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Leah Kelley



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    OS07 - Spectrum of Virtual Care (ID 11)

    • Event: e-Health 2019 Virtual Meeting
    • Type: Oral Session
    • Track:
    • Presentations: 1
    • Coordinates: 5/27/2019, 03:45 PM - 04:45 PM, Area 3
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      OS07.02 - Identifying Patient and Provider Value Propositions in Virtual Primary Care (ID 293)

      Leah Kelley, Institute for Health System Solutions and Virtual Care (WIHV), Women’s College Hospital; Toronto/CA

      • Abstract

      Purpose/Objectives:
      The Ontario Telemedicine Network is working with local health integration networks (LHINs) to implement virtual primary care visits. Patients want to engage with physicians remotely and find the quality to be equal to or better than in-person. Previous experience shows primary virtual care can be used to manage routine conditions and reduce health system costs. Yet integration of virtual primary care visits remains low, due partly to unclear physician value and payment models. The study objective is to explore how virtual visits can create value for both patients and clinicians, to facilitate uptake within Ontario primary care.


      Methodology/Approach:
      Four LHINs across Ontario, including 138 physicians, have implemented a customized virtual visits platform. The technology enables clinicians to respond to patients’ clinical requests using either asynchronous secure messaging or an audio/video visit. We conducted semi-structured interviews with providers and patients to understand the perceived value of virtual visits. We then extracted themes of value propositions for both providers and patients.


      Finding/Results:
      There is demonstrated value for patients to engage with virtual visits, due primarily to the convenience that it offers over in-person visits. Clinicians and patients generally agreed that it was appropriate to use this platform for simple visits, but not for new diagnostic issues. The most often used modality was asynchronous secure messaging (94% compared to 1% video and 5% audio). We identified several value propositions for both patients and providers. Patient value propositions: *Convenience: Easier access to clinician was of priority. Rapid response is not needed; rather, patients valued not having to take time off work, seek childcare, or drive long distances. Access: Can improve care continuity and access for patients who have moved out of the area but still have the same PCP, and homebound or low-mobility patients. Urgent issues: Patients identified an interest in accessing a platform that would provide rapid responses for urgent issues, particularly after hours. Provider value propositions: Efficiency: Increases the number of patients PCPs can see per day, while not overwhelming their workflow. Revenue: Increases provider revenue by enabling them to maximize care bonuses, or paying them for previously unpaid work (e.g. phone calls). Care quality*: Enables clinicians to improve the quality of care they can deliver to their patients. Table 1 presents some ways to use virtual primary care technology that align with provider and patient value propositions. Provider value Efficiency Revenue Patient care quality 1) Delegate work to administrative assistants and nurses 2) Send reminders, prescriptions, and follow-ups for disease management Convenience Patient value 3) Provide care to homebound patients 4) Provide care to rural/remote patients Access 5) Provide virtual after-hours care Urgent issues 6) Enable easier preventative care via reminders, education 7) Pay for work previously unpaid 8) Enable time for PCP to make informed decision on complex issues (asynchronous) No motivating value


      Conclusion/Implications/Recommendations:
      When implementing virtual visits, it is important to align implementation design with patient and provider value propositions to encourage maximum adoption. The value propositions and potential use cases outlined here can guide future implementation.


      140 Character Summary:
      Integrating virtual visits in primary care faces provider resistance; aligning implementation with patient/provider value propositions may improve uptake.

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    OS14 - Keeping Patients Healthy at Home (ID 5)

    • Event: e-Health 2019 Virtual Meeting
    • Type: Oral Session
    • Track:
    • Presentations: 1
    • Coordinates: 5/28/2019, 10:00 AM - 11:00 AM, Area 2
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      OS14.01 - Using Wound Monitoring Technologies to Demonstrate System-Level Digital Health Barriers (ID 418)

      Leah Kelley, Institute for Health System Solutions and Virtual Care (WIHV), Women’s College Hospital; Toronto/CA

      • Abstract

      Purpose/Objectives:
      WIHV collaborates with the National Research Council’s Industrial Research Assistance Program to provide advice to small-to-medium size enterprises in the digital health sector. Innovators experience several system-level barriers, including a lack of visible incentives to providers and patients to adopt such solutions. We use a collection of wound care applications accessing our program as a window to demonstrate recurring system-level barriers to their adoption.


      Methodology/Approach:
      Three digital wound monitoring applications were assessed through our program. For the purpose of this analysis, we focused on the use of wound monitoring applications in patients accessing provincially-funded homecare services. We extracted system barriers to successful clinical integration and placed these barriers within the context of current funding and incentive models.


      Finding/Results:
      Three primary system challenges to integrating a digital virtual wound care solution into the homecare setting were identified: *1) Unclear payer: There is no obvious payer for most digital solutions; incentives aligned to in-person visits so virtual care often creates cost for the user despite system savings. 2) Lack of integration with surrounding system: Key processes, such as escalation in the care pathway if adverse events occur, are poorly defined. 3) Lack of data governance models*: There are no consistent processes for defining who is responsible to capture data, who must review it, and where it should reside. The value propositions for homecare agencies and clinicians to purchase and utilize wound monitoring apps are unclear, despite potential improvements in patient health outcomes (Table 1). First, the benefits may be accrued elsewhere in the system (e.g. reduced emergency department utilization). Second, the siloing of homecare from key participants in the tool’s success (e.g. primary care providers and dermatologists), creates a system whereby homecare must try to govern processes where they have no control. It is essential to capture the value proposition of the tool for each relevant stakeholder, especially payers and users, as these value propositions may not be aligned. The challenge is to create “wins” for all core parties. A non-bundled, fee-for-service context given is a significant disincentive for institutions to adopt a virtual service model. Alternatively, outcomes-based bundles could offset some disincentives by encouraging institutions to improve outcomes through methods (e.g. virtual technology) that maximize their efficiency. Table 1. Understanding stakeholder funding and value propositions Stakeholder Payment Engagement Value proposition Homecare agency/PSW Fee-for-service (in-person) Use application to monitor healing; Escalate care as needed Fewer visits of value because high homecare demand Primary care provider Fee-for-service (in-person/e-consult) Review application data; Escalate to specialist if needed No incentive to reduce in-person visits Dermatologist Fee-for-service (in-person/e-consult) Review application data in consult No value proposition Local Health Integration Network Fixed homecare budget from Ministry Purchase application If app reduces visits, can increase patient coverage


      Conclusion/Implications/Recommendations:
      The current system creates an entanglement of complex incentives and payment models that stifle the success of digital innovations. Outcomes-based funding models, such as bundled payments to homecare agencies, would enable institutions and clinicians to utilize innovations to improve the quality and efficiency of care provision, as demonstrated by the above use case.


      140 Character Summary:
      Digital health solutions face barriers in system incentives due to funding models; use case of wound monitoring application demonstrates key challenges.