1. The 10 Steps to Establishing an eConsultation Service to Improve Access to Specialist Care Dr. Clare Liddy, Amir Afkham, Dr. Erin Keely ccelerating Change

2. “Timely feedback Excellent information that I can relay to my patient for excellent quality of care. I really appreciate this service! and so do my patients” Champlain BASE Service: Building Access to Specialists through eConsultation

3. A collaboration between: The Ottawa Hospital (TOH) The Bruyère Research Institute (BRI) Winchester District Memorial Hospital (WDMH) Champlain Local Health Integration Network (LHIN) Funding: TOHAMO AFP Innovation Fund Champlain LHIN e-Health Ontario The eConsultation Team

4. What is eConsult? A web-based service for primary care providers to access specialist care for their patients Leverages existing secure regional collaboration space. Primary Care Provider uses a simple template  Prompted for key information  May attach additional information (test results, images, EMR- generated consult letter)

5. Answering an e-Consultation Assigned to appropriate specialist Specialist receives an email notification Expected to answer within one week Can give one of three replies: 1. A reply to the question 2.A request for additional information 3.A recommendation for referral (along with any tests etc. to be completed beforehand) Initiator can then provide additional information, submit follow-up questions/clarification, or close the case (and respond to a brief survey)

6. Widely available in Champlain region… 244 PCP’s registered (MDs, NPs, and delegates) from 50 clinics in 24 different geographical areas

7. Current status – 25 specialty services  Cardiology  Dermatology  Nephrology  Neurology  Endocrinology  Pain Medicine  PainConnect “Re-Consult”  Psychiatry  Internal Medicine  Thrombosis  Hematology  Radiology: Abdominal Musculoskeletal NeuroRadiology Thoracic  Urology  ENT & Head/Neck Surgery  Diabetes Education  General Pediatrics  OB/GYN  Pediatric Hematology/Oncology  Rheumatology  Palliative Care  Infectious Disease  Clinical Pharmacy As of May 15 th 2013: 1163 cases in total

8. Value of eConsults for patients [from PCP survey responses completed for each case] Eliminate travel to specialist Dramatically reduce wait time Appropriate treatment starts quickly, avoids deterioration Reduced anxiety Overall value of the eConsult service in this case for patient (1083 Completed Cases) AVG.: 4.56/5 91% of PCP’s rate as high or very high value for their patients

9. Impact of eConsultation on Need for Face-to-Face Referral [ from PCP survey responses completed for each case ] N=1083 cases 40% of cases led to a referral being avoided

10. 10 Steps to eConsultation 1. Partners Form your project team Establish the key working partnerships  Clinical champions  Regional support  Technology partner

11. 10 Steps to e-Consultation 1. Partners Form your project team 2. Platform Leverage what’s already deployed Choose a platform for the e-Consultation system Should be based on local existing infrastructure  Facilitated by ensuring that key partners are part of initial project team  System should be user-friendly, simple, and to the point – easy to learn and re-learn

12. 10 Steps to e-Consultation 1. Partners Form your project team 2. Platform Leverage what’s already deployed Start small and build Facilitates the engagement of all users Allows you to identify obstacles early 3. Pilot Start small and grow

13. 10 Steps to e-Consultation 1. Partners Form your project team 2. Platform Leverage what’s already deployed 3. Pilot Start small and grow 4. Product Practical form & workflow design Design the e-Consultation form  ONE FORM for all specialties Three formats were explored:  Free text  Directed form (mandatory fields)  Existing EMR forms Consult with users to match form to workflow Use common tools for development to keep modifications quick and easy

14. 10 Steps to e-Consultation 1. Partners Form your project team 2. Platform Leverage what’s already deployed 3. Pilot Start small and grow 4. Product Practical form & workflow design Privacy impact, and threat risk assessments were performed Most health regions/health care orgs. will have a privacy office/officer who can help 5. Privacy Ensure security & privacy requirements met

15. 10 Steps to e-Consultation 1. Partners Form your project team 2. Platform Leverage what’s already deployed 3. Pilot Start small and grow 4. Product Practical form & workflow design 5. Privacy Ensure security & privacy requirements met 6. Process Fit into clinics’ workflows Determine the workflow  Must fit as seamlessly as possible into physician’s usual workflow to ensure participation Important to minimize system usage time

16. 10 Steps to e-Consultation 1. Partners Form your project team 2. Platform Leverage what’s already deployed 3. Pilot Start small and grow 4. Product Practical form & workflow design 5. Privacy Ensure security & privacy requirements met 6. Process Fit into clinics’ workflows

17. 10 Steps to e-Consultation 1. Partners Form your project team 2. Platform Leverage what’s already deployed 3. Pilot Start small and grow 4. Product Practical form & workflow design 5. Privacy Ensure security & privacy requirements met 6. Process Fit into clinics’ workflows 7. Participants Sustained engagement Solidifying clinical champions is the first important step in recruitment Physician participation will determine the success of e-Consultation-focus on motivated/enthusiastic participants Keep physician engagement aspects (joining, training, ongoing support) simple

18. 10 Steps to e-Consultation 1. Partners Form your project team 2. Platform Leverage what’s already deployed 3. Pilot Start small and grow 4. Product Practical form & workflow design 5. Privacy Ensure security & privacy requirements met 6. Process Fit into clinics’ workflows 7. Participants Sustained engagement Determine payment and liability aspects Specialist billing rate of $200/hr was established  Avg. of 11.7 min per case was observed Consultation with CMPA ensured that no novel litigation risks were created 8. Payment Remuneration and duty of care

19. 10 Steps to e-Consultation 1. Partners Form your project team 2. Platform Leverage what’s already deployed 3. Pilot Start small and grow 4. Product Practical form & workflow design 5. Privacy Ensure security & privacy requirements met 6. Process Fit into clinics’ workflows 7. Participants Sustained engagement Build in continuous quality feedback System usage and outcomes continuously evaluated Usage and outcome data fed back to users to encourage ongoing participation 8. Payment Remuneration and duty of care 9. Provide Feedback Evolve based on regular feedback

20. 10 Steps to e-Consultation 1. Partners Form your project team 2. Platform Leverage what’s already deployed 3. Pilot Start small and grow 4. Product Practical form & workflow design 5. Privacy Ensure security & privacy requirements met 6. Process Fit into clinics’ workflows 7. Participants Sustained engagement 8. Payment Remuneration and duty of care 9. Provide Feedback Evolve based on regular feedback 10. Plan the Transition Prepare for sustainability Plan your transition from pilot to sustainable program Three key elements are needed to ensure sustainability: 1.Maintaining the benefit of the service 2.Funded infrastructure 3.HR support

21. 10 Steps to e-Consultation 1. Partners Form your project team 2. Platform Leverage what’s already deployed 3. Pilot Start small and grow 4. Product Practical form & workflow design 5. Privacy Ensure security & privacy requirements met 6. Process Fit into clinics’ workflows 7. Participants Sustained engagement 8. Payment Remuneration and duty of care 9. Provide Feedback Evolve based on regular feedback 10. Plan the Transition Prepare for sustainability

22. “I love this service” "Fast, easy to use service. very user friendly. The advice I received was thorough and helpful. I am very grateful!" “Invaluable service for GPs” "This eConsult saved an in- person referral and months of wait. This is such an excellent service. Also, as a Nurse Practitioner, I really value this service... I get direct, timely access - this is improving care for my clients.“ On the Right Track! [ Direct quotes from PCP Surveys ] “Excellent collaboration, very quick response – so glad to have access to this service!”