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Campaz-Landazábal D, Vargas I, Vázquez ML. Impact of coordination mechanisms based on information and communication technologies on cross-level clinical coordination: A scoping review. Digit Health 2024; 10:20552076241271854. [PMID: 39130524 PMCID: PMC11311193 DOI: 10.1177/20552076241271854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 07/04/2024] [Indexed: 08/13/2024] Open
Abstract
Background Coordination mechanisms based on information and communication technologies (ICTs) are gaining attention, especially since the pandemic, due to their potential to improve communication between health professionals. However, their impact on cross-level clinical coordination remains unclear. The aim is to synthesize the evidence on the impact of ICT-based coordination mechanisms on clinical coordination between primary care and secondary care (SC) doctors and to identify knowledge gaps. Methods A scoping review was conducted by searching for original articles in six electronic databases and a manual search, with no restrictions regarding time, area, or methodology. Titles and abstracts were screened. Full texts of the selected articles were reviewed and analysed to assess the impact of each mechanism, according to the cross-level clinical coordination conceptual framework. Results Of the 6555 articles identified, 30 met the inclusion criteria. All had been conducted in high-income countries, most (n = 26) evaluated the impact of a single mechanism - asynchronous electronic consultations via electronic health records (EHR) - and were limited in terms of design and types and dimensions of cross-level clinical coordination analysed. The evaluation of electronic consultations showed positive impacts on the appropriateness of referrals and accessibility to SC, yet the qualitative studies also highlighted potential risks. Studies on other mechanisms were scarce (shared EHR, email consultations) or non-existent (videoconferencing, mobile applications). Conclusions Evidence of the impact of ICT-based mechanisms on clinical coordination between levels is limited. Rigorous evaluations are needed to inform policies and strategies for improving coordination between healthcare levels, thus contributing to high-quality, efficient healthcare.
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Affiliation(s)
- Daniela Campaz-Landazábal
- Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Barcelona, Spain
| | - Ingrid Vargas
- Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Barcelona, Spain
| | - María-Luisa Vázquez
- Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Barcelona, Spain
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Bifulco L, Grzejszczak L, Velez I, Angelocci T, Anderson D. A qualitative investigation of uninsured patient and primary care provider perspectives on specialty care eConsults. BMC Health Serv Res 2023; 23:1133. [PMID: 37864170 PMCID: PMC10589958 DOI: 10.1186/s12913-023-10086-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 09/28/2023] [Indexed: 10/22/2023] Open
Abstract
BACKGROUND Uninsured and underinsured patients face specialty care access disparities that prevent them from obtaining the care they need and negatively impact their health and well-being. We aimed to understand how making specialty care electronic consultations (eConsults) available at a multi-site Federally Qualified Health Center (FQHC) in central Texas affected uninsured patients' care-seeking experiences and impacted their ability to receive the needed care. METHODS We used concepts from Ecological Systems Theory to examine individual, interpersonal, organization-level, social, and health policy environment factors that impacted patients' access to specialty care and the use of eConsults. We conducted thematic analysis of semi-structured, qualitative interviews with patients about seeking specialty care while uninsured and with uninsured patients and FQHC PCPs about their experience using eConsults to obtain specialists' recommendations. RESULTS Patients and PCPs identified out-of-pocket cost, stigma, a paucity of local specialists willing to see uninsured patients, time and difficulty associated with travel and transportation to specialty visits, and health policy limitations as barriers to obtaining specialty care. Benefits of using eConsults for uninsured patients included minimizing/avoiding financial stress, expanding access to care, expanding scope of primary care, and expediting access to specialists. Concerns about the model included patients' limited understanding of eConsults, concern about cost, and worry whether eConsults could appropriately meet their specialty needs. CONCLUSIONS Findings suggest that eConsults delivered in a primary care FQHC addressed uninsured patients' specialty care access concerns. They helped to address financial and geographic barriers, provided time and cost savings to patients, expanded FQHC PCPs' knowledge and care provision options, and allowed patients to receive more care in primary care.
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Affiliation(s)
- Lauren Bifulco
- Weitzman Institute, 19 Grand Street, Middletown, CT, USA
| | | | - Idiana Velez
- Weitzman Institute, 19 Grand Street, Middletown, CT, USA
| | - Tracy Angelocci
- Lone Star Circle of Care, 205 East University, Suite 100, Georgetown, TX, USA
| | - Daren Anderson
- Weitzman Institute, 19 Grand Street, Middletown, CT, USA.
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Mattox EA, Yantsides KE, Borgerding J, Beste LA, Parsons EC, Fleet M, Palen BN, O'Hearn D, Germani MW, Chang MF. Participant Characteristics and Attendance Patterns for a Multispecialty Veterans Affairs ECHO Program 2012-2018. Telemed J E Health 2022; 28:1633-1641. [PMID: 35325561 DOI: 10.1089/tmj.2021.0626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Introduction: The Veteran Integrated Service Network (VISN) 20 Veterans Affairs-Extension for Community Healthcare Outcomes (VA-ECHO) program connects specialty and primary care providers (PCPs) across large geographic areas, utilizing video-teleconferencing with the intention of increasing access to care among underserved and isolated populations. No previously published work describes participation patterns of a multispecialty ECHO program. We describe the development of VISN 20 VA-ECHO program to inform the design and evaluation of ECHO programs. Methods: The participant cohort included VA-affiliated licensed health care professionals, including trainees, who attended at least one VISN 20 VA-ECHO session between April 2012 and December 2018. Participant characteristics reported include gender, clinical location, clinical specialty, discipline, and rurality. Results: Over the 6-year time frame, VISN 20 VA-ECHO offered 945 sessions in 14 clinical specialties and recorded 17,893 hours of attendance. The cohort included 1,346 participants, 74.3% of whom were female, 85.2% employed in medical centers, and 40.7% affiliated with primary care. Most participants (62.3%) attended one specialty exclusively; among all participants, 40% attended five or more sessions. Discussion: Although VA-ECHO was implemented to develop single specialty expertise among PCPs, our participant cohort represented a more diverse audience from a range of disciplines and specialties. Our experience may be valuable to other teams implementing ECHO programs. Conclusions: Through adaptability and strategies that actively promoted inclusion of a diverse audience, VISN 20 VA-ECHO expanded to include multiple clinical specialties and successfully engaged an audience across a large geographic area and beyond PCPs.
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Affiliation(s)
- Elizabeth A Mattox
- Pulmonary and Critical Care Section, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
| | - Konstantina E Yantsides
- Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
| | - Joleen Borgerding
- Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
| | - Lauren A Beste
- Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
- General Medicine Service, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
- Division of General Internal Medicine, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Elizabeth C Parsons
- Pulmonary and Critical Care Section, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Margaret Fleet
- Nephrology Section, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
- Division of Nephrology, University of Washington, Seattle, Washington, USA
| | - Brian N Palen
- Pulmonary and Critical Care Section, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Daniel O'Hearn
- Pulmonary and Critical Care Section, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Maureen Wylie Germani
- Health Services Research and Development Center for Innovation, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
| | - Michael F Chang
- Gastroenterology and Hepatology Service, Veterans Affairs Portland Health Care System, Portland, Oregon, USA
- Gastroenterology and Hepatology Division, Oregon Health & Sciences University, Portland, Oregon, USA
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Staff Experiences with a Team-based Approach to Sleep Medicine Referrals: A Qualitative Evaluation. Ann Am Thorac Soc 2021; 19:819-826. [PMID: 34788585 DOI: 10.1513/annalsats.202107-838oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Sleep disorders are highly prevalent, and the volume of referrals sent to sleep specialists frequently exceeds their capacity. In order to manage this demand, we will need to consider sustainable strategies to expand the reach of our sleep medicine workforce. The Referral Coordination Initiative (RCI) takes a team-based approach to streamlining care for new specialty care referrals by 1) incorporating registered nurses into initial decision-making, 2) integrating administrative staff for coordination, and 3) sharing resources across facilities. While prior work shows that RCI can improve access to sleep care, we have a limited understanding around staff experiences and perspectives with this approach. OBJECTIVE Assess staff experiences with a team-based approach to sleep medicine referrals. METHODS From June 2019 to September 2020, we conducted semi-structured interviews with staff members who interacted with RCI in sleep medicine. We recruited a variety of staff including RCI team members (nurses, medical support assistants), sleep specialists, and referring providers. Two analysts used content analysis to identify themes. RESULTS We conducted 48 interviews among 35 unique staff members and identified six themes. 1) Efficiency: Staff described impacts of the RCI program with regard to efficient use of staff time and resources. 2) Patient access and experience: Staff noted improvements to patient's ability to receive care. 3) Staff wellbeing and satisfaction: Specialists and RCI staff described how RCI mitigated the adverse impact of triage volume on staff wellbeing. 4) Sharing specialty knowledge: Nurses and specialists discussed the challenges of sharing specialty knowledge and training nurses to triage. 5) Nurse autonomy: Staff discussed nurses' ability to make triage decisions in the RCI system and highlighted the crucial role that decision support tools play in supporting that autonomy. 6) Coordination and communication: Staff noted the importance, challenges, and facilitators of coordination and communication across facilities and at the interface of primary and specialty care. CONCLUSION Staff endorsed positive and negative experiences around the RCI system, identifying opportunities to further streamline the referral process in support of access, patient experience, and staff wellbeing.
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Leonard C, Ayele R, Ladebue A, McCreight M, Nolan C, Sandbrink F, Frank JW. Barriers to and Facilitators of Multimodal Chronic Pain Care for Veterans: A National Qualitative Study. PAIN MEDICINE 2021; 22:1167-1173. [PMID: 32974662 DOI: 10.1093/pm/pnaa312] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Chronic pain is more common among veterans than among the general population. Expert guidelines recommend multimodal chronic pain care. However, there is substantial variation in the availability and utilization of treatment modalities in the Veterans Health Administration. We explored health care providers' and administrators' perspectives on the barriers to and facilitators of multimodal chronic pain care in the Veterans Health Administration to understand variation in the use of multimodal pain treatment modalities. METHODS We conducted semi-structured qualitative interviews with health care providers and administrators at a national sample of Veterans Health Administration facilities that were classified as either early or late adopters of multimodal chronic pain care according to their utilization of nine pain-related treatments. Interviews were conducted by telephone, recorded, and transcribed verbatim. Transcripts were coded and analyzed through the use of team-based inductive and deductive content analysis. RESULTS We interviewed 49 participants from 25 facilities from April through September of 2017. We identified three themes. First, the Veterans Health Administration's integrated health care system is both an asset and a challenge for multimodal chronic pain care. Second, participants discussed a temporal shift from managing chronic pain with opioids to multimodal treatment. Third, primary care teams face competing pressures from expert guidelines, facility leadership, and patients. Early- and late-adopting sites differed in perceived resource availability. CONCLUSIONS Health care providers often perceive inadequate support and resources to provide multimodal chronic pain management. Efforts to improve chronic pain management should address both organizational and patient-level challenges, including primary care provider panel sizes, accessibility of training for primary care teams, leadership support for multimodal pain care, and availability of multidisciplinary pain management resources.
