Improving Family Physician and Specialist Communication

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Improving Family Physician and Specialist
Communication CoordinationBridging General
and Specialist Care (BGSC) the Catalogue of
Specialized Services (CSS)

• Winnipeg, Manitoba
• October 29, 2009

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Overview Two Decision Support Systems

• Bridging General to Specialist Care (BGSC), and
• Catalogue of Specialized Services (CSS)

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Bridging General and Specialist Care

• What is BGSC?
• Project team
• Clinical Content Development Process
• IT Development / Specs
• Current Status Lessons learned to date
• Successes Challenges
• Screen Shots

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Catalogue of Specialized Services

• What is CSS?
• Progress?
• IT Specs
• Current Status
• Lessons Learned
• Success Challenges
• Screen Shots / Demo

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Bridging General and Specialist Care (BGSC)
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What Is BGSC?

• An IT system to support Primary Care
  interventions and referrals (when appropriate)
  which consists of
• mutually agreed upon scopes of practice, referral
  guidelines requirements
• mutually agreed upon information requirements for
  transitioning the patient back to primary care
• target timeframes for consultation recourse

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Implemented to

• Support agreed scopes of practice and streamline
  the referral to consultation journey
• Ensure patients are seen by the right specialist
  at the right time
• Ensure the first meeting between the patient and
  specialist is as productive as possible
• Foster communication between levels of care
• Provide patients with assurance that they will be
  provided care in a timely fashion

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Project Team

• Provincial Director, Patient Access
• Got clinicians bought in
• Set the vision
• Managed clinical issues
• Project Director / Project Manager
• Managed project activities / project team
• Budget / Reporting
• IT Project Director IT Project Manager
• Vendor contracting and coordination
• Clinic technical assessments
• Coordination of Hardware deployment

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Project Team

• Software Development Team
• Small, local, software development company
• 4 developers, 1 PM
• Project Coordinators / SMEs
• 4 WTTF PM staff, 1 admin
• Administrative activities, lit reviews, meeting
  management, brought food!
• Keep clinicians on track to meet deliverables
• Engagement
• Dissemination
• IT development
• Training
• Relationship management

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Clinical Content Development Process

• 5 on 5s
• Small groups of FPs and Specialists in each area
• Worked out the scope of practice and rules
  over 4 8 meetings
• Paid time, mostly evening meetings
• Disseminated to larger groups for feedback and
  input
• Presented to Forum of FPs and Specialists from
  other practice areas
• May December 2008 (minus the summer!)

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Clinical Content Development

• 28 FPs in practice groups
• 41 Specialists in practice groups
• up to additional 60 FPs and Specialists
  attending forums, participating in large group
  dissemination/feedback
• Modifications to some pathways made following
  feedback from IT system usage in August, Sept,
  Oct

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Pathways

• Pathways Completed
• Cancer Colorectal Screening
• Cancer Lung Cancer Dx
• Mental Health Depression Anxiety
• Orthopedics / Neurosurgery Back Assessment for
  Surgery
• Lower Back Pain Management
• Orthopedics Chronic Hip and/or Knee Pain
• Plastic Surgery Breast Reduction, Delayed
  Breast Reconstruction, Skin Lesion, Carpal Tunnel

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Pathways contd

• Requests for more!
• MRI
• Gynecology
• Other orthopedics
• Additional Cancer Paths
• ENT
• Dermatology

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IT Development

• RFP released Nov 5
• Vendor selected Dec 18
• Development began Jan 2
• IT Demo to clinicians February 19 for feedback
• Small Physician User Group Testing
• Go Live March 16
• Minor releases hot fixes based on user feedback
  throughout May, June
• V2 release August 1 IT functionality changes
• V3 release November 1 pathway changes

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IT Specs

• BGSC Web Application
• Written using ASP.net and Silverlight
• Hosted within IIS on Windows server
• Layered architecture consisting of
• ASP.NET web pages and controls
• third party ASP.NET controls
• Presenter and Controller classes (for MVC and MVP
  pattern implementation)
• Entity classes (for business objects)
• Service proxy classes (for accessing business
  services)
• This component is stateless so that it can scale
  efficiently to handle larger number of users, and
  so that multiple instances of the web application
  can be hosted on different servers to accomplish
  load-balancing if required.

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Engagement

• Clinician Engagement
• In person lunch time / evening demos overviews
  of the pathways
• RHA-specific events / dinners to demo
• Secondary engagement occurred at many sites
• Signed Letters of Understanding (clear
  articulation of expectations on both sides)
• 156 family physicians signed on, 40 specialists
• unable to quantify of psychologists,
  psychiatrists, pain clinicians as participating
  as central intakes

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Enticement

• Technical assessments performed at each clinic
• Provided hardware required to participate where
  necessary
• Includes desktops, laptops, internet connections,
  routers, clinic wiring
• Desktops / laptops pre-imaged to include
  necessary BGSC software (Adobe, Silverlight)
  other programs clinic / MD responsibility
• Approx 250K in hardware provided

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Training Support

• Training
• One on one group training with every clinician
  and office staff in clinics
• Retraining provided as requested or as determined
  necessary based on system utilization
• BGSC Support Line
• Level 1 support provided by SMEs, BGSC project
  team staff
• Help Desk staffed 9-5
• Help email available to users for non-urgent
  issues
• On site support / retraining available as
  requested / required
• Level 2 support provided by vendor, via BGSC
  project team staff (no vendor to clinician
  interaction)

