Reducing dermatology wait times to less than 5 days with Store Forward…Otn.teledermSF ® eHealth May 27, 2013

1. Reducing dermatology wait times to less than 5 days with Store Forward…Otn.teledermSF® eHealth May 27, 2013

2. Objectives • Who is OTN • What is Store Forward • Impact on wait times • Utilization • Why is it working? • User feedback • Where are we going from here? Page 2

3. About OTN • Veni – We came • Vidi – We saw • Video – We Video’d • Vaco…Store Forward OTN is a not-for-profit organization funded by the Government of Ontario

4. What is Otn.teledermSF®? • SF means Store Forward…move the information, not the patient • Whereas videoconferencing is real-time (synchronous), store forward is asynchronous • The information is stored and then forwarded for action by the consultant at a later time • Otn.teledermSF® is a OTN program that incorporates technology, workflow logic to allow the secure flow of information between referring doctors and dermatologists

5. How does it work? The referring doctor, or their delegate, takes a digital photo of the patient’s skin lesion Referring doc implements treatment with patient Photo and pertinent patient information is sent to the dermatologist through OTN’s secure software/servers Dermatologist returns a diagnosis and suggested treatment plan to the referrer

6. What is the need? • Access: 180 dermatologists in Ontario • Wait times: The further from a major centre the longer the wait times (anecdotal): • For example: • 45 minutes from Toronto 3-4 months • 1.5 hours from Toronto 6 months • 4 hours from Toronto 8-12 months • Even reports of 18+ months in some parts of northern Ontario • Time to treatment reduces costs

7. How the program was developed • Literature supports effectiveness of Store Forward • Patient satisfaction is equivalent to face-to-face • A study of nearly 1,500 shows improved clinical outcomes, with better diagnosis and disease management. • Teledermatology, when applied to all dermatology referrals, has a probability of being cost saving to society. • Pilot 2009-2010 • Operationalized 2011 • Remuneration for derms • (Remuneration for referrers not until April 2012)

8. Growth # of consults answered per month FY 2011-2012 FY 2012-2013 Month Currently, in FY 2013/14, 600+ consults/month…and growing

9. Growth Rate 5,101 1,240 Over 300% from FY2011/12

10. User stats • 18 Ontario-based dermatologists • 700+ referring physicians • 1000+ “delegate” referring users (NPs, Nurses, etc.) • 225+ Primary Care referring sites (FHTs, FHOs, CHCs, etc.) • The list of dermatologists and referring users grows every week.

11. How is Otn.teledermSF affecting wait times? • On average wait times are less than 5 days • Current trending: Less than 3 days • Dermatologists are telling us they are not near capacity • Will add more derms as required • Derms welcome to join any time (referrers too!) • Otn.teledermSF is freeing up time for f-2-f appointments

12. What dermatologists are saying • “[Telederm] can free up some time in my clinic so the quick patients can be done through telemedicine.” • “I do find that I can better screen subjects to see who needs to be brought in sooner, or who needs a referral to surgery sooner rather than later. I saw a woman with melanoma a couple of weeks ago through Telederm and referred her directly to Plastics - it was excised in a week. Wouldn't have happened on real clinic referral time.” • Dr. Melinda Gooderham, Dermatologist

13. Talk about setting expectations…. • Recall that wait times for a face-to-face appointment can be more than 12 months • “…and I have to say that I’ve been waiting a long time to get responses back from the consultants. I know I used to get responses back as quickly as a couple of hours and now for some, 3-5 days.”

14. Why is it working so well? • 5 day turn around • Ease of use • For dermatologists, removes the shackles of regular office hours* • OHIP billable (for derms) • OHIP billable for referrers • Delegate model allows for distributed workflow “I spent the day today relaxing poolside with my laptop and was able to catch up on a few cases while my kids swam. I find the flexibility of doing the cases on my own time is convenient.”

15. Like using you iPad as a cutting board… • Work flow at some referring clinics: hybrid of Otn.teledermSF and paper • Delegate handles Otn.teledermSF • Consult notes are printed and handed to the physician • Perhaps complete physician adoption requires full integration with EMR

16. Adoption Strategies Referring: • Delegate model • Any camera • Standardized photo kit Dermatologists: • Dermatologists encourage adoption with their usual referrers General: • Supports: training, work flow, RMs, Service Desk • Continuous quality improvements No iPhones for you!

17. Benefits for dermatologists • OHIP Billable • Flexibilityto provide diagnosis and treatment when and where convenient • Efficient & effective way to treat patients leading to decreased wait times

18. Benefits for referrers • Consults provided within 5 days on average • OHIP billable as an eReferral • Reduces “n” trials of “X” treatments • Timely referrals leading to improved patient outcomes • Increased collaboration with specialist = increased capacity • Potential to reduce costs through efficient referral process (vs. f2f)

19. Other User Benefits • OTN develops relationship with dermatologists – no need to search for available derms • Pan-provincial initiative • Collaboration with OneID • OTN Service desk • OTN RMs • Advocacy

20. What referring docs are saying • I find Telederm incredibly useful, I have sent 3-4 patients so far and I received speedy advice within 2 days. It is an amazing service. I am very happy being able to use it. Thanks for your help Dr. Lili Mileva

