TCLHIN Urban
Telemedicine
Initiative for
WMS
AGHPS 3rd Leadership Summit 2013
November 15, 2013
Overview
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Context - Urban Telemedicine Initiative
Urban Telemedicine Model Development
Implementation Journey Highlights
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MOU
Documentation
Practice Guideline
Evaluation
Lessons Learned
Critical Success Factors
Telemedicine
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Medical support to patients in
remote areas
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History
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1900’s - two-way radio connection to
Royal Flying Doctor Service of Australia
1950’s to 1990’s – telephone
connection to remote areas
Late 1990’s - urban telemedicine
(Britain, US) via computer
2012 - TC LHIN Urban
Telemedicine Initiatives
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Client and healthcare provider within
the same LHIN
Mechanism to increase access
Withdrawal Management
Services (WMS) In TC LHIN
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Hospital-affiliated, situated off site
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Separate facilities with some integrated practices
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Non-medical withdrawal system – care by
unregulated health care providers
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Two-way impact on ED patient flow
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High level of client medical and withdrawal
related complexity
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Patients go to different sites for episodes of care
Drivers for Change
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ED visits by mental health and addictions
clients increasing steadily in TC LHIN
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Some sites sending every client to ER for
medical clearance prior to accepting – bed
held at site
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Many WMS clients have issues accessing
primary care and use ED as a substitute
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Coroner’s Report
Urban Telemedicine
Model Development
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Proposal to Charter & Funding – 4 months
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NP role for model included developing an
understanding of:
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Scope of practice
Clinical consultation
Medical clearance
Primary care focus opportunities
Model for sharing resource across sites
Telemedicine capabilities
Final Model
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Partnership
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TEGH – Lead Agency
St. Joseph’s Health Center
UHN
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Nurse Practitioner (NP) hired and paid by TEGH
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NP visits a different site daily while supporting
others via Telemedicine
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Utilize clinical expertise to defer people from
ED, provide primary care and WMS staff
consultation
Milestones
Apr’12
1 Initial proposal
Funding confirmation
(Charter)
Telemedicine model
3
development
2
4 NP hiring
5 MOU development
6 OTN installation
7 OTN training
8 NP site orientation
Project workflows
established
Documentation system
10
strategy
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11 Client care initiated
12 Interim report to LHIN
Legend
Planned
Actual
Jul’12
Oct’12
Jan’13
Apr’13
Jul’13
Oct’13
Jan’14
Memorandum of
Understanding (MOU)
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Single MOU
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Sets out expectations and accountabilities
including;
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Role responsibilities of lead and partner hospitals
Human resources and practice accountabilities
for NP
PHIPA Compliance, Privacy and Health
Information Custodianship
Policy development
Implementation Challenges
Expected
Actual
Technology limitations
NP Hiring – need for seasoned
clinician
Collaboration across hospitals
and sites
Documentation strategy for
accessible record
Client perception of
telemedicine
Privacy considerations across
sites
Documentation system per
site
Practice Guideline
development
Evaluation Framework
Implementation Challenges
Expected
Actual
Technology limitations
NP Hiring – need for seasoned
clinician
Collaboration across hospitals
and sites
Documentation strategy for
accessible record
Client perception of
telemedicine
Privacy considerations across
sites
Documentation system per
site
Practice Guideline
development
Evaluation Framework
Documentation
The Situation
Paper
based, site-specific client care documentation
Existing data extraction software (Catalyst)
No budget for electronic medical record
Ideal System
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Unique medical record for each client accessible by
NP at any site
Supported by pharmaceutical data base
Integration of diagnostic test results/ reports
Means to flow relevant information for handoff
PHIPA compliance
Capacity for data extraction
The Documentation Journey
The Process
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Several meetings over 6 months with LHIN
representation
Goal to balance privacy, IT perspective, user needs
and available alternatives
Considerations
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Cost
Simplicity vs complexity
Approval times for external software vendor
Access to client health care information by
unregulated staff
Documentation Options
Paper Record
Paper Record
with Electronic
version
EMR
Catalyst Superuser
Paper record
One copy
Resides in WMS
paper chart
Staff fax to NP as
required for
referencing care
to make clinical
decisions
Produced on
computer
Printed to chart
NP keeps
documents (ie in
Word) for
reference on
laptop
Original in chart
EMR installed on
laptop, server or
web based
EMR version is
original
NP progress note
printed for WMS
chart
? Site access
On Catalyst
NP as super-user
Partitioned by site
visits but
contiguous for
patient??