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Dissemination

• Mail out dissemination of pathways to all FPs in
  MB
• In-person visits with over 30 rural clinics
  throughout MB, 100 urban clinics
• CME sessions planned for U of M Fridays at Noon
  throughout 09/10
• Individual clinic lunch and learns arranged at
  several clinics

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Successes

• High participation rates from clinicians in
  pathway development
• Clinicians expressing belief that Primary Care
  referrals will be improved as a result of
  guidelines / pathways
• Clinical content delivered on time / within
  budget
• Broad awareness and interest of the project
• IT delivered on time, on budget
• FPs and specialists participating as developers
  of the product not just testers part of the
  project team

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Successes

• Vendor and product being showcased by Microsoft
  worldwide as innovated solution using Silverlight
  
• Vendor and product nominated as 1 of 3 Canadian
  companies for Microsoft international innovation
  award
• Interest from other provinces and national
  agencies such as Canadian Mental Health
  Association, Canadian Spinal Society
• Desire expressed by Health Canada to build on the
  Manitoba model through creation of a national
  BGSC initiative, engaging Canadian Medical
  Association, affiliated specialist associations
  and family physician associations

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Challenges

• Highly intensive process for project team,
  extremely hands on, managed moment by moment
• Extremely tight timelines for IT development and
  implementation
• Coordinating IT deployment, IT hardware, training
• Tight timelines work for you, and against you
• Fitting in the system in the context of 1000
  other referrers

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Challenges

• Navigating a partially electronic, partially
  paper based system
• DI, labs, physio reports paper faxed, referral
  hx electronic
• Implemented attachments on system, visual cues of
  faxed documentation to align with BGSC referrals
• Getting users to use the system!
• If users arent on the system within 1 week of
  training date, they dont seem to get on the
  system
• Reconnect, retrain, and as last resort take the
  computers back!
• Visual reminders and cues to use the system
• Implemented BGSC posters for clinic rooms, BGSC
  stickers for files
• Using the system for 10 of workload, using
  traditional processes for 90 of workload

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Tour of BGSC
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Catalogue of Specialized Services (CSS)
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What is the Catalogue of Specialized Services?

• A web-based inventory of physicians and the
  specific specialized services they provide within
  their given service area (i.e. orthopedics does
  feet, ankles, does not do shoulders) and links
  with other providers (Contact)
• Physician maintained on the web
• Implemented to
• Ensure patients are seen by the right physicians
  (one who delivers the service)
• Maximize awareness of who is providing which
  services (not just traditional referral paths)
• We are tired of sending referrals to a
  specialist, only to get it back 6 months later
  with a note saying they dont provide that
  service or they dont provide it any more

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IT Specs

• CSS Web Application
• Written using C ASP.NET
• Hosted within IIS on Windows Server 2003
• N-tier architecture consisting of
• ASP.NET AJAX web pages and controls
• Separate App server Web server
• both using II6 Microsoft .NET framework v3.5
• Database server SQL Server 2005
• Web technology selected to
• Minimize dependency on proprietary products
• handle larger number of users across diverse
  environment
• Allow multiple instances of the web application
  can be hosted on different servers to accomplish
  load-balancing if required.

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Progress?

• Compilation of data completed March to September
  08
• CD version released October 15th 08, distributed
  to FPs, NPs, RHAs
• Web development initiated September 08
• Web-version soft release December 16th 08, hard
  release Jan 12, 09
• Passwords and usernames provided to all MB
  physicians, RNEPs, midwives and RHAs
• Significant functionality updates and
  improvements since go live
• Continuing to do demos of CSS, teach users how to
  maximize usage
• Establishing partnerships in RHAs to increase
  clinician usage in uptake, updating and
  efficiency in usage
• Lots of FPs asking to be listed for specialized
  FP services or functional specialties (i.e.
  sports med, vasectomies, etc)

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Current Status

• Approx 2500 user names assigned
• Currently 1869 logins (other than staff and Dr.
  Oppenheimer!)
• 6347 searches performed
• 1177 user maintenance activities captured
• Currently analyzing searches (most common, etc)

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Successes

• 70 response rate in paper version, growing with
  IT version
• Clinicians expressing excitement about the
  product
• 1st product of its kind in Canada
• Numerous provinces requesting information,
  indicating intent to duplicate Catalogue
• Expanding participation (everyone wants to be in
  scope!)
• Helpful info on what services are being looked for

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Challenges

• Keeping it up to date (getting clinicians to keep
  their info up to date)
• Nomenclature the details
• Expanding participation (everyone wants to be in
  scope!)
• Sustainability

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Tour of Catalogue of Specialized Services

• And other non-physician resources

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Abnormal (Cardiac), nobody does CABG
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Display Contac Search (Other services).
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Lessons Learned

• CSS is a market research tool
• What FPs are searching for and how
• If not found why (not easy to find or not
  available).
• Allows to improve with feedback
• FPs and Specialists talk different languages.
• List only what makes them special
• List more than they can handle.

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Next Steps

• Improving and Developing Booking System

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Thank You

• Questions?