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Affiliation(s)
- Chelsea Leonard
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, Colorado
| | - Roman Ayele
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, Colorado.,Colorado School of Public Health, University of Colorado-Anschutz Medical Campus, Aurora, Colorado
| | - Amy Ladebue
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, Colorado
| | - Marina McCreight
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, Colorado
| | - Charlotte Nolan
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, Colorado
| | - Friedhelm Sandbrink
- Department of Neurology, Washington DC VA Medical Center, Washington, DC.,Department of Neurology, George Washington University, Washington, DC
| | - Joseph W Frank
- Denver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, Colorado.,Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado
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Wingfield T, Beadsworth MB, Beeching NJ, Gould S, Mair L, Nsutebu E. An evaluation of 1 year of advice calls to a tropical and infectious disease referral Centre. Clin Med (Lond) 2021; 20:424-429. [PMID: 32675151 DOI: 10.7861/clinmed.2019-0201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Many secondary care departments receive external advice calls. However, systematic advice-call documentation is uncommon and evidence on call nature and burden infrequent. The Liverpool tropical and infectious disease unit (TIDU) provides specialist advice locally, regionally and nationally. We created and evaluated a recording system to document advice calls received by TIDU. METHODS An electronic advice-call recording system was created for TIDU specialist trainees to document complex, predominantly external calls. Fourteen months of advice calls were summarised, analysed and recommendations for other departments wishing to replicate this system made. RESULTS Five-hundred and ninety calls regarding 362 patients were documented. Median patient age was 44 years (interquartile range 29-56 years) and 56% were male. Sixty-nine per cent of patients discussed were referred from secondary healthcare, half from emergency or acute medicine departments; 43% of patients were returning travellers; 59% of returning travellers had undifferentiated fever, one-third of whom returned from sub-Saharan Africa; 32% of patients discussed were further reviewed at TIDU. Interim 6-month review showed good user acceptability of the system. CONCLUSIONS Implementing an advice-call recording system was feasible within TIDU. Call and follow-up burden was high with advice regarding fever in returned travellers predominating. Similar systems could improve clinical governance, patient care and service delivery in other secondary care departments.
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Affiliation(s)
- Tom Wingfield
- Liverpool School of Tropical Medicine, Liverpool, UK, The Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK and Karolinska Institutet, Stockholm, Sweden
| | - Mike Bj Beadsworth
- Liverpool School of Tropical Medicine, Liverpool, UK and The Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Nicholas J Beeching
- Liverpool School of Tropical Medicine, Liverpool, UK and The Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Susan Gould
- The Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Luke Mair
- The Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Emmanuel Nsutebu
- The Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
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Abstract
Abstract
NEW TECHNOLOGIES HAVE FACILITATED DOCTOR–PATIENT EMAIL CONSULTATIONS (E-CONSULTATIONS). GUIDELINES FOR E-CONSULTATION USE IN DENMARK STATE THAT THEY SHOULD BE USED FOR SIMPLE, CONCRETE AND NON-URGENT QUERIES; HOWEVER, A SMALL-SCALE DANISH STUDY SUGGESTED THAT DOCTORS ENCOUNTER E-CONSULTATIONS THAT DO NOT MATCH THE GUIDELINES. THE PURPOSE OF THIS ARTICLE IS TO EXPLORE WHETHER E-CONSULTATIONS IN DENMARK REFLECT RECOMMENDATIONS THAT THEY SHOULD BE SIMPLE, SHORT, CONCRETE AND WELL DEFINED, AND IF NOT, WHAT FORMS OF COMPLEXITY ARE EVIDENT. WE INDUCTIVELY ANALYSED 1,671 E-CONSULTATIONS FROM 38 PATIENTS AGED 21–91 YEARS COMMUNICATING WITH 28 DOCTORS, 6 NURSES, 1 MEDICAL STUDENT AND 8 SECRETARIES. RESULTS SHOWED BOTH QUANTITATIVE COMPLEXITY IN TERMS OF NUMBER OF INTERACTION TURNS, COMMUNICATIVE PARTICIPANTS, AND QUESTIONS ASKED, AND QUALITATIVE COMPLEXITY RELATING TO PATIENTS’ PSYCHOSOCIAL CONTEXTS AND GPS’ BIOMEDICAL DISEASE PERSPECTIVE. THUS, DESPITE EXISTING GUIDELINES AND THE LEANNESS ASSOCIATED WITH THE EMAIL MEDIUM, MULTIPLE FORMS OF COMPLEXITY WERE EVIDENT. THIS MISMATCH HIGHLIGHTS THE NEED FOR THEORETICAL DEVELOPMENT AS WELL AS THE VALUE OF RE-EXAMINING EXISTING POLICIES AND GUIDELINES REGARDING EXPECTATIONS FOR E-CONSULTATION USE.
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Understanding How to Improve the Use of Clinical Coordination Mechanisms between Primary and Secondary Care Doctors: Clues from Catalonia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18063224. [PMID: 33804691 PMCID: PMC8003988 DOI: 10.3390/ijerph18063224] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 03/10/2021] [Accepted: 03/11/2021] [Indexed: 01/27/2023]
Abstract
Clinical coordination between primary (PC) and secondary care (SC) is a challenge for health systems, and clinical coordination mechanisms (CCM) play an important role in the interface between care levels. It is therefore essential to understand the elements that may hinder their use. This study aims to analyze the level of use of CCM, the difficulties and factors associated with their use, and suggestions for improving clinical coordination. A cross-sectional online survey-based study using the questionnaire COORDENA-CAT was conducted with 3308 PC and SC doctors in the Catalan national health system. Descriptive bivariate analysis and logistic regression models were used. Shared Electronic Medical Records were the most frequently used CCM, especially by PC doctors, and the one that presented most difficulties in use, mostly related to technical problems. Some factors positively associated with frequent use of various CCM were: working full-time in integrated areas, or with local hospitals. Interactional and organizational factors contributed to a greater extent among SC doctors. Suggestions for improving clinical coordination were similar between care levels and related mainly to the improvement of CCM. In an era where management tools are shifting towards technology-based CCM, this study can help to design strategies to improve their effectiveness.
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Geissler KH. Differences in referral patterns for rural primary care physicians from 2005 to 2016. Health Serv Res 2019; 55:94-102. [PMID: 31845328 DOI: 10.1111/1475-6773.13244] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To examine differences in referral patterns in a nationally representative sample between primary care physicians (PCP) practicing in rural vs nonrural areas and changes over time. STUDY DESIGN Using the 2005-2016 National Ambulatory Medical Care Survey and multivariate logit regression models, I compare referral patterns of PCPs in rural vs nonrural areas. DATA COLLECTION Multiple years of data were combined. PRINCIPAL FINDINGS A PCP visit was 1.9 percentage points (95% confidence interval: 0.1 pp, 3.8 pp) more likely to result in a referral in nonrural areas than rural areas, controlling for physician and patient characteristics, a 17 percent increase. This difference is driven by a widening gap in referral rates between nonrural and rural areas over time, with large differences in later periods. The regression-adjusted predicted probability of a PCP visit resulting in a referral was 71 percent higher in nonrural than rural areas in 2013-2014 and 92 percent higher in 2015-2016. CONCLUSIONS Recognizing that the optimal PCP referral rate is unknown, referrals are less common in rural areas with a widening gap in recent years. This difference may reflect specialist availability, distance to care, or patient preferences. As changes occur to health care financing and delivery, continuing to monitor practice patterns is important to ensure patients are receiving appropriate levels of care across geographic regions.
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Affiliation(s)
- Kimberley H Geissler
- Department of Health Promotion and Policy, School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, Massachusetts
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Katz N, Roman R, Rados DV, Oliveira EBD, Schmitz CAA, Gonçalves MR, Mengue SS, Umpierre RN. Access and regulation of specialized care in Rio Grande do Sul: the RegulaSUS strategy of TelessaúdeRS-UFRGS. CIENCIA & SAUDE COLETIVA 2019; 25:1389-1400. [PMID: 32267440 DOI: 10.1590/1413-81232020254.28942019] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 10/23/2019] [Indexed: 12/15/2022] Open
Abstract
In Primary Health Care (PHC), access, and integrality are strongly influenced by the coordination of care, which in turn receives a positive impact from the articulation of telehealth actions for teleregulation of care. We created a teleregulation method (RegulaSUS Project) based on specific protocols firmly grounded in scientific evidence. From data of the regulatory system and TelessaúdeRS, we explored the effects of RegulaSUS on PHC and access to specialized care. This method set comprehensive protocols, with a significant mean reduction of 30% in the specialized visits queue over 360 days. It reduced waiting time for medical clinical visits (median of 66 days) but not for surgical appointments. Waiting times for queued cases varied inversely, increasing for clinical and declining for surgical specialties. The use of teleconsultations unrelated to regulation increased with the exposure of professionals to RegulaSUS. The intervention evidence potentiality in the integration of health systems, mainly among low- and middle-income countries, and makes telehealth act as a meta-service, building efficient, qualified, and equitable networks.
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Affiliation(s)
- Natan Katz
- Núcleo Técnico-Científico de Telessaúde, Universidade Federal do Rio Grande do Sul. R. Mostardeiro 366/901, Moinhos de Vento. 90430-000 Porto Alegre RS Brasil.
| | - Rudi Roman
- Núcleo Técnico-Científico de Telessaúde, Universidade Federal do Rio Grande do Sul. R. Mostardeiro 366/901, Moinhos de Vento. 90430-000 Porto Alegre RS Brasil.
| | - Dimitris Varvaki Rados
- Núcleo Técnico-Científico de Telessaúde, Universidade Federal do Rio Grande do Sul. R. Mostardeiro 366/901, Moinhos de Vento. 90430-000 Porto Alegre RS Brasil.
| | - Elise Botteselle de Oliveira
- Núcleo Técnico-Científico de Telessaúde, Universidade Federal do Rio Grande do Sul. R. Mostardeiro 366/901, Moinhos de Vento. 90430-000 Porto Alegre RS Brasil.
