eConsults' Impact on Care Access and Wait Times in Rheumatology.

BACKGROUND/OBJECTIVE: A growing number of health systems have implemented eConsults to improve access to specialty advice, but few studies have described their use in rheumatology or impact on visit wait times. We evaluated the uptake of an eConsult program and its impact on wait times for in-person rheumatology visits. METHODS: In this quality improvement project, we analyzed electronic health record data from 4 intervention clinics and 4 comparison clinics, 12 months before and after implementation of an eConsult program. We compared median wait time for rheumatology appointments using a pre-post difference-in-differences analysis and quantile regression, adjusting for patient age, race, sex, clinic pair, and primary insurance payer. We also interviewed 11 primary care providers from the intervention clinics and conducted a rheumatology provider focus group (n = 4) to elucidate experiences with the program. RESULTS: Rheumatologists recommended management in primary care or referral to another specialty for 41% of eConsults, reducing initial demand for in-person visits. The median wait times dropped in the intervention and the comparison clinics (42 and 25 days, respectively). Intervention clinic median wait time dropped 17 days more than comparison clinics, and this was nonstatistically significant (p = 0.089). eConsults fit provider care tasks best for triage or initial workup for diagnosis, and less well when tests required interpretation, or when back and forth communication was needed to manage the patient's condition. CONCLUSIONS: Implementation of eConsults for rheumatology was associated with reduced wait times for rheumatology appointments and supported primary care providers in the triage and workup for a substantial portion of patients.

Implementation Evaluation of a Teledermatology Virtual Clinic at an Academic Medical Center.

Background: Teledermatology (TD) is an evidence-based practice that may increase access to dermatologic care. We sought to evaluate implementation of TD at four Duke primary care practices. Methods: We implemented a hybrid TD program where trained primary care providers (PCPs) sent referrals with clinical and dermatoscopic images to dermatology. Patients were seen by dermatologists over video visit within days, and dermatologists managed the patient plan. We evaluated implementation using the Reach, Efficacy, Adoption, Implementation, and Maintenance (RE-AIM) framework using electronic health record data. Implementation barriers and facilitators were collected through surveys (n = 24 PCPs, n = 10 dermatologists, n = 10 dermatology residents). Results: At four PCP clinics throughout 9/1/2021-4/30/2022 there were 218 TD referrals. Video visits occurred on average 7.5 days after referral and 18/18 patients completing the post-visit survey were satisfied. Adoption varied between clinics, with one placing 22% of all dermatology referrals as TD and another placing 2%. The primary PCP barriers to TD were time burdens, lack of fit in clinic flow, and discomfort with image taking. Top-endorsed potential facilitating interventions included allowing for rash referrals without dermoscopy and assurance for clinical evaluation within 3 days. Conclusions: Addressing TD process fit into PCP clinic flow and reducing time burdens may increase PCP uptake of TD.

Implementation evaluation of a teledermatology virtual clinic at an academic medical center.

BACKGROUND: Teledermatology (TD) is an evidence-based practice that may increase access to dermatologic care. We sought to use the Exploration, Preparation, Implementation, and Sustainment (EPIS) and the Reach, Efficacy, Adoption, Implementation, and Maintenance (RE-AIM) frameworks to evaluate implementation of TD at Duke. METHODS: The EPIS and RE-AIM frameworks were deployed to design and implement a TD program that leveraged the strengths of the Duke University Health System and addressed previously reported barriers to implementation of store-and-forward and synchronous TD models. In the resultant hybrid TD model, trained primary care providers (PCPs) sent e-comm referrals with clinical and dermatoscopic images to dermatology. These e-consults were reviewed asynchronously and patients were scheduled for a synchronous video visit with dermatology within days. Dermatologists managed the patient plan. This hybrid TD model was piloted at four primary care clinics. Pertinent outcomes from a TD-adapted RE-AIM framework were tracked using electronic health record data. Patient satisfaction was assessed using a post-video visit survey (n = 18). Implementation barriers and facilitators were also collected through provider surveys (n = 24 PCPs, n = 10 dermatologists, n = 10 dermatology residents). RESULTS: At four PCP clinics throughout 9/1/2021-4/30/2022, there were 218 TD referrals. Video visits occurred on average 7.5 ± 0.5 days after referral and 18/18 patients completing the post-visit survey were satisfied. Adoption varied between clinics, with one placing 22% of all dermatology referrals as TD and another placing 2%. The primary PCP barriers to TD were time burdens, lack of fit in clinic flow, and discomfort with image taking. Top-endorsed potential facilitating interventions included allowing for rash referrals without dermoscopy and assurance for clinical evaluation within 3 days. CONCLUSIONS: The use of implementation science frameworks allowed for identification of system and contextual strengths which informed the hybrid TD pilot. Barriers and facilitating interventions will provide guidance for expansion and ongoing maintenance of TD.

Care teams misunderstand what most upsets patients about their care.

BACKGROUND: Negative healthcare delivery experiences can cause lasting patient distress and medical service misuse and disuse. Yet no multi-site study has examined whether care-team members understand what most upsets patients about their care. METHODS: We interviewed 373 patients and 360 care-team members in the medical oncology and ambulatory surgery clinics of 11 major healthcare organizations across six U.S. census regions. Patients deeply upset by a service-related experience (n = 99, 27%) answered questions about that experience, while care-team members (n = 360) answered questions about their beliefs regarding what most upsets patients. We performed content analysis to identify memorably upsetting care (MUC) themes; a generalized estimating equation to explore whether MUC theme mention frequencies varied by participant role (care-team member vs. patient), specialty (oncology vs. surgery), facility (academic vs. community), and gender; and logistic regressions to investigate the effects of participant characteristics on individual themes. RESULTS: MUC themes included three systems issues (inefficiencies, access barriers, and facilities problems) and four care-team issues (miscommunication, neglect, coldness, and incompetence). MUC theme frequencies differed by role (all Ps < 0.001), with more patients mentioning care-team coldness (OR = 0.37; 95% CI, 0.23-0.60) and incompetence (OR = 0.17; 95% CI, 0.09-0.31); but more care-team members mentioning system inefficiencies (OR = 7.01; 95% CI, 4.31-11.40) and access barriers (OR, 5.48; 95% CI, 2.81-10.69). CONCLUSIONS: When considering which service experiences most upset patients, care-team members underestimate the impact of their own behaviors and overestimate the impact of systems issues. IMPLICATIONS: Healthcare systems should reconsider how they collect, interpret, disseminate, and respond to patient service reports. LEVEL OF EVIDENCE: Level III.