Reducing dermatology wait times to less than 5 days with Store Forward…Otn.teledermSF®

eHealth

May 27, 2013

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Objectives

Who is OTN

What is Store Forward

Impact on wait times

Utilization

Why is it working?

User feedback

Where are we going from here?

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About OTN

Veni – We came

Vidi – We saw

Video – We Video’d

Vaco…Store ForwardOTN is a not-for-profit organization funded by the Government of Ontario

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What is Otn.teledermSF®?

SF means Store Forward…move the information, not the patient

Whereas videoconferencing is real-time (synchronous), store forward is asynchronous

The information is stored and then forwarded for action by the consultant at a later time

Otn.teledermSF® is a OTN program that incorporates technology, workflow logic to allow the secure flow of information between referring doctors and dermatologists

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Referring doc implements treatment with patient

Photo and pertinent patient information is sent to the dermatologist through OTN’s secure software/servers

How does it work?The referring doctor, or their delegate, takes a digital photo of the patient’s skin lesion

Dermatologist returns a diagnosis and suggested treatment plan to the referrer

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What is the need?

Access: 180 dermatologists in Ontario

Wait times: The further from a major centre the longer the wait times (anecdotal):

For example: – 45 minutes from Toronto 3-4 months– 1.5 hours from Toronto 6 months– 4 hours from Toronto 8-12 months– Even reports of 18+ months in some parts of northern

Ontario

Time to treatment reduces costs

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How the program was developed

Literature supports effectiveness of Store Forward– Patient satisfaction is equivalent to face-to-face– A study of nearly 1,500 shows improved clinical outcomes,

with better diagnosis and disease management.– Teledermatology, when applied to all dermatology referrals,

has a probability of being cost saving to society.

Pilot 2009-2010

Operationalized 2011

Remuneration for derms

(Remuneration for referrers not until April 2012)

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Apr 11

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Jun 11Jul 1

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100

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Growth

FY 2011-2012 FY 2012-2013

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# of

con

sults

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Currently, in FY 2013/14, 600+ consults/month…and growing

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5,101

Growth Rate

2011-2012 TOTAL 2012-2013 TOTAL0

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1,240

Over 300% from FY2011/12

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User stats

18 Ontario-based dermatologists

700+ referring physicians

1000+ “delegate” referring users (NPs, Nurses, etc.)

225+ Primary Care referring sites (FHTs, FHOs, CHCs, etc.)

The list of dermatologists and referring users grows every week.

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How is Otn.teledermSF affecting wait times?

On average wait times are less than 5 days

Current trending: Less than 3 days

Dermatologists are telling us they are not near capacity

Will add more derms as required

Derms welcome to join any time (referrers too!)

Otn.teledermSF is freeing up time for f-2-f appointments

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What dermatologists are saying

“[Telederm] can free up some time in my clinic so the quick patients can be done through telemedicine.”

“I do find that I can better screen subjects to see who needs to be brought in sooner, or who needs a referral to surgery sooner rather than later. I saw a woman with melanoma a couple of weeks ago through Telederm and referred her directly to Plastics - it was excised in a week. Wouldn't have happened on real clinic referral time.”

Dr. Melinda Gooderham, Dermatologist

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Talk about setting expectations….

“…and I have to say that I’ve been waiting a long time to get responses back from the consultants. I know I used to get responses back as quickly as a couple of hours and now for some, 3-5 days.”

Recall that wait times for a face-to-face appointment can be more than 12 months

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Why is it working so well?

5 day turn around

Ease of use

For dermatologists, removes the shackles of regular office hours*

OHIP billable (for derms)

OHIP billable for referrers

Delegate model allows for distributed workflow

“I spent the day today relaxing poolside with my laptop and was able to catch up on a few cases while my kids swam. I find the flexibility of doing the cases on my own time is convenient.”

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Like using you iPad as a cutting board…

Work flow at some referring clinics: hybrid of Otn.teledermSF and paper

Delegate handles Otn.teledermSF

Consult notes are printed and handed to the physician Perhaps complete physician adoption requires full integration with EMR

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Adoption Strategies

Referring:

Delegate model

Any camera

Standardized photo kit

Dermatologists:

Dermatologists encourage adoption with their usual referrers

General:

Supports: training, work flow, RMs, Service Desk

Continuous quality improvements

No iPhones for you!

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Benefits for dermatologists

OHIP Billable

Flexibility to provide diagnosis and treatment when and where convenient

Efficient & effective way to treat patients leading to decreased wait times

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Benefits for referrers

Consults provided within 5 days on average

OHIP billable as an eReferral

Reduces “n” trials of “X” treatments

Timely referrals leading to improved patient outcomes

Increased collaboration with specialist = increased capacity

Potential to reduce costs through efficient referral process (vs. f2f)

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Other User Benefits

OTN develops relationship with dermatologists – no need to search for available derms

Pan-provincial initiative

Collaboration with OneID

OTN Service desk

OTN RMs

Advocacy

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What referring docs are saying

I find Telederm incredibly useful, I have sent 3-4 patients so far and I received speedy advice within 2 days. It is an amazing service. I am very happy being able to use it. Thanks for your help

Dr. Lili Mileva

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What referring users are sayingWe had less than 24 hour turn around with 2 of our uploaded files and they were to Dr. G. [Our] doctors  had a faxed copy of consultation report in less than 24 hours. That's amazing!