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Osman MA, Schick-Makaroff K, Thompson S, Bialy L, Featherstone R, Kurzawa J, Zaidi D, Okpechi I, Habib S, Shojai S, Jindal K, Braam B, Keely E, Liddy C, Manns B, Tonelli M, Hemmelgarn B, Klarenbach S, Bello AK. Barriers and facilitators for implementation of electronic consultations (eConsult) to enhance access to specialist care: a scoping review. BMJ Glob Health 2019; 4:e001629. [PMID: 31565409 PMCID: PMC6747903 DOI: 10.1136/bmjgh-2019-001629] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 08/04/2019] [Accepted: 08/10/2019] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION Electronic consultation (eConsult)-provider-to-provider electronic asynchronous exchanges of patient health information at a distance-is emerging as a potential tool to improve the interface between primary care providers and specialists. Despite growing evidence that eConsult has clinical benefits, it is not widely adopted. We investigated factors influencing the adoption and implementation of eConsult services. METHODS We applied established methods to guide the review, and the recently published Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews to report our findings. We searched five electronic databases and the grey literature for relevant studies. Two reviewers independently screened titles and full texts to identify studies that reported barriers to and/or facilitators of eConsult (asynchronous (store-and-forward) use of telemedicine to exchange patient health information between two providers (primary and secondary) at a distance using secure infrastructure). We extracted data on study characteristics and key barriers and facilitators were analysed thematically and classified using the Quadruple Aim framework taxonomy. No date or language restrictions were applied. RESULTS Among the 2579 publications retrieved, 130 studies met eligibility for the review. We identified and summarised key barriers to and facilitators of eConsult adoption and implementation across four domains: provider, patient, healthcare system and cost. Key barriers were increased workload for providers, privacy concerns and insufficient reimbursement for providers. Main facilitators were remote residence location, timely responses from specialists, utilisation of referral coordinators, addressing medicolegal concerns and incentives for providers to use eConsult. CONCLUSION There are multiple barriers to and facilitators of eConsult adoption across the domains of Quadruple Aim framework. Our findings will inform the development of practice tools to support the wider adoption and scalability of eConsult implementation.
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Affiliation(s)
- Mohamed A Osman
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Stephanie Thompson
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Liza Bialy
- Alberta Research Centre for Health Evidence, University of Alberta, Edmonton, Alberta, Canada
- Alberta SPOR SUPPORT Unit, Knowledge Translation platform, Edmonton, Alberta, Canada
| | - Robin Featherstone
- Alberta Research Centre for Health Evidence, University of Alberta, Edmonton, Alberta, Canada
- Alberta SPOR SUPPORT Unit, Knowledge Translation platform, Edmonton, Alberta, Canada
| | - Julia Kurzawa
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Deenaz Zaidi
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Ikechi Okpechi
- Division of Nephrology and Hypertension, University of Cape Town, Cape Town, South Africa
| | - Syed Habib
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Soroush Shojai
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Kailash Jindal
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Branko Braam
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Erin Keely
- Departments of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Division of Endocrinology/Metabolism, The Ottawa Hospital, Ottawa, Ontario, Canada
- Ottawa Research Institute, Ottawa, Ontario, Canada
| | - Clare Liddy
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
- CT Lamont Primary Healthcare Research Centre, Bruyere Research Institute, Ottawa, Ontario, Canada
| | - Braden Manns
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Marcello Tonelli
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Brenda Hemmelgarn
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Scott Klarenbach
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Aminu K Bello
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Maier MM, Gylys-Colwell I, Lowy E, Van Epps P, Ohl M, Chartier M, Beste LA. Health Care Facility Characteristics are Associated with Variation in Human Immunodeficiency Virus Pre-exposure Prophylaxis Initiation in Veteran's Health Administration. AIDS Behav 2019; 23:1803-1811. [PMID: 30547331 DOI: 10.1007/s10461-018-2360-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
To quantify health care facility-level variation in pre-exposure prophylaxis (PrEP) use in the Veteran's Health Administration (VHA); to identify facility characteristics associated with PrEP use. Retrospective analysis of the health care facility-level rate of PrEP initiation in VHA through June 30, 2017. Standardized PrEP initiation rates were used to rank facilities. Characteristics of facilities, prescribers, and PrEP recipients were examined within quartiles. Multiple linear regression was used to identify associations between facility characteristics and PrEP use. We identified 1600 PrEP recipients. Mean PrEP initiation rate was 20.0/100,000 (SD 22.8), ranging from 3.0/100,000 (SD 2.0) in the lowest quartile to 48.1/100,000 (SD 29.1) in the highest. PrEP prescribing was positively associated with proportions of urban dwellers and individuals < 45, tertiary care status, and location. Variability in PrEP uptake across a national health care system highlights opportunities to expand access in non-tertiary care facilities and underserved areas.
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Affiliation(s)
- Marissa M Maier
- VA Portland Health Care System, Infectious Diseases, 3710 SW US Veterans Hospital Road, VA P3ID, Portland, OR, 97239, USA.
- HIV, Hepatitis, and Related Conditions Programs, Office of Specialty Care Services, Veterans Health Administration, Washington, DC, USA.
- Division of Infectious Diseases, Oregon Health and Science University, Portland, OR, USA.
| | - Ina Gylys-Colwell
- VA Puget Sound Health Care System, Health Services Research and Development, Seattle, WA, USA
| | - Elliott Lowy
- VA Puget Sound Health Care System, Health Services Research and Development, Seattle, WA, USA
- School of Public Health, University of Washington, Seattle, WA, USA
| | - Puja Van Epps
- Geriatric Research Education and Clinical Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA
- Division of Infectious Disease, Case Western School of Medicine, Cleveland, OH, USA
| | - Michael Ohl
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
- Center for Access and Delivery Research and Evaluation (CADRE) at the Iowa City, Iowa City, IA, USA
| | - Maggie Chartier
- HIV, Hepatitis, and Related Conditions Programs, Office of Specialty Care Services, Veterans Health Administration, Washington, DC, USA
| | - Lauren A Beste
- VA Puget Sound Health Care System, Health Services Research and Development, Seattle, WA, USA
- VA Puget Sound Health Care System, General Medicine Service, Seattle, WA, USA
- Division of General Internal Medicine, University of Washington, Seattle, WA, USA
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13
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Liddy C, Moroz I, Keely E, Taljaard M, Deri Armstrong C, Afkham A, Kendall CE. Understanding the impact of a multispecialty electronic consultation service on family physician referral rates to specialists: a randomized controlled trial using health administrative data. Trials 2019; 20:348. [PMID: 31182123 PMCID: PMC6558850 DOI: 10.1186/s13063-019-3393-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 05/04/2019] [Indexed: 12/03/2022] Open
Abstract
Background Electronic consultation (eConsult) services are secure online applications facilitating provider-to-provider communication. They have been found to improve access to specialist care. However, little is known about eConsult’s impact on family physicians’ referral rates to specialty care. The objective of this study was to assess the impact of a multispecialty eConsult service on referral rates from primary care. Methods In this parallel-arm, randomized controlled trial, we recruited primary care providers across Ontario not previously enrolled with eConsult. We randomly assigned participants to intervention and control arms. Participants in the intervention arm received access to eConsult for a period of 1 year while those in the control arm received no access to eConsult. The main outcome was specialist referral rate, expressed as the total number of referrals to (1) specialties available through eConsult, and (2) all medical specialties, per 100 patients seen. Multivariable negative binomial regression analysis was used to evaluate the effect of the intervention before and after adjusting for provider characteristics, using health administrative data. Results One hundred and thirteen participants were randomized (56 to control and 57 to intervention). For the primary outcome (referrals to eConsult specialties), the results show a statistically significant reduction in the number of referrals in both arms (control-arm Rate Ratio (RR), 0.85, 95% CI 0.79 to 0.91; intervention-arm RR, 0.80, 95% CI 0.74 to 0.85; unadjusted and adjusted RR values almost identical), as compared to the baseline data collected during the 12-month period before randomization, with a non-statistically significant 6% greater reduction in referrals in the intervention arm, compared to the control arm (unadjusted RR 0.94, 95% CI 0.85 to 1.03; adjusted RR 0.93, 95% CI 0.85 to 1.03). Conclusions Our randomized controlled trial of a multispecialty eConsult service demonstrated inconclusive results in terms of the impact of eConsult on physician referral rates. Findings are discussed in light of important limitations associated with conducting randomized controlled trials (RCTs) of complex interventions in the primary care context with intent to inform the design and analysis of future trials. Trial registration Clinicaltrials.gov, ID: NCT02053467. Registered prospectively on 3 February 2014.
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Affiliation(s)
- Clare Liddy
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, 43 Bruyère St. Annex E, Room 106, Ottawa, ON, K1N 5C8, Canada. .,Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada.
| | - Isabella Moroz
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, 43 Bruyère St. Annex E, Room 106, Ottawa, ON, K1N 5C8, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Erin Keely
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Division of Endocrinology/Metabolism, The Ottawa Hospital, Ottawa, ON, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Amir Afkham
- Champlain Local Health Integration Network, Ottawa, ON, Canada
| | - Claire E Kendall
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, 43 Bruyère St. Annex E, Room 106, Ottawa, ON, K1N 5C8, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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14
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Cordasco KM, Frayne SM, Kansagara D, Zulman DM, Asch SM, Burke RE, Post EP, Fihn SD, Klobucar T, Meyer LJ, Kirsh SR, Atkins D. Coordinating Care Across VA Providers and Settings: Policy and Research Recommendations from VA's State of the Art Conference. J Gen Intern Med 2019; 34:11-17. [PMID: 31098966 PMCID: PMC6542870 DOI: 10.1007/s11606-019-04970-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Delivering well-coordinated care is essential for optimizing clinical outcomes, enhancing patient care experiences, minimizing costs, and increasing provider satisfaction. The Veterans Health Administration (VA) has built a strong foundation for internally coordinating care. However, VA faces mounting internal care coordination challenges due to growth in the number of Veterans using VA care, high complexity in Veterans' care needs, the breadth and depth of VA services, and increasing use of virtual care. VA's Health Services Research and Development service with the Office of Research and Development held a conference assessing the state-of-the-art (SOTA) on care coordination. One workgroup within the SOTA focused on coordination between VA providers for high-need Veterans, including (1) Veterans with multiple chronic conditions; (2) Veterans with high-intensity, focused, specialty care needs; (3) Veterans experiencing care transitions; (4) Veterans with severe mental illness; (5) and Veterans with homelessness and/or substance use disorders. We report on this workgroup's recommendations for policy and organizational initiatives and identify questions for further research. Recommendations from a separate workgroup on coordinating VA and non-VA care are contained in a companion paper. Leaders from research, clinical services, and VA policy will need to partner closely as they develop, implement, assess, and spread effective practices if VA is to fully realize its potential for delivering highly coordinated care to every Veteran.
