Tuot Delphine S, Liddy Clare, Vimalananda Varsha G, Pecina Jennifer, Murphy Elizabeth J, Keely Erin, Simon Steven R, North Frederick, Orlander Jay D, Chen Alice Hm
Center for Innovation in Access and Quality at Priscilla Chan and Mark Zuckerberg San Francisco General Hospital and Trauma Center, University of California San Francisco, San Francisco, CA, 94110, USA.
Deparment of Medicine, University of California, San Francisco, San Francisco, CA, USA.
BMC Health Serv Res. 2018 Oct 24;18(1):814. doi: 10.1186/s12913-018-3626-4.
Electronic consultation is an emerging mode of specialty care delivery that allows primary care providers and their patients to obtain specialist expertise without an in-person visit. While studies of individual programs have demonstrated benefits related to timely access to specialty care, electronic consultation programs have not achieved widespread use in the United States. The lack of common evaluation metrics across health systems and concerns related to the generalizability of existing evaluation efforts may be hampering further growth. We sought to identify gaps in knowledge related to the implementation of electronic consultation programs and develop a set of shared evaluation measures to promote further diffusion.
Using a case study approach, we apply the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) and the Quadruple Aim frameworks of evaluation to examine electronic consultation implementation across diverse delivery systems. Data are from 4 early adopter healthcare delivery systems (San Francisco Health Network, Mayo Clinic, Veterans Administration, Champlain Local Health Integration Network) that represent varied organizational structures, care for different patient populations, and have well-established multi-specialty electronic consultation programs. Data sources include published and unpublished quantitative data from each electronic consultation database and qualitative data from systems' end-users.
Organizational drivers of electronic consultation implementation were similar across the systems (challenges with timely and/or efficient access to specialty care), though unique system-level facilitators and barriers influenced reach, adoption and design. Effectiveness of implementation was consistent, with improved patient access to timely, perceived high-quality specialty expertise with few negative consequences, garnering high satisfaction among end-users. Data about patient-specific clinical outcomes are lacking, as are policies that provide guidance on the legal implications of electronic consultation and ideal remuneration strategies.
A core set of effectiveness and implementation metrics rooted in the Quadruple Aim may promote data-driven improvements and further diffusion of successful electronic consultation programs.
电子会诊是一种新兴的专科护理服务模式，它使初级保健提供者及其患者无需亲自就诊就能获得专科医生的专业意见。虽然对个别项目的研究已证明其在及时获得专科护理方面具有益处，但电子会诊项目在美国尚未得到广泛应用。卫生系统缺乏通用的评估指标以及与现有评估工作的可推广性相关的担忧可能会阻碍其进一步发展。我们试图找出与电子会诊项目实施相关的知识差距，并制定一套共享的评估措施以促进其进一步推广。
我们采用案例研究方法，应用“覆盖范围、有效性、采用率、实施情况和维持情况”（RE-AIM）以及四重目标评估框架来考察不同医疗服务系统中的电子会诊实施情况。数据来自4个早期采用电子会诊的医疗服务系统（旧金山卫生网络、梅奥诊所、退伍军人管理局、尚普兰地方卫生整合网络），这些系统代表了不同的组织结构，为不同的患者群体提供护理，并且拥有成熟的多专科电子会诊项目。数据来源包括每个电子会诊数据库已发表和未发表的定量数据以及系统终端用户的定性数据。
各系统中电子会诊实施的组织驱动因素相似（在及时和/或高效获得专科护理方面存在挑战），尽管独特的系统层面的促进因素和障碍影响了覆盖范围、采用率和设计。实施效果是一致的，患者能够更及时地获得高质量的专科专业意见，且几乎没有负面影响，终端用户满意度很高。目前缺乏关于患者特定临床结果的数据，也缺乏为电子会诊的法律影响和理想薪酬策略提供指导的政策。
基于四重目标的一套核心有效性和实施指标可能会推动以数据为驱动的改进，并促进成功的电子会诊项目进一步推广。
