
Lessons Learned
Continuous quality improvement (CQI) is an important part of the initiative, to understand impacts and refine practices through small tests of change.
There is much work to be done to manage the medical complexity of clients and enhance risk management.
In addition to ED diversion, there are several promising practices from this initiative; virtual rounds, CAMH patient flow, using practice guidelines across sites and establishing a means to track ED interfaces through CATALYST.
Client Voice
"I didn't think I could do this (alcohol withdrawal) - and manage my diabetes and liver cirrhosis at the same time“
52 year old male: heavy alcohol binge-type use and extensive alcohol use history, admitted from ED After admission to WMS NP noted that client had both medical and withdrawal related risks Client was transferred to the medical Withdrawal Management Service of CAMH (Centre for Addiction and Mental Health) for stabilization of his diabetes and acute withdrawal phase Client then returned to TEGH non-medical WMS site to complete withdrawal and participate in day program, before being admitted to a long-term substance use treatment program During stay at TEGH WMS, NP and client worked to improve client's diabetic control through assessments, health teaching and assistance with system navigation
In Summary: Critical Success Factors
Ongoing dialogue at many levels to understand complexity of service model Being open to learning and discovering new ways of providing care Building on the strong foundation that exists in WMS to ensure collaborative input at all levels for shaping initiative.
Discussion Questions?
Suggestions?
Contacts
Pat Larson Linda Young Jan Lackstrom
TEGH TEGH UHN [email protected]