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Affiliation(s)
- Kristina M Cordasco
- VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation, and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA. .,Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA. .,Department of Medicine, University of California Los Angeles (UCLA) Geffen School of Medicine, Los Angeles, CA, USA.
| | - Susan M Frayne
- VA HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, USA.,Women's Health Section, VA Palo Alto Health Care System, Palo Alto, CA, USA.,Division of Primary Care and Population Health, Stanford University, Stanford, CA, USA
| | - Devan Kansagara
- VA Portland Healthcare System, Portland, OR, USA.,Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Donna M Zulman
- Women's Health Section, VA Palo Alto Health Care System, Palo Alto, CA, USA.,VA Portland Healthcare System, Portland, OR, USA
| | - Steven M Asch
- Women's Health Section, VA Palo Alto Health Care System, Palo Alto, CA, USA.,VA Portland Healthcare System, Portland, OR, USA
| | - Robert E Burke
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA.,Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Edward P Post
- VA Center for Clinical Management Research, Ann Arbor, MI, USA.,University of Michigan Medical School, Ann Arbor, MI, USA
| | - Stephan D Fihn
- VA Office of Clinical System Development and Evaluation, Seattle, WA, USA.,VA Puget Sound Health Care System, Seattle, WA, USA.,Department of Health Services and Department of Medicine, University of Washington, Seattle, WA, USA
| | | | - Laurence J Meyer
- VA Office of Specialty Care Services, Washington, DC, USA.,VA Salt Lake City Health Care System, Salt Lake City, UT, USA.,University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Susan R Kirsh
- Office of Veterans Access to Care, Washington, DC, USA.,Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA.,Department of Medicine, School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - David Atkins
- VA Office of Research and Development, Health Services Research and Development, Washington, DC, USA
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15
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Afable MK, Gupte G, Simon SR, Shanahan J, Vimalananda V, Kim EJ, Strymish J, Orlander JD. Innovative Use Of Electronic Consultations In Preoperative Anesthesiology Evaluation At VA Medical Centers In New England. Health Aff (Millwood) 2019; 37:275-282. [PMID: 29401018 DOI: 10.1377/hlthaff.2017.1087] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Electronic consultations (e-consults) improve access to specialty care without requiring face-to-face patient visits. We conducted a mixed-methods descriptive study to understand the variability in e-consult use across anesthesiology departments in the Veterans Affairs New England Healthcare System (VANEHS). In the period 2012-15, the system experienced a rapid increase in the use of anesthesiology e-consults: 5,023 were sent in 2015, compared with 103 in 2012. Uptake across sites varied from near-universal use of e-consults for preoperative assessment to use for only selected low-risk patients or no use. Interviews with stakeholders revealed considerable differences in the perceived impact of e-consults on workflow and patient-centeredness. Clinicians at sites with high use of e-consults noted that they improved workflow efficiency. In comparison, clinicians at sites with low use preferentially valued face-to-face visits for some or all patients. The adoption of a health information technology innovation can alter the process of care delivery, depending on perceptions of its value by key stakeholders.
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Affiliation(s)
- Melissa K Afable
- Melissa K. Afable ( ) is a project manager in the Department of Quality, Safety, and Value at Partners HealthCare System, in Boston, Massachusetts. When this work was conducted, she was a project manager for health policy, law, and management at Boston University School of Public Health and at the Center for Healthcare Organization and Implementation Research, Veterans Affairs (VA) Boston Healthcare System, in Boston
| | - Gouri Gupte
- Gouri Gupte is an assistant professor of health policy, law, and management at Boston University School of Public Health and director of performance improvement at Cambridge Health Alliance, in Massachusetts
| | - Steven R Simon
- Steven R. Simon is an associate professor of medicine at Harvard Medical School and Brigham and Women's Hospital and chief of the Geriatrics and Extended Care Service, VA Boston Healthcare System
| | - Jessica Shanahan
- Jessica Shanahan is an anesthesiologist in the Department of Anesthesia, VA Boston Healthcare System
| | - Varsha Vimalananda
- Varsha Vimalananda is an assistant professor in the Section of Endocrinology, Diabetes, and Metabolism, Boston University School of Medicine, and a research health scientist at the Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Medical Center, in Bedford, Massachusetts
| | - Eun Ji Kim
- Eun Ji Kim is an assistant professor of medicine at Zucker School of Medicine at Hofstra/Northwell in Manhasset, New York. When this work was conducted, she was a fellow in the Section of General Internal Medicine, Boston University School of Medicine
| | - Judith Strymish
- Judith Strymish is an assistant professor of infectious diseases at Harvard Medical School and the VA Boston Healthcare System
| | - Jay D Orlander
- Jay D. Orlander is a professor of medicine, Section of General Medicine, at Boston University School of Medicine and associate chief of Medical Service, VA Boston Healthcare System
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16
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Liddy C, Moroz I, Keely E, Taljaard M, Mark Fraser A, Deri Armstrong C, Afkham A, Kendall C. The use of electronic consultations is associated with lower specialist referral rates: a cross-sectional study using population-based health administrative data. Fam Pract 2018; 35:698-705. [PMID: 29635449 DOI: 10.1093/fampra/cmy020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The referral-consultation process can be difficult to navigate. Electronic consultations (eConsults) can help streamline referrals by facilitating inter-provider communication. OBJECTIVE We evaluated the potential effect of eConsult on specialist referral rates in Ontario among family physicians providing comprehensive care. METHODS We conducted a retrospective 1:3 matched cohort study examining total referrals and referrals to all available medical specialties from primary care providers between 1 April 2014 and 31 March 2015. We used multivariable random effects Poisson regression analysis to compare referral rates between eConsult and non-eConsult users while adjusting for relevant patient and provider characteristics. Referral rates were expressed per physician, per 100 patients and per 100 patient encounters. RESULTS There were 113197 referrals across all medical specialties made by 119 eConsult physicians and 352 matched controls. Referral rates per physician were significantly lower in the eConsult group for all specialty groupings [unadjusted rate ratio (RR) = 0.87, 95% confidence interval (CI) = 0.80-0.95; adjusted RR = 0.92, 95% CI = 0.85-1.00]. Referral rates per patient were lower among eConsult physicians (unadjusted RR = 0.91, 95% CI = 0.84-0.98) but this difference was not statistically significant after adjustment (adjusted RR = 0.96, 95% CI = 0.90-1.02). No statistically significant difference was observed when referrals were expressed per 100 patient encounters. CONCLUSION This is the first Canadian study to examine the potential effect of eConsult on overall referrals at a population level. Our findings demonstrate that using eConsult service is associated with fewer referrals from primary to specialist care, with considerable potential for cost savings to our single-payer system.
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Affiliation(s)
- Clare Liddy
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, Canada
| | - Isabella Moroz
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Erin Keely
- Department of Medicine, University of Ottawa, Ottawa, Canada.,Division of Endocrinology/Metabolism, The Ottawa Hospital, Ottawa, Canada
| | - Monica Taljaard
- Ottawa Hospital Research Institute, Ottawa, Canada.,School of Epidemiology, Public Health, and Preventive Medicine, University of Ottawa, Ottawa, Canada
| | - Amy Mark Fraser
- Ottawa Hospital Research Institute, Ottawa, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Canada
| | | | - Amir Afkham
- Enabling Technologies, Champlain Local Health Integration Network, Ottawa, Canada
| | - Claire Kendall
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, Canada
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17
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Tuot DS, Liddy C, Vimalananda VG, Pecina J, Murphy EJ, Keely E, Simon SR, North F, Orlander JD, Chen AH. Evaluating diverse electronic consultation programs with a common framework. BMC Health Serv Res 2018; 18:814. [PMID: 30355346 PMCID: PMC6201558 DOI: 10.1186/s12913-018-3626-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 10/15/2018] [Indexed: 11/17/2022] Open
Abstract
Background Electronic consultation is an emerging mode of specialty care delivery that allows primary care providers and their patients to obtain specialist expertise without an in-person visit. While studies of individual programs have demonstrated benefits related to timely access to specialty care, electronic consultation programs have not achieved widespread use in the United States. The lack of common evaluation metrics across health systems and concerns related to the generalizability of existing evaluation efforts may be hampering further growth. We sought to identify gaps in knowledge related to the implementation of electronic consultation programs and develop a set of shared evaluation measures to promote further diffusion. Methods Using a case study approach, we apply the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) and the Quadruple Aim frameworks of evaluation to examine electronic consultation implementation across diverse delivery systems. Data are from 4 early adopter healthcare delivery systems (San Francisco Health Network, Mayo Clinic, Veterans Administration, Champlain Local Health Integration Network) that represent varied organizational structures, care for different patient populations, and have well-established multi-specialty electronic consultation programs. Data sources include published and unpublished quantitative data from each electronic consultation database and qualitative data from systems’ end-users. Results Organizational drivers of electronic consultation implementation were similar across the systems (challenges with timely and/or efficient access to specialty care), though unique system-level facilitators and barriers influenced reach, adoption and design. Effectiveness of implementation was consistent, with improved patient access to timely, perceived high-quality specialty expertise with few negative consequences, garnering high satisfaction among end-users. Data about patient-specific clinical outcomes are lacking, as are policies that provide guidance on the legal implications of electronic consultation and ideal remuneration strategies. Conclusion A core set of effectiveness and implementation metrics rooted in the Quadruple Aim may promote data-driven improvements and further diffusion of successful electronic consultation programs. Electronic supplementary material The online version of this article (10.1186/s12913-018-3626-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Delphine S Tuot
- Center for Innovation in Access and Quality at Priscilla Chan and Mark Zuckerberg San Francisco General Hospital and Trauma Center, University of California San Francisco, San Francisco, CA, 94110, USA. .,Deparment of Medicine, University of California, San Francisco, San Francisco, CA, USA.
