Virtual Clinics and Electronic Decision Support

Dr Anna RantaConsultant Neurologist, Lead Stroke Physician &

Head of NeurologyMidCentral Health

Associate Dean, Undergraduate Studies University of Otago (PN)

Innovative Approaches to Improving Access to FSAs in Neurology

The Problems – 4 years ago• 2 ½ year neurology wait lists• “Urgent” patients waiting up to 6 months• Limited ability to see very high risk patients in

outpatient clinic frequent preventable admissions

• Neurophysiology reporting times taking up to 6 months from when test performed

Solutions• Pts waiting for > 6 month returned w/ request for

updates re-referral 1 re-referred• FSA clinic appointments shortened• RN doing phone F/U; Limited specialist F/U• Technician reporting; reporting time tracking• Inpatient service consultative only• GP referrals programme for CT for HA pts• Virtual Clinics• Electronic Decision Support for GPs

Virtual Clinics

• A.k.a. non-contact first specialist assessments• Patients anticipated to

– (a) likely wait more than 6 months– (b) have simple problems better served with quick

written response– (c) needing primarily an investigation

• Triaged into “Virtual Clinics”• Full record, imaging, and laboratory review

Audit Data

• July 2008 – August 2009• 1,107 referrals to Neurology outpatient clinic• Referrals to TIA clinic excluded*• 802 (72.5%) traditional face-to-face appt• 83 (7.5%) returned or forwarded• 222 (20%) triaged into virtual FSA• Face-to-face = 45 min; virtual = 15 min

GPs77%

Hospital20%

Private3%

Referral Details

Headache59%

Seizure/Blackout21%

Movement Disorder6%

Chronic Pain 5%

Dizzy/Vertifo6%

Memory3%

Outcomes

• Re-referrals:– 5 (2.25%) at 1 month 4 triaged into reg. clinic– 25 (11.26%) at 6 months 17 into reg clinic

• Admissions:– 4 (1.8%) at 1 month– 13 (5.86%) at 6 months

• Adverse events:– 3 (1.35%) delays in dx (BIH,neuropathy, meningioma)– 1 of these 3 (0.45%) w/ detriment (meningioma)

Outcomes• Wait list from nearly > 2 years to 3-6 months• All patients receive some type of advice• Early GP feed back very positive• Formal GP and patient survey on going• Now funded as ~ 1/3 of full FSA (1/3 time)• Hoping for funding for

– (a) virtual follow-ups– (b) reimbursement for tests ordered– (c) RN follow-up calls

TIA/Stroke: Special Case

• TIA and minor strokes are medical emergencies• Early Rx initiation essential to prevent stroke• In confirmed cases work-up needs to be

accomplished within 24hrs - 7 days• Difficult to achieve in specialist TIA clinic

– (a) too many non-TIAs referred clogged clinic– (b) 24 hours not feasible ED– (c) some patients prefer not to come to hospital

may never get access to appropriate care

Electronic Decision Support

• Helps GP make accurate diagnosis• Helps GP triage/assess 7 day stroke risk• Helps GP to manage in community if desired• Helps GP order tests and manage according to NZ

guidelines• Helps GP with referrals, prescriptions, and patient

information• Free adjunct to “bestpractice” modules in place of

70% of GPs practices across NZ

Baseline Data• Jan-Jun 2009 TIA Clinic Audit Data:

– 79 patients referred to TIA clinic w/ ?TIA (57% GPs)

• 29% definite TIA; 71% Not TIA/Dx uncertain• 78% high Risk (ABCD2 =>4) and 22% low risk• Only 1.6% high risk seen w/in 24 hrs• Only 30% Rx’d best medical therapy (BMT) w/in 24hrs

• Stroke expert vs GP (Cross sectional study)

– 23 practitioners assessed 7 cases– Stroke experts highly consistent and guideline

based– GPs 24% correct Dx; Only 23% started drugs;

F/U TIA audit data

• Jan-March 2010

• 26 total TIA referrals (4/month vs 7.5/month pre EDS)

• TIA referral, BMT and Carotid US happen earlier

• More complex cases seen in TIA clinic• To date no adverse events identified except

for when GP did not follow EDS advice• EDS more consistent/guideline based in care

than GPs or specialist (cross sectional study)

GP TIA clinic GP Carotid US

GPBMT accomplishedBMT w/in 24 hrs ‘09 vs’10

Best Medical Rx Started <24 hrs?

Summary

Amongst several other innovative changes VIRTUAL CLINICS and ELECTRONIC DECISION SUPPORT appear to make a real difference in specialist access

Thank you!

Questions?