Electronic Consultation and Referral (ecr) to Achieve the Quadruple Aim

Electronic Consultation and Referral (ecr) to Achieve the Quadruple Aim Session # 307, February 21, 2017 J. Nwando Olayiwola, MD, MPH, FAAFP, Director, Center for Excellence in Primary Care, University of California, San Francisco Delphine Tuot, MDCM, MAS, Director, ereferral at Zuckerberg San Francisco General, Co-Director, Center for innovation in Access & Quality 1

Presenters J. Nwando Olayiwola, MD, MPH, FAAFP Director, Center for Excellence in Primary Care (CEPC), University of California, San Francisco Delphine S. Tuot, MDCM, MAS Director, ereferral at Zuckerberg San Francisco General & Co-Director, Center for innovation in Access & Quality (CIAQ), University of California, San Francisco 2

Conflict of Interest J. Nwando Olayiwola, MD, MPH, FAAFP & Delphine Tuot, MDCM, MAS Have no real or apparent conflicts of interest to report. 3

Agenda Background Terms: econsult / ereferral / ecr ecr @ San Francisco Health Network Organizational Readiness Elements for Successful Implementation Metrics & Data Sources Quadruple aim IOM s Quality Domains Data Collection Audience Discussion & Breakouts 4

Learning Objectives Compare approaches to ecr system development and adoption based on organizational resources, interest and demographics Identify potential evaluation metrics and data sources using the Quadruple Aim framework or IOM quality domains Design short and long term evaluation plans for individual organizations and systems 5

Opening Question 1 My primary role in my organization is: 1. Clinical Leader or Clinician 2. Admin / Operations / Finance 3. IT / Informatics 4. Other 6

Opening Question 2 I would describe my organization s status on econsults as: 1. Actively considering 2. Early stage implementation 3. Implemented and optimizing 4. Not considering / Huh? 7

Applying the STEPS Model to Evaluation of ecr Systems S the evaluation model emphasizes the importance of assessing the satisfaction and experience of all stakeholders, including health care providers and patients T- the evaluation model focuses on developing a robust set of clinical and outcomes metrics based on available data source E- the evaluation model is centered around electronic information and data capture, which requires invaluable input from delivery, IT and senior leadership P the evaluation model also includes strategies for elucidating patient engagement roles and experiences from diverse voices, using ecr systems for better population health S- the evaluation model also prepares organizations to identify cost related measures and examine potential areas for cost-savings 8

STEPS: Patient Engagement & Population Management 6 days for econsult vs. 24 days for visit Access to Specialty Care (Olayiwola, Ann Fam Med, 2016) Communication Between Primary & Specialty Care (Tuot, Healthcare, 2015) 71% of primary care providers report high quality specialist communication Wait Times for In-Person Specialty Appointments (Chen, NEJM 2013) Average wait times dropped from 112 days to 49 days after 9-months postimplementation 9

Background 10

Background System Types econsult ecr ereferral 11

Background ereferral econsult Expectation that patient will be seen by specialist Efficient referral management/tracking and review by specialist Integrated ecr electronic consultation and referral system Request for a patient s condition/treatment to be evaluated by a specialist Does not carry the expectation that a specialist will see the patient Focus on bi-directional communication Single portal of entry for referring providers; does not require providers to distinguish referrals from consultations All submissions are reviewed by a specialist 12 Tuot, BMC Health Services Research, 2016.

Background ecr at San Francisco Health Network Problem: inefficient referral process AND poor specialty access Developed in 2005 Piloted with gastroenterology, expanded to 120+ services Now a model for improving access to specialty care. 13

Background ecr Process Adapted from Chen AH, NEJM, 2013. 14

Organizational Readiness 15

Organizational Readiness 10 Steps for Successful Implementation (Liddy et al, 2015) 16

Organizational Readiness Successful Implementation Facilitators (Tuot, BMC Health Services Research, 2015) 17

Metrics & Data Sources 18

Metrics & Data Sources Quadruple Aim Framework Lower Costs Population Health Patient Care Experience Care Team Experience (Bodenheimer and Sinsky, 2014) 19

Metrics & Data Sources Institute of Medicine Quality Domains Patient- Centered Timely Effective Efficient Safe Healthcare Quality Equitable Institute of Medicine, 2001 20

Lower Costs Patient Care Experience Population Health Care Team Experience Measures Used at San Francisco Health Network Population Health Unclosed loop Average time for response Time for third next available appointment Strategy: health system and ecr platform metrics Care Team Experience Satisfaction Educational value Patient benefit Strategy: Provider surveys, focus groups Patient Focus Groups Satisfaction with access Acceptability Convenience Strategy: Patient focus groups and surveys 21

Audience discussion What type of ecr system might be best for your organization? Is your organization ready to implement an ecr? What framework of evaluation resonates with you? What are some possible short-term evaluation metrics? What are example long-term evaluation metrics? 22

Audience Discussion How will I tell if an ecr is working? Measure Data Source Definition Why this measure? 23

References 1. Olayiwola, J.N., et al., Electronic consultations to improve the primary care-specialty care interface for cardiology in the medically underserved: a cluster-randomized controlled trial. The Annals of Family Medicine, 2016. 14(2): p. 133-140. 2. Tuot, D.S., et al., Leveraging an electronic referral system to build a medical neighborhood. Healthcare, 2015. 3(4): p. 202-8. 3. Chen, A.H., E.J. Murphy, and H.F. Yee Jr, ereferral a new model for integrated care. New England Journal of Medicine, 2013. 368(26): p. 2450-2453. 4. Tuot, D.S., et al., Facilitators and barriers to implementing electronic referral and/or consultation systems: a qualitative study of 16 health organizations. BMC health services research, 2015. 15(1): p. 1. 5. Liddy, C., et al., Impact of and Satisfaction with a New econsult Service: A Mixed Methods Study of Primary Care Providers. J Am Board Fam Med, 2015. 28(3): p. 394-403. 6. Bodenheimer, T. and C. Sinsky, From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med, 2014. 12(6): p. 573-6. 7. Institute of Medicine, Committee on Quality of Health Care in America. Crossing the quality chasm: A new health system for the 21st century. 2001: National Academy Press. 24

Applying the STEPS Model to Evaluation of ecr Systems S the evaluation model emphasizes the importance of assessing the satisfaction and experience of all stakeholders, including health care providers and patients T- the evaluation model focuses on developing a robust set of clinical and outcomes metrics based on available data source E- the evaluation model is centered around electronic information and data capture, which requires invaluable input from delivery, IT and senior leadership P the evaluation model also includes strategies for elucidating patient engagement roles and experiences from diverse voices, using ecr systems for better population health S- the evaluation model also prepares organizations to identify cost related measures and examine potential areas for cost-savings 25

Questions J. Nwando Olayiwola, MD, MPH, FAAFP Associate Professor, Department of Family and Community Medicine Director, Center for Excellence in Primary Care University of California, San Francisco Nwando.Olayiwola@ucsf.edu http://cepc.ucsf.edu @UCSFCEPC @DrNwando Delphine Tuot, MDCM, MAS Assistant Professor, Division of Nephrology, Director, ereferral at ZSFG Co-Director, Center for Innovation in Access and Quality at ZSFG University of California San Francisco Delphine.Tuot@ucsf.edu www.ciaqsf.org 26