| | - Clare Liddy
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Varsha G Vimalananda
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Medical Center, Bedford, MA, USA.,Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Jennifer Pecina
- Department of Family Medicine, Mayo Clinic, Rochester, MN, USA
| | - Elizabeth J Murphy
- Center for Innovation in Access and Quality at Priscilla Chan and Mark Zuckerberg San Francisco General Hospital and Trauma Center, University of California San Francisco, San Francisco, CA, 94110, USA.,Deparment of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Erin Keely
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,The Ottawa Hospital, Ottawa, ON, Canada
| | - Steven R Simon
- Harvard Medical School, Boston, USA.,VA Boston Healthcare System, Boston, USA
| | - Frederick North
- Department of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jay D Orlander
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA.,VA Boston Healthcare System, Boston, USA
| | - Alice Hm Chen
- Center for Innovation in Access and Quality at Priscilla Chan and Mark Zuckerberg San Francisco General Hospital and Trauma Center, University of California San Francisco, San Francisco, CA, 94110, USA.,Deparment of Medicine, University of California, San Francisco, San Francisco, CA, USA
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18
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Venkatesh RD, Campbell EJ, Thiim M, Rao SK, Ferris TG, Wasfy JH, Richter JM. e-Consults in gastroenterology: An opportunity for innovative care. J Telemed Telecare 2018; 25:499-505. [DOI: 10.1177/1357633x18781189] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background and aim Deploy and evaluate a gastroenterology (GI) electronic consultation (e-consult) program. E-consults are a promising approach to enhance provider communication, facilitate timely specialty advice and may replace some outpatient visits. Study As part of our health system’s efforts to provide more cost-effective care under risk-based contracts, we implemented an e-consult program where referring providers submit patient-specific clinical questions electronically via an electronic referral system. A GI consultant then reviews the patient’s record and provides a written recommendation back to the referring physician. For our program evaluation, we conducted chart reviews of each e-consult to understand how the program was being used and surveyed the participating providers and consultants. Results From September 2015 to March 2016, we received 144 e-consults, with most questions concerning GI symptoms or abnormal hepatology labs. Only 36% of e-consults recommended an in-person GI consult or procedure. In our survey of participating providers, referring providers strongly agreed that the GI e-consults promoted good patient care (88%) and were satisfied with the program (84%). The majority of GI consultants felt strongly that e-consults were useful for referring providers and their patients, but that current reimbursement and time allotted were not adequate. Conclusions We report on the implementation of a GI e-consult program within an ACO, showing that many clinical questions could be answered using this mechanism. E-consults in gastroenterology have the potential to reduce unnecessary visits and/or procedures for patients who can be managed by their primary provider, potentially increasing access for other patients.
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Affiliation(s)
- Rajitha D Venkatesh
- Duke Pediatric GI & Nutrition, Duke University Medical Center, Durham, NC, USA
| | - Emily J Campbell
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | - Michael Thiim
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Sandhya K Rao
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Timothy G Ferris
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jason H Wasfy
- Harvard Medical School, Boston, MA, USA
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
| | - James M Richter
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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19
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Dodick D, Edvinsson L, Makino T, Grisold W, Sakai F, Jensen R, Balch A, Ruiz de la Torre E, Henscheid-Lorenz D, Craven A, Ashina M. Vancouver Declaration on Global Headache Patient Advocacy 2018. Cephalalgia 2018; 38:1899-1909. [PMID: 29882695 DOI: 10.1177/0333102418781644] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Headache disorders comprise the three most prevalent medical disorders globally and contribute almost 20% to the total burden of neurologic illness. Although the experience of a recurrent headache disorder tends to be highly individualized, patient preferences tend to be a low priority in guidelines for the management of patients with headache. METHODS In September 2017, the first Global Patient Advocacy Summit was convened, bringing together patients, patient advocates, patient advocacy organizations, healthcare professionals, pharmaceutical manufacturers, scientists, and regulatory agencies to advance issues of importance to patients affected by headache worldwide. RESULTS Presentations and discussion covered multiple issues, such as improving access to appropriate medical care; incorporating the insights of independent patient advocates and advocacy organizations; leveraging the insights, experience and influence of leading health and neurological organizations; and raising awareness of the role of regulatory agencies in disease advocacy. Attendees agreed that it is important to understand and promote the global, regional, and local interests of people with headache disorders, as well as challenge the pervasive stigma associated with headache. They also agreed that those with severe, recurrent, or disabling headache disorders should have reliable access to competent medical care; healthcare professionals should have access to adequate training in Headache Medicine; global benchmarks should be established for accurate diagnosis and the use of evidence-based treatments in patients with headache; and that information is needed about consultation, diagnosis, and treatment of headache, particularly in regard to patient preferences. CONCLUSION Based on the group's consensus around these issues, a series of statements was developed, and they are collectively presented herein as the Vancouver Declaration on Global Headache Patient Advocacy 2018.
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Affiliation(s)
| | | | - Tomohiko Makino
- 3 World Health Organization, Regional Office for the Western Pacific, Manila, Philippines
| | | | | | - Rigmor Jensen
- 6 Danish Headache Center, University of Copenhagen, Rigshopitalet, Glostrup, Denmark
| | - Alan Balch
- 7 Patient Advocate Foundation, Hampton, VA, USA
| | | | | | | | - Messoud Ashina
- 6 Danish Headache Center, University of Copenhagen, Rigshopitalet, Glostrup, Denmark
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20
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Barnett ML, Yee HF, Mehrotra A, Giboney P. Los Angeles Safety-Net Program eConsult System Was Rapidly Adopted And Decreased Wait Times To See Specialists. Health Aff (Millwood) 2018; 36:492-499. [PMID: 28264951 DOI: 10.1377/hlthaff.2016.1283] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Lack of timely access to specialty care is a significant problem among disadvantaged populations, such as those served by the Los Angeles County Department of Health Services. In 2012 the department implemented an electronic system for the provision of specialty care called the eConsult system, in which all requests from primary care providers for specialty assistance were reviewed by specialists. In many cases, the specialist can address the primary care provider's question via an electronic dialogue, thereby eliminating the need for the patient to see a specialist in person. We observed rapid growth in the use of eConsult: By 2015 the system was in use by over 3,000 primary care providers, and 12,082 consultations were taking place per month, compared to 86 in the third quarter of 2012. The median time to an electronic response from a specialist was one day, and 25 percent of eConsults were resolved without a specialist visit. Three to four years after implementation, the median time to a specialist appointment decreased significantly, while the volume of visits remained stable. eConsult systems are a promising and sustainable intervention that could improve access to specialist care for underserved patients.
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Affiliation(s)
- Michael L Barnett
- Michael L. Barnett is an assistant professor of health policy and management at the Harvard T. H. Chan School of Public Health and an instructor in the Division of General Medicine and Primary Care at Brigham and Women's Hospital, both in Boston, Massachusetts
| | - Hal F Yee
- Hal F. Yee Jr. is chief medical officer at the Los Angeles County Department of Health Services, in Los Angeles, California
| | - Ateev Mehrotra
- Ateev Mehrotra is an associate professor of health care policy at Harvard Medical School, in Boston
| | - Paul Giboney
- Paul Giboney is director of specialty care at the Los Angeles County Department of Health Services
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21
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Koenig CJ, Wenger M, Graham GD, Asch S, Rongey C. Managing professional knowledge boundaries during ECHO telementoring consultations in two Veterans Affairs specialty care liver clinics: A theme-oriented discourse analysis. J Telemed Telecare 2018. [PMID: 29514547 DOI: 10.1177/1357633x18756454] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Consultations are the traditional method of communication between generalist and specialist providers managing patients with specialty care needs. Traditional written consultations have limitations, including inadequate clinical information and inappropriate, or unclear consultation questions. Teleconsultations minimize these limitations through real-time communication between generalist and specialist providers to actively manage professional knowledge boundaries about specialty care problems. METHODS We video-recorded 37 teleconsultation sessions, resulting in 115 consultations between generalist and specialty care providers participating in Veterans Affairs (VA) Extension for Community Healthcare Outcomes (ECHO) liver clinics. Data were collected at two US sites across nine months to observe consultation communication among 33 primary care generalists and three liver specialists. Video recordings were transcribed verbatim and analysed using theme-oriented discourse analysis to characterize consultation question content and format. RESULTS Generalists' consultation question content addressed a range of topics, including treatment, diagnosis, interpreting results, patient communication, screening and surveillance, and care coordination. Some generalists relied on descriptive narratives rather than a specific question to convey complex patient cases. Consultation question format showed nearly even division between targeting general medical knowledge and specialty care knowledge domains, including specialty care, medical, organizational, and experiential knowledge. DISCUSSION Timely access to specialists through teleconsultation has the potential to transform specialty care delivery. This article examines provider-to-provider interactions to understand how the communication process contributes to knowledge management during teleconsultations. Video studies of health information technology use provide a rich opportunity for analysing real-time communication that may help improve cross-specialty collaboration and the coordinated management of patients with specialty care needs.
