Julie Maranger

Ten Steps to Establishing an e-Consultation Service to Improve Access to Specialist Care

There is dissatisfaction among primary care physicians, specialists, and patients with respect to the consultation process. Excessive wait times for receiving specialist services and inefficient communication between practitioners result in decreased access to care and jeopardize patient safety. We created and implemented an electronic consultation (e-consultation) system in Eastern Ontario to address these problems and improve the consultation process. The e-consultation system has passed through the proof-of-concept and pilot study stages and has effectively reduced unnecessary referrals while receiving resoundingly positive feedback from physician-users. Using our experience, we have outlined the 10 steps to developing an e-consultation service. We detail the technical, administrative, and strategic considerations with respect to (1) identifying your partners, (2) choosing your platform, (3) starting as a pilot project, (4) designing your product, (5) ensuring patient privacy, (6) thinking through the process, (7) fostering relationships with your participants, (8) being prepared to provide physician payment, (9) providing feedback, and (10) planning the transition from pilot to permanency. In following these 10 steps, we believe that the e-consultation system and its associated improvements on the consultation process can be effectively implemented in other healthcare settings.

Transition of Patients with Type 2 Diabetes from Specialist to Primary Care: A Survey of Primary Care Physicians on the Usefulness of Tools for Transition

Transition from specialty to primary care for patients with type 2 diabetes has not been well studied. Stable patients may be retained in specialty clinics due to concern over the maintenance of diabetes care post-discharge, thus limiting access to specialists for new referrals. Understanding primary care physicians’ perceptions of barriers to diabetes care and the helpfulness of existing tools used in the transition back to primary care is important for facilitating the transition process. Objectives were 1) to determine the perceived helpfulness of preselected tools that could be used in the transition of patients from specialist to primary care; 2) to identify the barriers to implementation of evidence-based diabetes care from the primary care perspective; and 3) to identify the tools used currently by primary care physicians during the transition process.

Using a Structured Discharge Letter Template to Improve Communication During the Transition from a Specialized Outpatient Diabetes Clinic to a Primary Care Physician.

OBJECTIVE Transition from specialists to primary care physicians is dependent on clear communication by means of a discharge letter. Primary care physicians have indicated that letters from specialists rarely contain the details they require. As part of a quality-improvement project to improve the transition from diabetes clinics to primary care physicians, a structured discharge letter template was developed to facilitate the dictation of useful letters by specialists. The objective was to evaluate the content and quality of discharge letters created using a structured discharge letter template as compared to letters completed without the template. METHODS Retrospective study of patients treated at the Ottawa Hospital and discharged from the outpatient diabetes clinic between November 1, 2009, and December 1, 2010. The letters were reviewed by 2 independent reviewers and were assessed for content, brevity, clarity, management plan, organization and quality. Word count, dictation and transcription times were also compared. RESULTS Letters completed using the structured discharge letter template were more comprehensive and more likely to contain guidelines on management for glycemic control (51.1% vs. 14.1%; p<0.001); cardiovascular risk factors (65.61% vs. 9.8%; p<0.001); diabetes complications (79.9% vs. 5.9%; p<0.001); and provided re-referral criteria (89.3% vs. 15.7%; p<0.001). Dictation time did not differ between formats. Transcription time (20:65 min vs. 13:45 min; p<0.01) and word count (502 words vs. 292 words; p<0.001) were higher with the template. CONCLUSIONS The use of a structured discharge letter template improved the content and quality of discharge letters dictated by specialists. Primary care physicians were more consistently provided with valued information and given criteria for re-referral.

Transition of Patients with Diabetes From Specialist To Primary Care: A Survey Of Specialists on Tools, Determinants & Barriers for Transition

The Tools For TransitionTM Program: Characteristics and Disposition of Patients referred to a Multidisciplinary Diabetes Clinic *CHETNA TAILOR, JANINE C MALCOLM, JULIE MARANGER, ERIN KEELY, SHARON BREZ, SHERYL IZZI, MONICA TALJAARD, TEIK CHYE OOI Division of Endocrinology & Metabolism, University of Ottawa. The Tools for TransitionTM Program at the University of Ottawa was developed to improve the transition of patients with type 2 diabetes (T2D) from specialists back to their primary care physicians (PCP). To understand the current situation, a chart review of 120 T2D patients referred to the Foustanellas Endocrine and Diabetes Center from January 1, 2005 to June 30, 2005 by PCP was completed to Nov 2007 to Feb 2008 to document demographic data, medical status, medication use, process and outcome of care indicators. Results: mean age 59.5 years, mean duration of diabetes 8.84 years, 60% male, HTN 74%, dyslipidemia 75%, CVD 20%, nephropathy 28%, neuropathy 26%, retinopathy 17%, and psychiatric illness 19%, 27% were on insulin at the time of referral, and 18% were later placed on insulin by the clinic. 23/120 (19%) were discharged back to their primary care physician after attending the clinic for a mean duration of 12 months, 38/120 (32%) continue to be followed in the clinic and 55/120 (46%) were lost to follow-up (patient did not attend clinic despite scheduled visit), 2/120 (1.5%) died and 2/120 (1.5%) were transferred to another clinic. As expected, a high proportion of patients referred to a speciality diabetes clinic have complications of diabetes, co-morbid conditions, and are treated with insulin Only 1 in 5 patients were discharged within the audit period of about 3 years. An unexpectedly high proportion of patients were lost to follow-up. This has inadvertently helped to relieve the build-up of follow-up patients in the centre caused by a low discharge rate. Further study into the low discharge rate and possible reasons for the loss to follow-up is warranted. ABSTRACT #197