Virtual Clinics and Electronic Decision Support Dr Anna Ranta Consultant Neurologist, Lead Stroke Physician & Head of Neurology MidCentral Health Associate Dean, Undergraduate Studies University of Otago (PN) Innovative Approaches to Improving Access to FSAs in Neurology
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Virtual Clinics and Electronic Decision Support Dr Anna Ranta Consultant Neurologist, Lead Stroke Physician & Head of Neurology MidCentral Health Associate.
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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
• 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