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Affiliation(s)
- Christopher J Koenig
- 1 San Francisco State University, San Francisco, CA, USA.,2 Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, USA.,3 San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
| | - Matthew Wenger
- 3 San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
| | - Glenn D Graham
- 3 San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA.,4 Specialty Care Services, VA Central Office, Washington, DC, USA
| | - Steven Asch
- 2 Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, USA.,5 Division of General Medical Disciplines, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Catherine Rongey
- 6 University of California, San Francisco, San Francisco, CA, USA.,7 Kaiser Permanente, Vallejo, CA, USA
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22
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Der-Martirosian C, Griffin AR, Chu K, Dobalian A. Telehealth at the US Department of Veterans Affairs after Hurricane Sandy. J Telemed Telecare 2018; 25:310-317. [PMID: 29384428 DOI: 10.1177/1357633x17751005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Like other integrated health systems, the US Department of Veterans Affairs has widely implemented telehealth during the past decade to improve access to care for its patient population. During major crises, the US Department of Veterans Affairs has the potential to transition healthcare delivery from traditional care to telecare. This paper identifies the types of Veterans Affairs telehealth services used during Hurricane Sandy (2012), and examines the patient characteristics of those users. METHODS This study conducted both quantitative and qualitative analyses. Veterans Affairs administrative and clinical data files were used to illustrate the use of telehealth services 12 months pre- and 12 months post- Hurricane Sandy. In-person interviews with 31 key informants at the Manhattan Veterans Affairs Medical Center three-months post- Hurricane Sandy were used to identify major themes related to telecare. RESULTS During the seven-month period of hospital closure at the Manhattan Veterans Affairs Medical Center after Hurricane Sandy, in-person patient visits decreased dramatically while telehealth visits increased substantially, suggesting that telecare was used in lieu of in-person care for some vulnerable patients. The most commonly used types of Veterans Affairs telehealth services included primary care, triage, mental health, home health, and ancillary services. Using qualitative analyses, three themes emerged from the interviews regarding the use of Veterans Affairs telecare post- Hurricane Sandy: patient safety, provision of telecare, and patient outreach. CONCLUSION Telehealth offers the potential to improve post-disaster access to and coordination of care. More information is needed to better understand how telehealth can change the processes and outcomes during disasters. Future studies should also evaluate key elements, such as adequate resources, regulatory and technology issues, workflow integration, provider resistance, diagnostic fidelity and confidentiality, all of which are critical to telehealth success during disasters and other crises.
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Affiliation(s)
| | - Anne R Griffin
- 1 Veterans Emergency Management Evaluation Center, US Department of Veterans Affairs, USA
| | - Karen Chu
- 1 Veterans Emergency Management Evaluation Center, US Department of Veterans Affairs, USA
| | - Aram Dobalian
- 1 Veterans Emergency Management Evaluation Center, US Department of Veterans Affairs, USA.,2 Division of Health Systems Management and Policy, University of Memphis, USA
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23
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Young JP, Achtmeyer CE, Bensley KM, Hawkins EJ, Williams EC. Differences in Perceptions of and Practices Regarding Treatment of Alcohol Use Disorders Among VA Primary Care Providers in Urban and Rural Clinics. J Rural Health 2018; 34:359-368. [PMID: 29363176 DOI: 10.1111/jrh.12293] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 11/13/2017] [Accepted: 12/12/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Effective behavioral and pharmacological treatments are available and recommended for patients with alcohol use disorders (AUD) but rarely received. Barriers to receipt and provision of evidence-based AUD treatments delivered by specialists may be greatest in rural areas. METHODS A targeted subanalysis of qualitative interview data collected from primary care providers at 5 Veterans Affairs clinics was conducted to identify differences in provider perceptions and practices regarding AUD treatment across urban and rural clinics. Key contacts were used to recruit 24 providers from 3 "urban" clinics at medical centers and 2 "rural" community-based outpatient clinics. Providers completed 30-minute semistructured interviews, which were recorded, transcribed, and analyzed using inductive content analysis. RESULTS Thirteen urban and 11 rural providers participated. Urban and rural providers differed regarding referral practices and in perceptions of availability and utility of specialty addictions treatment. Urban providers described referral to specialty treatment as standard practice, while rural providers reported substantial barriers to specialty care access and infrequent specialty care referral. Urban providers viewed specialty addictions treatment as accessible and comprehensive, and perceived addictions providers as "experts" and collaborators, whereas rural providers perceived inadequate support from the health care system for AUD treatment. Urban providers desired greater integration with specialty addictions care while rural providers wanted access to local addictions treatment resources. CONCLUSIONS Providers in rural settings view referral to specialty addictions treatment as impractical and resources inadequate to treat AUD. Additional work is needed to understand the unique needs of rural clinics and decrease barriers to AUD treatment.
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Affiliation(s)
- Jessica P Young
- Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, Washington
| | - Carol E Achtmeyer
- Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, Washington.,Primary and Specialty Medical Care Service, VA Puget Sound Health Care System - Seattle Division, Seattle, Washington
| | - Kara M Bensley
- Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, Washington.,Department of Health Services, University of Washington, Seattle, Washington
| | - Eric J Hawkins
- Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, Washington.,Center of Excellence in Substance Abuse Treatment and Education, VA Puget Sound Health Care System - Seattle Division, Seattle, Washington.,Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington
| | - Emily C Williams
- Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, Washington.,Department of Health Services, University of Washington, Seattle, Washington
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24
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Development of a Sleep Telementorship Program for Rural Department of Veterans Affairs Primary Care Providers: Sleep Veterans Affairs Extension for Community Healthcare Outcomes. Ann Am Thorac Soc 2018; 14:267-274. [PMID: 27977293 DOI: 10.1513/annalsats.201605-361bc] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Primary care providers (PCPs) frequently encounter sleep complaints, especially in regions with limited specialty care access. OBJECTIVES The U.S. Department of Veterans Affairs Extension for Community Healthcare Outcomes (VA-ECHO) program (based on Project ECHO) has successfully provided rural PCP education in subspecialty areas, including hepatitis C. We describe the feasibility of an ECHO program for sleep medicine. METHODS ECHO creates a virtual learning community through video-teleconferencing, combining didactics with individualized clinical case review. We invited multidisciplinary providers to attend up to 10 stand-alone, 1-hour sessions. Invitees completed a needs assessment, which guided curriculum development. After program completion, we examined participant characteristics and self-reported changes in practice and comfort with managing sleep complaints. We surveyed participation barriers among invitees with low/no attendance. MEASUREMENTS AND MAIN RESULTS Of the 39 program participants, 38% worked in rural healthcare. Participants included nurse practitioners (26%), registered nurses (21%), and physicians (15%). Seventeen (44%) completed the summative program evaluation. Respondents anticipated practice change from the program, especially in patient education about sleep disorders (93% of respondents). Respondents reported improved comfort managing sleep complaints, especially sleep-disordered breathing, insomnia, and sleep in post-traumatic stress disorder (80% of respondents each). A follow-up survey of program invitees who attended zero to two sessions reported scheduling conflicts (62%) and lack of protected time (52%) as major participation barriers. CONCLUSIONS Participants in a pilot sleep medicine VA-ECHO program report practice change and increased comfort managing common sleep complaints. Future work is needed to identify objective measures of return on investment and address participation barriers.
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25
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Mann R, van de Weijer PHM. Adopting innovation in gynaecology: The introduction of e-consult. Aust N Z J Obstet Gynaecol 2018; 58:449-453. [PMID: 29327350 DOI: 10.1111/ajo.12764] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 11/29/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To describe the development of an e-consultation service as part of the triaging and grading process of referrals and to report on the efficacy and safety of such a service. METHODS All gynaecology e-consults in the study period June 2015 to March 2016 were retrospectively reviewed. The outcomes of interest were the initial reduction in first face-to-face hospital visits, and the rate of re-referrals. Acute admission for the same reason, a subsequent diagnosis of underlying (pre)-malignancy, or patient death from the condition related to the index referral were selected as measures for patient safety. RESULTS Seven thousand and forty-two (7042) referrals were made to the gynaecology service in the 10 month study period. After exclusion of referrals to colposcopy and the early pregnancy clinic, 4738 e-referrals remained. Of these, 1013 referrals (21.4%) were triaged for an e-consult. One hundred and forty-seven patients (14.5%) with an initial e-consult were re-referred within 6 months for the same condition. The reduction in face-to-face contacts was 18.2% (866/4738). No death and/or acute admission for the same reason as stated in the initial referral occurred among the patients with e-consultation and none were later diagnosed with an underlying (pre)-malignancy. CONCLUSION E-consultation was effective at reducing the number of first outpatient face-to-face contacts without notable compromise of the quality of care or patient safety. E-consultation allows specialists to provide expert clinical guidance, management and support to the referring provider when appropriate. Topics for further study include patient benefits and satisfaction, and further assessment of the social, economic and financial impacts on all parties involved.
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Affiliation(s)
- Rebecca Mann
- Department of Obstetrics & Gynaecology, Waitemata District Health Board, Auckland, New Zealand
| | - Peter H M van de Weijer
- Head of Division Child & Women and Family Services, Waitemata District Health Board, Auckland, New Zealand
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26
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Fort MP, Namba LM, Dutcher S, Copeland T, Bermingham N, Fellenz C, Lantz D, Reusch JJ, Bayliss EA. Implementation and Evaluation of the Safety Net Specialty Care Program in the Denver Metropolitan Area. Perm J 2017; 21:16-022. [PMID: 28241908 DOI: 10.7812/tpp/16-022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES In response to limited access to specialty care in safety-net settings, an integrated delivery system and three safety-net organizations in the Denver, CO, metropolitan area launched a unique program in 2013. The program offers safety-net providers the option to electronically consult with specialists. Uninsured patients may be seen by specialists in office visits for a defined set of services. This article describes the program, identifies aspects that have worked well and areas that need improvement, and offers lessons learned. METHODS We quantified electronic consultations (e-consults) between safety-net clinicians and specialists, and face-to-face specialist visits between May 2013 and December 2014. We reviewed and categorized all e-consults from November and December 2014. In 2015, we interviewed 21 safety-net clinicians and staff, 12 specialists, and 10 patients, and conducted a thematic analysis to determine factors facilitating and limiting optimal program use. RESULTS In the first 20 months of the program, safety-net clinicians at 23 clinics made 602 e-consults to specialists, and 81 patients received face-to-face specialist visits. Of 204 primary care clinicians, 103 made e-consults; 65 specialists participated in the program. Aspects facilitating program use were referral case managers' involvement and the use of clear, concise questions in e-consults. Key recommendations for process improvement were to promote an understanding of the different health care contexts, support provider-to-provider communication, facilitate hand-offs between settings, and clarify program scope. CONCLUSION Participants perceived the program as responsive to their needs, yet opportunities exist for continued uptake and expansion. Communitywide efforts to assess and address needs remain important.
