TCLHIN Urban Telemedicine Initiative for WMS
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Transcript of TCLHIN Urban Telemedicine Initiative for WMS
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 [email protected]
Linda Young TEGH [email protected]
Jan Lackstrom UHN [email protected]
Paula Podolski St. Joseph's Health Center [email protected]