I set this up approximately 3 months ago and the MD's at my clinic are really impressed with the efficient manner in which the referrals are received and processed. The MD's are also satisfied with the recommendations from the specialists. I would highly recommend this program; it meets the needs of many clients.  Regular wait times for a Dermatologist can be 8 mo to 1yr. We facilitate their assessment in less than a month.  Fantastic!!!

I have found the OTN TeleDerm process to be a very quick and easy way of obtaining a specialist's opinion for our patients. The average response time is about 2 days, which is remarkable!  The patients are very happy to have a diagnosis so quickly. In most of the cases the specialist recommended medication and it was beneficial to the patient to be able to start on the treatment in a timely fashion.

I got my first SF referral answered in less than 24 hrs!! It’s amazing.

I personally have had two consults now with Dr. W and have been thrilled with the results.  One actually came back the same day I sent it. She lays out the differential diagnoses, advises if biopsy necessary to determine correct diagnosis, and then provides outline of therapeutic plan for each possible outcome. Clear as can be, and so helpful. Patients are thrilled.

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What dermatologists are saying

I must say that I enjoy doing these store forward consultations.  I find that the focus is somewhat different than in-office consultations.  I tend to give more useful basic information to the PCP, knowing that this physician will be taking active care of the patient in most cases, especially when located some distance from major centres.

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eConsult fees

Referring docs can bill the referral as an eConsult

E-Consultation (Physician to Physician):– This is a service where the referring Physician, in light of

his/her professional knowledge of the patient, requests the opinion of another Physician. The “consultant Physician” is able to offer competent advice to provide an accurate opinion. Both the request and the opinion are sent electronically through the use of a secure server.

Billing Code:– K738 Physician to Physician e-consultation (Referring

Physician)

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Challenges to the program

In polite conversation topics to avoid:1. Religion

2. Politics

3. Sex

4. OHIP fees

Consult fees were $72 up to March 31st 2013

As of April 1st 2013 fees moved to $44

MoHLTC and OMA have been apprised of the concerns expressed over the reduced fees

eReferral cannot be billed same day

Counter productive to the efficiency of Store Forward

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Potential Expansion

TeleWound care

(in pilot now)

TeleDentistry

(exploration)

TelePsychiatry

(pilot starting summer 2013)

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What are the steps to get Otn.teledermSF?

Contact OTN (info@otn.ca)

OTN will contact you

You will receive a password

The password gives you access to the online training

materials/videos as well as to Otn.teledermSF itself

Once training is completed (about 45 minutes) you

can start referring patients right away

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It takes a village…

Manish Rughani– Supervisor & Systems Administrator, Technical

Operations

Sev Derghazarian– Telehealth Hardware/Software System Support

Specialist & Systems, Technical Operations

Joy Harris – Provisioning Group, New Site

Matt Sherman – Business Analyst, Service Optimization

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Contact information

Stewart SteinManager Store ForwardEmail: sstein@otn.ca (preferred)

Phone: 416-446-4110 x4118

Thank you!

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APPENDIX

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Costs

No annual fees

No set-up fees

No licensing costs

OTN is a not-for-profit funded by the Government of Ontario

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The Ontario Telemedicine Network

An independent not-for-profit corporation funded by the Government of Ontario

Members include 1,000 health care and education organizations

Delivery partners include:– e-Health Ontario– Keewaytinook Okamakanak

Telemedicine– Canada Health Infoway

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OTN: Available Everywhere

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One of the world’s largest & most active TM networks

Programs & services delivered collaboratively at more than 1,600 sites (>3,000 systems) across Ontario

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Studies

Teledermatology Patient Satisfaction in the Pacific Northwest - Martha T. Hsueh, R.N., Kristin Eastman, M.D., Lynne V. McFarland, Ph.D., Gregory J. Raugi, M.D., Ph.D., and Gayle E. Reiber, M.P.H., Ph.D.

A cost minimisation analysis in teledermatology: model-based approach - Nina Eminović1*, Marcel G Dijkgraaf2, Rosanne M Berghout1, Astrid H Prins3, Patrick JE Bindels4, Nicolette F de Keizer1

Netherlands study shows dermatologists using telemedicine to provide efficient care at lower costs - van der Heijden JP, de Keizer NF, Bos JD, Spuls PI, Witkamp L.

Teledermatology Operational Considerations, Challenges,and Benefits: The Referring Providers’ Perspective - April W. Armstrong, M.D., M.P.H.,1 Mei W. Kwong, J.D.,2, Elizabeth P. Chase, M.D.,1 Lynda Ledo, B.S.,1, Thomas S. Nesbitt, M.D., M.P.H.,3, and Sandra Louise Shewry, M.P.H., M.S.W.2

Telemedicine boosting dermatology care - CAROLYNE KRUPA http://www.ama--assn.org/amednews/2012/01/30/prsc0131.htm