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Affiliation(s)
- Meredith P Fort
- Research Assistant Professor in the Department of Health Systems, Management and Policy and the Centers for American Indian and Alaska Native Health at the University of Colorado Denver in Aurora.
| | - Lynnette M Namba
- Senior Community Health Specialist in the Community Benefit and Relations Department at Kaiser Permanente Colorado in Denver.
| | - Sarah Dutcher
- Community Health Center Advocate and a former Senior Manager in the Quality Initiatives Division of the Colorado Community Health Network in Denver.
| | - Tracy Copeland
- Project Coordinator for Community Care in the Community Benefit and Relations Department at Kaiser Permanente Colorado in Denver.
| | - Neysa Bermingham
- Former Access to Care Manager in the Community Benefit and Relations Department at Kaiser Permanente Colorado in Denver.
| | - Chris Fellenz
- Physician Lead for Safety Net Partnerships and Access to Care in the Community Benefit and Relations Department at Kaiser Permanente Colorado in Denver.
| | - Deborah Lantz
- Clinical Services Director for the Department of Neurology and Community Patient Access for Kaiser Permanente Colorado in Denver.
| | - John J Reusch
- Cardiologist with the Colorado Permanente Medical Group in Denver.
| | - Elizabeth A Bayliss
- Clinician Investigator for the Institute for Health Research of Kaiser Permanente Colorado in Denver and a Professor of Family Medicine at the University of Colorado School of Medicine.
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27
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Systematic Heuristic Evaluation of Computerized Consultation Order Templates: Clinicians’ and Human Factors Engineers’ Perspectives. J Med Syst 2017; 41:129. [DOI: 10.1007/s10916-017-0775-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 07/09/2017] [Indexed: 01/17/2023]
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28
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Ball S, Montpetite M, Kowalski C, Gerdes Z, Graham G, Kirsh S, Lowery J. Care coordination agreements in the Veterans Healthcare Administration. JOURNAL OF INTEGRATED CARE 2017. [DOI: 10.1108/jica-11-2016-0045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
The Veterans Healthcare Administration (VHA) has promoted Specialty Care Neighborhoods (SCN) to enhance the coordination of services between primary and specialty care. Care coordination agreements (CCAs) were included as a critical element in the SCN program. The purpose of this paper is to examine the role of these documents in the successful implementation of SCNs.
Design/methodology/approach
Content, quality, and perceived usefulness of CCAs from 19 SCN sites were evaluated. CCA content was defined as the presence or absence of eight key components: contact information, process for urgent consults, process for e-consults, content of consults, primary and specialty care responsibilities, expected response time, discharge criteria, and review criteria. CCA quality was based on a qualitative assessment of CCA content; and perceived usefulness was based on a qualitative assessment of interview responses from CCA users. CCA characteristics were compared to SCN implementation levels using descriptive statistics. SCN implementation level was defined and measured by VHA Specialty Care Services.
Findings
Participating sites with medium-high or high SCN implementation levels had CCAs with more key components and of higher quality than sites with medium-low to medium SCN implementation levels. Perceived usefulness of CCAs was not associated with implementation level.
Research limitations/implications
Since this study built on a quality improvement effort to facilitate care coordination, a rigorous research approach was not used. Specific CCA components could not be examined nor could specific hypotheses be tested due to the small and diverse sample. Findings presented are only preliminary.
Practical implications
The examination of CCAs suggests that these documents may be helpful to improve communication among primary and specialty care providers by explicitly stating agreed upon processes, mechanisms and criteria for referrals, roles and responsibilities for the co-management of patients, and timelines for review of CCAs.
Originality/value
This small study suggests that high-quality CCAs, which include a number of key components, can facilitate the implementation of coordinated care. Key characteristics of CCAs are identified in this study, including measures of CCA content, quality, and usefulness, which can be used in future efforts to develop and evaluate efforts to improve care coordination.
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29
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Beste LA, Glorioso TJ, Ho PM, Au DH, Kirsh SR, Todd-Stenberg J, Chang MF, Dominitz JA, Barón AE, Ross D. Telemedicine Specialty Support Promotes Hepatitis C Treatment by Primary Care Providers in the Department of Veterans Affairs. Am J Med 2017; 130:432-438.e3. [PMID: 27998682 DOI: 10.1016/j.amjmed.2016.11.019] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 10/28/2016] [Accepted: 11/08/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND The Department of Veterans Affairs is the largest US provider of hepatitis C treatment. Although antiviral regimens are becoming simpler, hepatitis C antivirals are not typically prescribed by primary care providers. The Veterans Affairs Extension for Community Health Outcomes (VA-ECHO) program was launched to promote primary care-based hepatitis C treatment using videoconferencing-based specialist support. We aimed to assess whether primary care provider participation in VA-ECHO was associated with hepatitis C treatment and sustained virologic response. METHODS We identified 4173 primary care providers (n = 152 sites) responsible for 38,753 patients with chronic hepatitis C infection. A total of 6431 patients had a primary care provider participating in VA-ECHO; 32,322 patients had an unexposed primary care provider. Exposure was modeled as a patient-level time-varying covariate. Patients became exposed after primary care provider participation in ≥1 VA-ECHO session. Multivariable Cox proportional hazards frailty modeling assessed the association between VA-ECHO exposure and hepatitis C treatment. Among treated patients, modified Poisson regression assessed the relationship between exposure and sustained virologic response. RESULTS After adjustment, exposed patients received significantly higher rates of antiviral treatment compared with unexposed patients (adjusted hazard ratio, 1.20; 95% confidence interval, 1.10-1.32; P <.01). The rate of primary care provider-initiated antiviral medication was 21.4% among treated patients reviewed on VA-ECHO teleconferences compared with 2.5% among unexposed patients (P <.01). No difference in adjusted rates of sustained virologic response was observed for patients with exposed primary care providers (P = .32), with similar crude rates for primary care providers versus specialists. CONCLUSIONS National implementation of VA-ECHO was positively associated with hepatitis C treatment initiation by primary care providers, without differences in sustained virologic response.
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Affiliation(s)
- Lauren A Beste
- Health Services Research & Development, VA Puget Sound Health Care System, Seattle, Wash; Department of Medicine, School of Medicine, University of Washington, Seattle; General Medicine Service, VA Puget Sound Health Care System, Seattle, Wash.
| | - Thomas J Glorioso
- VA Eastern Colorado Health Care System, Denver; Department of Biostatistics and Informatics, University of Colorado Denver, Aurora
| | - P Michael Ho
- VA Eastern Colorado Health Care System, Denver; Department of Medicine, University of Colorado School of Medicine, Aurora
| | - David H Au
- Health Services Research & Development, VA Puget Sound Health Care System, Seattle, Wash; Department of Medicine, School of Medicine, University of Washington, Seattle; Hospital and Specialty Medicine Service, VA Puget Sound Health Care System, Seattle, Wash
| | - Susan R Kirsh
- Louis Stokes Cleveland VA Medical Center, Ohio; Department of Medicine, School of Medicine, Case Western Reserve University, Cleveland, Ohio; Office of Specialty Care Services, Veterans Health Administration, Washington, DC
| | - Jeffrey Todd-Stenberg
- Health Services Research & Development, VA Puget Sound Health Care System, Seattle, Wash
| | - Michael F Chang
- Portland VA Medical Center, Ore; Department of Medicine, Division of Gastroenterology, Oregon Health & Sciences University, Portland
| | - Jason A Dominitz
- Health Services Research & Development, VA Puget Sound Health Care System, Seattle, Wash; Department of Medicine, School of Medicine, University of Washington, Seattle; Hospital and Specialty Medicine Service, VA Puget Sound Health Care System, Seattle, Wash
| | - Anna E Barón
- Department of Medicine, School of Medicine, University of Washington, Seattle
| | - David Ross
- Department of Veterans Affairs, Washington, DC; Department of Medicine, George Washington University, DC
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Golberstein E, Kolvenbach S, Carruthers H, Druss B, Goering P. Effects of electronic psychiatric consultations on primary care provider perceptions of mental health care: Survey results from a randomized evaluation. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2017; 6:17-22. [PMID: 28162990 DOI: 10.1016/j.hjdsi.2017.01.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 01/04/2017] [Accepted: 01/26/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Primary care is the main point-of-entry for identifying and treating mental health problems. This research examines the effect of a new model of supporting primary care providers (PCPs) treating mental health disorders, the electronic consultation (eConsults), a standard process for communication between PCPs and psychiatrists through an electronic health records system. METHODS A cluster-randomized evaluation of the psychiatric eConsults model, as implemented in a large integrated delivery system. Web survey data before and after the implementation of psychiatric eConsults were collected on PCPs' perceptions of their capability and skill to deliver mental health services, and analyzed with linear regression models. RESULTS At baseline PCPs had mixed assessments of perceived support for delivering mental health services and of the availability of specialist consultations, but had relatively high perceived self-efficacy and skill for identifying, diagnosing and treating depression. PCPs in the Treatment group had statistically significant 18%, 13%, and 16% improvements in perceived support for diagnosing mental health problems, making treatment decisions, and changing treatment regimens, respectively; and 24% improved perceived ease of access to consultations for mental health, compared to the Control group. Evidence of effects on self-efficacy and perceived skill around depression was more limited. CONCLUSIONS The psychiatric eConsults model improved PCPs' perceptions of support for delivering mental health care and perceptions of access to specialist consultations. IMPLICATIONS Electronic consultations may be a promising approach to support the delivery of mental health services in primary care settings. LEVEL OF EVIDENCE Pre- and post-intervention web surveys from a cluster-randomized trial.