21. What referring users are saying • We had less than 24 hour turn around with 2 of our uploaded files and they were to Dr. G. [Our] doctors  had a faxed copy of consultation report in less than 24 hours. That's amazing! • I set this up approximately 3 months ago and the MD's at my clinic are really impressed with the efficient manner in which the referrals are received and processed. The MD's are also satisfied with the recommendations from the specialists. I would highly recommend this program;it meets the needs of many clients.  Regular wait times for a Dermatologist can be 8 mo to 1yr. We facilitate their assessment in less than a month.  Fantastic!!! • I have found the OTN TeleDerm process to be a very quick and easy way of obtaining a specialist's opinion for our patients. The average response time is about 2 days, which is remarkable!  The patients are very happy to have a diagnosis so quickly. In most of the cases the specialist recommended medication and it was beneficial to the patient to be able to start on the treatment in a timely fashion. • I got my first SF referral answered in less than 24 hrs!! It’s amazing. • I personally have had two consults now with Dr. W and have been thrilled with the results.  One actually came back the same day I sent it. She lays out the differential diagnoses, advises if biopsy necessary to determine correct diagnosis, and then provides outline of therapeutic plan for each possible outcome. Clear as can be, and so helpful. Patients are thrilled.

22. What dermatologists are saying • I must say that I enjoy doing these store forward consultations.  I find that the focus is somewhat different than in-office consultations.  I tend to give more useful basic information to the PCP, knowing that this physician will be taking active care of the patient in most cases, especially when located some distance from major centres.

23. eConsult fees • Referring docs can bill the referral as an eConsult • E-Consultation (Physician to Physician): • This is a service where the referring Physician, in light of his/her professional knowledge of the patient, requests the opinion of another Physician. The “consultant Physician” is able to offer competent advice to provide an accurate opinion. Both the request and the opinion are sent electronically through the use of a secure server. • Billing Code: • K738 Physician to Physician e-consultation (Referring Physician)

24. Challenges to the program • In polite conversation topics to avoid: 1. Religion 2. Politics 3. Sex 4. OHIP fees • Consult fees were $72 up to March 31st 2013 • As of April 1st 2013 fees moved to $44 • MoHLTC and OMA have been apprised of the concerns expressed over the reduced fees • eReferral cannot be billed same day • Counter productive to the efficiency of Store Forward

25. Potential Expansion TeleDentistry TelePsychiatry TeleWound care (in pilot now) (pilot starting summer 2013) (exploration)

26. What are the steps to get Otn.teledermSF? • Contact OTN (info@otn.ca) • OTN will contact you • You will receive a password • The password gives you access to the online training materials/videos as well as to Otn.teledermSF itself • Once training is completed (about 45 minutes) you can start referring patients right away

27. It takes a village… • Manish Rughani • Supervisor & Systems Administrator, Technical Operations • Sev Derghazarian • Telehealth Hardware/Software System Support Specialist & Systems, Technical Operations • Joy Harris • Provisioning Group, New Site • Matt Sherman • Business Analyst, Service Optimization

28. Thank you! Contact information Stewart Stein Manager Store Forward Email: sstein@otn.ca(preferred) Phone: 416-446-4110 x4118

30. APPENDIX

31. Costs • No annual fees • No set-up fees • No licensing costs • OTN is a not-for-profit funded by the Government of Ontario

32. The Ontario Telemedicine Network • An independent not-for-profit corporation funded by the Government of Ontario • Members include 1,000 health care and education organizations • Delivery partners include: • e-Health Ontario • Keewaytinook Okamakanak Telemedicine • Canada Health Infoway Page 32

33. OTN: Available Everywhere • One of the world’s largest & most active TM networks • Programs & services delivered collaboratively at more than 1,600 sites (>3,000 systems) across Ontario Page 33

34. Studies • Teledermatology Patient Satisfaction in the Pacific Northwest - Martha T. Hsueh, R.N., Kristin Eastman, M.D., Lynne V. McFarland, Ph.D., Gregory J. Raugi, M.D., Ph.D., and Gayle E. Reiber, M.P.H., Ph.D. • A cost minimisation analysis in teledermatology: model-based approach - Nina Eminović1*, Marcel G Dijkgraaf2, Rosanne M Berghout1, Astrid H Prins3, Patrick JE Bindels4, Nicolette F de Keizer1 • Netherlands study shows dermatologists using telemedicine to provide efficient care at lower costs - van der Heijden JP, de Keizer NF, Bos JD, Spuls PI, Witkamp L. • Teledermatology Operational Considerations, Challenges,and Benefits: The Referring Providers’ Perspective - April W. Armstrong, M.D., M.P.H.,1 Mei W. Kwong, J.D.,2, Elizabeth P. Chase, M.D.,1 Lynda Ledo, B.S.,1, Thomas S. Nesbitt, M.D., M.P.H.,3, and Sandra Louise Shewry, M.P.H., M.S.W.2 • Telemedicine boosting dermatology care - Carolyne Krupahttp://www.ama--assn.org/amednews/2012/01/30/prsc0131.htm