1. 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

2. 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

3. 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

4. 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

5. 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

6. Referral Details

7. 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)

8. 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 – (a) virtual follow-ups – (b) reimbursement for tests ordered – (c) RN follow-up calls

9. TIA/Stroke: Special Case 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

10. 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

15. 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 Stroke expert vs GP (Cross sectional study) – 23 practitioners assessed 7 cases – Stroke experts highly consistent and guideline based – GPs 24% correct Dx; Only 23% started drugs;

16. F/U TIA audit data Jan-March 2010 26 total TIA referrals (4/month vs 7.5/month pre EDS) TIA referral, BMT and Carotid US happen earlier More complex cases seen in TIA clinic To date no adverse events identified except for when GP did not follow EDS advice EDS more consistent/guideline based in care than GPs or specialist (cross sectional study)

17. GP  TIA clinicGP  Carotid US GP  BMT accomplishedBMT w/in 24 hrs ‘09 vs’10

18. Best Medical Rx Started <24 hrs?

19. Summary Amongst several other innovative changes VIRTUAL CLINICS and ELECTRONIC DECISION SUPPORT appear to make a real difference in specialist access Thank you! Questions?