Above and beyond: How do SCAN-ECHO consultations facilitate communication between primary and specialty care providers?

1. Above and beyond How doesSCAN-ECHOfacilitate communicationbetweenprimaryand specialtycare providers? HSR&D/QUERI National Conference Philadelphia, PA July 10, 2015

2. Authors Christopher J. Koenig, PhD San Francisco VA Matthew Wenger, MD San Francisco VA Glenn Graham, MD San Francisco VA/VISN Susan Kirsch, MD Office of Specialty Care Thom Taylor, PhD Palo Alto VA Steve Asch, MD, MPH Palo Alto VA Catherine Rongey, MD, MPH San Francisco VA Supported by VA HIV/Hepatitis QUERI SDP #12-550 (PIs: Rongey & Asch)

3. Consultations Consults enable cross-provider collaboration. Written consults are traditional. Communication quality is variable Inappropriate referral Incomplete and partial information Outcome uncertainty Sewell, et al., 2013 AM J Med

4. Health Information Technology HIT proposes additional solutions. E-Consults Video teleconferencing Project ECHO VHAs SCAN-ECHO Arora et al., 2011 N Engl J Med 1. Foster general & specialist communication 2. Create knowledge networks 3. Improve patient health outcomes

5. Knowledge Gap How does SCAN-ECHO facilitate generalist-specialist communication and collaboration for specialty care needs?

6. Data Collection Qualitative Data Scale Qualitative Data Types SCAN-ECHO sessions n= 2 VAMC sites Session video recordings N= 32 sessions Site 1 = 17 Site 2 = 15 ~45-60 minutes ~1440-1920 min Session transcripts 20-30 pages/session ~640-960 pages

7. Analysis Discourse analysis Sociolinguistic methodology Naturalistic paradigm Analyzes language in use in real-world settings To discern recurrent activities and social actions To make social practices available for critical evaluation and improvement

8. What activities make up a single SCAN-ECHO session?

9. SCAN-ECHO Session Organization Team Work Logistics Consults Didactic 7 min 10 min 15 min15 min Average Session Duration Site 1 52 min Site 2 55 min

10. What activities make up asingle SCAN-ECHO consult?

11. SCAN-ECHO Consult Organization Next Speaker Presentation Discussion Assessment & Plan Social Talk Average Consults/Session Site 1 4.3 Site 2 4.6 Average Consult Duration Site 1 6 min Site 2 10.5 min Consult 1+n Consult 1

12. SCAN-ECHO Consult Organization Next Speaker Presentation Discussion Assessment & Plan Social Talk Consult 1+n Question Problem Consult 1 Solution

13. Verbatim Consult Question So, hes a 60-year-old guy, hepatitis C, phenotype I. He has been told that he has a diffusely nodular liver. And I dont think he had a history of a biopsy prior. As he was getting his housing and his other stuff stabilized, he had a series of follow-up appointments. He had three things to do: an education class, which he completed; and two, he needs more psychosocial stuff; and then third thing is to complete the MRCP. So, he has this MRI result, and I just need feedback on how were interpreting it for him.

14. Data transformation Verbatim Question Standard Question Generalizable Question What is the meaning of test finding X? So, hes a 60-year-old guy, hepatitis C, phenotype I. He has been told that he has a diffusely nodular liver. And I dont think he had a history of a biopsy prior. As he was getting his housing and his other stuff stabilized, he had a series of follow-up appointments. He had three things to do: an education class, which he completed; and two, he needs more psychosocial stuff; and then third thing is to complete the MRCP. So, he has this MRI result, and I just need feedback on how were interpreting it for him. How do I interpret this MRI result?

15. Standard question categories 0 10 20 30 40 50 60 70 Site 1 (N=57) Site 2 (N=63)

16. Data transformation Verbatim Question Standard Question Generalizable Question What is the meaning of test finding X? So, hes a 60-year-old guy, hepatitis C, phenotype I. He has been told that he has a diffusely nodular liver. And I dont think he had a history of a biopsy prior. As he was getting his housing and his other stuff stabilized, he had a series of follow-up appointments. He had three things to do: an education class, which he completed; and two, he needs more psychosocial stuff; and then third thing is to complete the MRCP. So, he has this MRI result, and I just need feedback on how were interpreting it for him. How do I interpret this MRI result?

17. Generalizable question categories 1 What is the cause of symptom X? 2 How should I manage disease or finding X? 3 How should I treat finding or disease X? 4 What is the meaning of test finding X? 5 Could this patient have disease or condition X? 6 Is test X indicated in situation Y? 7 What is the drug of choice for condition X? 8 Is drug X indicated in situation Y? 9 Should I dis/continue with drug X? 10 How can I best communicate situation X to patient? 11 How should I respond to patient request for treatment X? 12 How do I order a non-standard text X? 13 Is condition X the cause of test finding Y? 14 No identifiable question*

18. Limitations Limits to generalizability Two high-performing sites One disease condition (HCV) Questions are a single aspect of the consultation New methodology to open the black box of provider-to-provider interaction

19. Conclusions Provider-to-provider communication is largely unexplored and under-researched. SCAN-ECHO consults have an advantage over standard consults. Provide clinical, psychological, and social contexts in a narrative format that can be tailored to the situation. Interactive feedback according to unique concerns. Novel methodology can be used to Evaluate complex (HIT) interventions Develop recommendations for improving communication between providers

20. Thank you! For questions or comments please contact: [email protected]

Above and beyond: How do SCAN-ECHO consultations facilitate communication between primary and specialty care providers?

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