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Affiliation(s)
- Ezra Golberstein
- Division of Health Policy & Management, University of Minnesota School of Public Health, 420 Delaware St. SE, MMC 729, Minneapolis, MN 55455, United States.
| | | | | | - Benjamin Druss
- Department of Health Policy & Management, Rollins School of Public Health, Emory University, Atlanta, GA, United States
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Wasfy JH, Rao SK, Essien UR, Richardson CA, Jeune T, Goldstein SA, Laikhter E, Chittle MD, Weil M, Wein M, Ferris TG. Initial experience with endocrinology e-consults. Endocrine 2017; 55:640-642. [PMID: 27507674 DOI: 10.1007/s12020-016-1053-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 07/04/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Jason H Wasfy
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
- Massachusetts General Physicians Organization, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Sandhya K Rao
- Massachusetts General Physicians Organization, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Utibe R Essien
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Tamika Jeune
- Massachusetts General Physicians Organization, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Susan A Goldstein
- Massachusetts General Physicians Organization, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Elizabeth Laikhter
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Melissa D Chittle
- Division of Interventional Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Michelle Weil
- Endocrine Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Marc Wein
- Endocrine Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Timothy G Ferris
- Massachusetts General Physicians Organization, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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32
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Stevenson L, Ball S, Haverhals LM, Aron DC, Lowery J. Evaluation of a national telemedicine initiative in the Veterans Health Administration: Factors associated with successful implementation. J Telemed Telecare 2016; 24:168-178. [PMID: 27909208 DOI: 10.1177/1357633x16677676] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background The Consolidated Framework for Implementation Research was used to evaluate implementation facilitators and barriers of Specialty Care Access Network-Extension for Community Healthcare Outcomes (SCAN-ECHO) within the Veterans Health Administration. SCAN-ECHO is a video teleconferencing-based programme where specialist teams train and mentor remotely-located primary care providers in providing routine speciality care for common chronic illnesses. The goal of SCAN-ECHO was to improve access to speciality care for Veterans. The aim of this study was to provide guidance and support for the implementation and spread of SCAN-ECHO. Methods Semi-structured telephone interviews with 55 key informants (primary care providers, specialists and support staff) were conducted post-implementation with nine sites and analysed using Consolidated Framework for Implementation Research constructs. Data were analysed to distinguish sites based on level of implementation measured by the numbers of SCAN-ECHO sessions. Surveys with all SCAN-ECHO sites further explored implementation information. Results Analysis of the interviews revealed three of 14 Consolidated Framework for Implementation Research constructs that distinguished between low and high implementation sites: design quality and packaging; compatibility; and reflecting and evaluating. The survey data generally supported these findings, while also revealing a fourth distinguishing construct - leadership engagement. All sites expressed positive attitudes toward SCAN-ECHO, despite struggling with the complexity of programme implementation. Conclusions Recommendations based on the findings include: (a) expend more effort in developing and distributing educational materials; (b) restructure the delivery process to improve programme compatibility;
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Affiliation(s)
| | - Sherry Ball
- 1 Louis Stokes Cleveland VA Medical Center, USA
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33
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Tam-Tham H, King-Shier KM, Thomas CM, Quinn RR, Fruetel K, Davison SN, Hemmelgarn BR. Prevalence of Barriers and Facilitators to Enhancing Conservative Kidney Management for Older Adults in the Primary Care Setting. Clin J Am Soc Nephrol 2016; 11:2012-2021. [PMID: 27551007 PMCID: PMC5108196 DOI: 10.2215/cjn.04510416] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 07/14/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Conservative management of adults with stage 5 CKD (eGFR<15 ml/min per 1.73 m2) is increasingly being provided in the primary care setting. We aimed to examine perceived barriers and facilitators for conservative management of older adults by primary care physicians. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In 2015, we conducted a cross-sectional, population-based survey of all primary care physicians in Alberta, Canada. Eligible participants had experience caring for adults ages ≥75 years old with stage 5 CKD not planning on initiating dialysis. Questionnaire items were on the basis of a qualitative descriptive study informed by the Behavior Change Wheel and tested for face and content validity. Physicians were contacted via postal mail and/or fax on the basis of a modified Dillman method. RESULTS Four hundred nine eligible primary care physicians completed the questionnaire (9.6% response rate). The majority of respondents were men (61.6%), were ages 40-60 years old (62.6%), and practiced in a large/medium population center (68.0%). The most common barrier to providing conservative care in the primary care setting was the inability to access support to maintain patients in the home setting (39.1% of respondents; 95% confidence interval, 34.6% to 43.6%). The second most common barrier was working with nonphysician providers with limited kidney-specific clinical expertise (32.3%; 95% confidence interval, 28.0% to 36.7%). Primary care physicians indicated that the two most common strategies that would enhance their ability to provide conservative management would be the ability to use the telephone to contact a nephrologist or clinical staff from the conservative care clinic (86.9%; 95% confidence interval, 83.7% to 90.0% and 85.6%; 95% confidence interval, 82.4% to 88.9%, respectively). CONCLUSIONS We identified important areas to inform clinical programs to reduce barriers and enhance facilitators to improve primary care physicians' provision of conservative kidney care. In particular, primary care physicians require additional resources for maintaining patients in their home and telephone access to nephrologists and conservative care specialists.
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Affiliation(s)
| | - Kathryn M. King-Shier
- Departments of Community Health Sciences and
- Faculty of Nursing, University of Calgary, Calgary, Alberta, Canada; and
| | | | - Robert R. Quinn
- Departments of Community Health Sciences and
- Medicine, Cumming School of Medicine and
| | | | - Sara N. Davison
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Brenda R. Hemmelgarn
- Departments of Community Health Sciences and
- Medicine, Cumming School of Medicine and
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Tuot DS, Leeds K, Murphy EJ, Sarkar U, Lyles CR, Mekonnen T, Chen AHM. Facilitators and barriers to implementing electronic referral and/or consultation systems: a qualitative study of 16 health organizations. BMC Health Serv Res 2015; 15:568. [PMID: 26687507 PMCID: PMC4684927 DOI: 10.1186/s12913-015-1233-1] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Accepted: 12/11/2015] [Indexed: 11/15/2022] Open
Abstract
Background Access to specialty care remains a challenge for primary care providers and patients. Implementation of electronic referral and/or consultation (eCR) systems provides an opportunity for innovations in the delivery of specialty care. We conducted key informant interviews to identify drivers, facilitators, barriers and evaluation metrics of diverse eCR systems to inform widespread implementation of this model of specialty care delivery. Methods Interviews were conducted with leaders of 16 diverse health care delivery organizations between January 2013 and April 2014. A limited snowball sampling approach was used for recruitment. Content analysis was used to examine key informant interview transcripts. Results Electronic referral systems, which provide referral management and triage by specialists, were developed to enhance tracking and operational efficiency. Electronic consultation systems, which encourage bi-directional communication between primary care and specialist providers facilitating longitudinal virtual co-management, were developed to improve access to specialty expertise. Integrated eCR systems leverage both functionalities to enhance the delivery of coordinated, specialty care at the population level. Elements of successful eCR system implementation included executive and clinician leadership, established funding models for specialist clinician reimbursement, and a commitment to optimizing clinician workflows. Conclusions eCR systems have great potential to streamline access to and enhance the coordination of specialty care delivery. While different eCR models help solve different organizational challenges, all require institutional investments for successful implementation, such as funding for program management, leadership and clinician incentives. Electronic supplementary material The online version of this article (doi:10.1186/s12913-015-1233-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Delphine S Tuot
- Division of Nephrology at San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, 94110, USA. .,Center for Innovation in Access and Quality at San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, 94110, USA.
| | - Kiren Leeds
- Center for Innovation in Access and Quality at San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, 94110, USA.
| | - Elizabeth J Murphy
- Center for Innovation in Access and Quality at San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, 94110, USA. .,Division of Endocrinology at San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, 94110, USA.
| | - Urmimala Sarkar
- Division of General Internal Medicine at San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, 94110, USA.
| | - Courtney R Lyles
- Division of General Internal Medicine at San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, 94110, USA.
| | - Tekeshe Mekonnen
- Center for Innovation in Access and Quality at San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, 94110, USA
| | - Alice H M Chen
- Center for Innovation in Access and Quality at San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, 94110, USA. .,Division of General Internal Medicine at San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, 94110, USA.
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A Multicenter Cardiovascular MR Network for Tele-Training and Beyond: Setup and Initial Experiences. J Am Coll Radiol 2015; 12:876-83. [DOI: 10.1016/j.jacr.2015.03.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 03/04/2015] [Indexed: 12/21/2022]
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Frank JW, Carey EP, Fagan KM, Aron DC, Todd-Stenberg J, Moore BA, Kerns RD, Au DH, Ho PM, Kirsh SR. Evaluation of a Telementoring Intervention for Pain Management in the Veterans Health Administration. PAIN MEDICINE 2015; 16:1090-100. [DOI: 10.1111/pme.12715] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Vimalananda VG, Gupte G, Seraj SM, Orlander J, Berlowitz D, Fincke BG, Simon SR. Electronic consultations (e-consults) to improve access to specialty care: a systematic review and narrative synthesis. J Telemed Telecare 2015; 21:323-30. [PMID: 25995331 PMCID: PMC4561452 DOI: 10.1177/1357633x15582108] [Citation(s) in RCA: 269] [Impact Index Per Article: 29.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 03/22/2015] [Indexed: 11/15/2022]
Abstract
BACKGROUND We define electronic consultations ("e-consults") as asynchronous, consultative, provider-to-provider communications within a shared electronic health record (EHR) or web-based platform. E-consults are intended to improve access to specialty expertise for patients and providers without the need for a face-to-face visit. Our goal was to systematically review and summarize the literature describing the use and effects of e-consults. METHODS We searched PubMed, EMBASE, the Cochrane Library, and CINAHL for studies related to e-consults published between 1990 through December 2014. Three reviewers identified empirical studies and system descriptions, including articles on systems that used a shared EHR or web-based platform, connected providers in the same health system, were used for two-way provider communication, and were text-based. RESULTS Our final review included 27 articles. Twenty-two were research studies and five were system descriptions. Eighteen originated from one of three sites with well-developed e-consult programs. Most studies reported on workflow impact, timeliness of specialty input, and/or provider perceptions of e-consults. E-consultations are used in a variety of ways within and across medical centers. They provide timely access to specialty care and are well-received by primary care providers. DISCUSSION E-consults are feasible in a variety of settings, flexible in their application, and facilitate timely specialty advice. More extensive and rigorous studies are needed to inform the e-consult process and describe its effect on access to specialty visits, cost and clinical outcomes.
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Affiliation(s)
- Varsha G Vimalananda
- Center for Healthcare Organization and Implementation Research (CHOIR), US Department of Veterans Affairs, Bedford, Massachusetts, USA Section of Endocrinology, Diabetes, and Nutrition, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Gouri Gupte
- Department of Health Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Siamak M Seraj
- Department of Health Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Jay Orlander
- VA Boston Healthcare System, Boston, Massachusetts, USA Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Dan Berlowitz
- Center for Healthcare Organization and Implementation Research (CHOIR), US Department of Veterans Affairs, Bedford, Massachusetts, USA Department of Health Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Benjamin G Fincke
- Center for Healthcare Organization and Implementation Research (CHOIR), US Department of Veterans Affairs, Bedford, Massachusetts, USA
| | - Steven R Simon
- Center for Healthcare Organization and Implementation Research (CHOIR), US Department of Veterans Affairs, Bedford, Massachusetts, USA VA Boston Healthcare System, Boston, Massachusetts, USA Division of General Internal Medicine, Brigham and Women's Hospital, Boston Massachusetts, USA Harvard Medical School, Massachusetts, USA
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