TCLHIN Urban Telemedicine Initiative for WMS

AGHPS 3rd Leadership Summit 2013November 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

Milestones1 Initial proposal

2 Funding confirmation (Charter)

3 Telemedicine model development

4 NP hiring

5 MOU development

6 OTN installation

7 OTN training

8 NP site orientation

9 Project workflows established

10 Documentation system strategy

11 Client care initiated

12 Interim report to LHIN

Apr’12 Jul’12 Oct’12 Jan’13 Apr’13 Jul’13 Oct’13 Jan’14

LegendPlanned

Actual

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 ChallengesExpected Actual

Technology limitations NP Hiring – need for seasoned clinician

Collaboration across hospitals and sites

Documentation strategy for accessible record

Client perception of telemedicine

Privacy considerations across sites

Documentation system per site

Practice Guideline development

Evaluation Framework

Implementation ChallengesExpected Actual

Technology limitations NP Hiring – need for seasoned clinician

Collaboration across hospitals and sites

Documentation strategy for accessible record

Client perception of telemedicine

Privacy considerations across sites

Documentation system per site

Practice Guideline development

Evaluation Framework

DocumentationThe 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 JourneyThe 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

with Electronic

version

EMR Catalyst Super-user

Paper recordOne copyResides in WMS paper chartStaff fax to NP as required for referencing care to make clinical decisions

WMS Site as custodian

Produced on computerPrinted to chartNP keeps documents (ie in Word) for reference on laptopOriginal in chart

WMS Site as custodian

EMR installed on laptop, server or web basedEMR version is originalNP progress note printed for WMS chart? Site access

TEGH as health records custodian

On CatalystNP as super-userPartitioned by site visits but contiguous for patient??Same system as registration

Health record custodian ??

Documentation DecisionModel

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

July August September0

20406080

100120140160

140

99

138

Clinical Encounters -NP

July August September0.0%

10.0%20.0%30.0%40.0%50.0%60.0%70.0%

59.7%

37.9%

64.8%High Risk Clients

July August September0.0%1.0%2.0%3.0%4.0%5.0%6.0%7.0%8.0%

5.9%6.9% 7.2%

ED Diversion Rates

July August September0.0%

10.0%20.0%30.0%40.0%50.0%60.0%70.0%

49.6%59.8% 62.4%

Follow-up Care Ratio

Key Findings: Client CareTrending reasons for a visit

16%6%

59%

9% 9%Substance AbuseMental Health IssueMedical IssueMedication IssueSystem Navigation Issue

Key Findings: Patient Satisfaction

Metric Jul-Sep 2012Number of respondents 32Accessibility of the NP 96.9%Excellent quality of care 87.5%

100%Good quality of care 12.5%Impact on self-management: "a lot" 90.0%

100%Impact on self-management: "some" 10.0%Self-estimated diversion 53.1%Use again ? 100.0%Recommend to others? 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 TEGH plars@tegh.on.ca

Linda Young TEGH lyoun@tegh.on.ca

Jan Lackstrom UHN jan.lackstrom@uhn.ca

Paula Podolski St. Joseph's Health Center podolp@stjoe.on.ca