Same system as
registration
WMS Site as
custodian
WMS Site as
custodian
TEGH as health
Health record
records custodian custodian ??
Documentation Decision
Model
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TEGH as health information (HIC) custodian
Separate medical record for each client
contiguous if care at more than one site
NP provides needed clinical information to WMS
staff on “as needed” basis
Strategy
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Electronic medical record
Web-based access from all sites to ensure
timeliness (Application Service Provider)
Relevant notes to paper chart
Practice Guideline
Development
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Purpose
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Intent
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To establish common Urban Telemedicine
Initiative practices among sites.
Guideline to be a “living” document, reflecting
evolving practice.
Process
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Involvement of WMS staff, supervisors, managers
and directors in development.
Practice Guideline Content
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Primary Health Care
NP Practice
Telemedicine
Practice
Client Eligibility and
Priority
Referrals to UTM/NP
Consultation and
Continuity
Location, Frequency
and Scheduling
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Documentation
Privacy and Consent
Health Information
Management
Telemedicine
Assessments
Infection Control
Evaluation, Program
Development, CQI
Evaluation Design
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Conceptual framework
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Access
Integration
Patient centered care
Safety
Development of data elements, definitions,
sources, frequency, accountabilities
Need for pre-data identified
Design of data collection tools and scorecard
Reporting accountabilities to LHIN established
Key Findings: Client Care
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A challenge to distinguish unique clients and encounters
ED Diversion Rates
Clinical Encounters -NP
150
140
100
138
8.0%
99
7.2%
6.9%
6.0%
5.9%
4.0%
50
2.0%
0
July
August
September
0.0%
July
High Risk Clients
70.0%
60.0%
64.8%
59.7%
37.9%
30.0%
20.0%
10.0%
0.0%
0.0%
July
August
49.6%
40.0%
20.0%
September
September
Follow-up Care Ratio
60.0%
50.0%
40.0%
80.0%
August
July
59.8%
August
62.4%
September
Key Findings:
Client Care
Trending reasons for a visit
10%
9%
16%
6%
Substance Abuse
Mental Health Issue
Medical Issue
59%
Medication Issue
System Navigation Issue
Key Findings:
Patient Satisfaction
Metric
Number of respondents
Jul-Sep 2012
32
Accessibility of the NP
96.9%
Excellent quality of care
87.5%
Good quality of care
12.5%
Impact on self-management: "a lot"
90.0%
Impact on self-management: "some"
10.0%
Self-estimated diversion
53.1%
Use again ?
100.0%
Recommend to others?
100.0%
100%
100%
Scorecard
Scorecard
Lessons Learned
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Our history of voluntary integration and WMS committee
structure supported the process of change.
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New uses of telemedicine are challenging due to
already existing definitions for type of engagement.
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Site differences posed both challenge and opportunity.
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MOU development can be a lengthy process when
combining privacy, human resources and site
accountabilities.
Lessons Learned
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Continuous quality improvement (CQI) is an important
part of the initiative, to understand impacts and refine
practices through small tests of change.
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There is much work to be done to manage the medical
complexity of clients and enhance risk management.
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In addition to ED diversion, there are several promising
practices from this initiative;
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virtual rounds,
CAMH patient flow,
using practice guidelines across sites and
establishing a means to track ED interfaces through
CATALYST.
Client Voice
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"I didn't think I could do this (alcohol withdrawal) - and
manage my diabetes and liver cirrhosis at the same time“
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52 year old male: heavy alcohol binge-type use and extensive
alcohol use history, admitted from ED
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After admission to WMS NP noted that client had both medical
and withdrawal related risks
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Client was transferred to the medical Withdrawal Management
Service of CAMH (Centre for Addiction and Mental Health) for
stabilization of his diabetes and acute withdrawal phase
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Client then returned to TEGH non-medical WMS site to complete
withdrawal and participate in day program, before being
admitted to a long-term substance use treatment program
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During stay at TEGH WMS, NP and client worked to improve
client's diabetic control through assessments, health teaching
and assistance with system navigation
In Summary:
Critical Success Factors
 Ongoing
dialogue at many levels to
understand complexity of service model
 Being
open to learning and discovering
new ways of providing care
 Building
on the strong foundation that
exists in WMS to ensure collaborative input
at all levels for shaping initiative.
Discussion
Questions?
Suggestions?
Contacts
Pat Larson
TEGH
plars@tegh.on.ca
Linda Young
TEGH
lyoun@tegh.on.ca
Jan Lackstrom
UHN
jan.lackstrom@uhn.ca
Paula Podolski
St. Joseph's Health
Center
podolp@stjoe.on.ca