3004 — E-Consult Implementation: Lessons Learned Using Consolidated Framework for Implementation Research

Haverhals LM, Denver VA Medical Center; Sayre G, VA Puget Sound Health Care System; Helfrich CD, VA Puget Sound Health Care System; Battaglia C, Denver VA Medical Center; Aron DC, Louis Stokes Cleveland VA Medical Center; Stevenson L, Louis Stokes Cleveland VA Medical Center; Kirsh S, Louis Stokes Cleveland VA Medical Center; Ho PM, Denver VA Medical Center; Lowery J, VA Ann Arbor HealthcareSystem;

Objectives:
In 2011 the Veterans Health Administration (VHA) implemented electronic consults (E-Consults) as an alternative to in-person specialty care visits to improve access and reduce travel for Veterans. We conducted an evaluation to understand variation in use of E-Consults and causes of variable implementation across sites, guided by the Consolidated Framework for Implementation Research (CFIR).

Methods:
We conducted qualitative case studies of three high and five low volume E-Consult implementation sites, identified from E-Consult volume data from May 2011 - February 2012. A structured survey was administered electronically to E-Consult site leaders to identify key constructs of implementation based on the CFIR. We then conducted open-ended telephone interviews with providers and staff, focused on CFIR constructs gathered from surveys. Finally, we created structured, site-level ratings of CFIR constructs and compared them between high and low volume sites. Interview participants included E-Consult site leaders, primary care providers (PCPs), specialists, and support staff using E-Consults (N = 37).

Results:
Interview data identified four CFIR constructs distinguishing high from low volume E-Consults sites: compatibility, networks and communications, training, and access to knowledge and information. Illustrating compatibility, high volume sites integrated E-Consults to foster consistency with usual consult processes. In contrast, some PCPs at low volume sites felt E-Consults changed peoples' responsibilities in a way that was very different from usual roles. Specialists at high volume sites reached out to engage PCPs more so than low volume sites, facilitating stronger networks and communications. Compared to low volume sites, high volume sites devoted greater effort to making E-Consults more efficient for staff, invested in training, and designated a point person to answer questions and provide information.

Implications:
To facilitate dissemination of E-Consults, attention should be paid to factors shown to distinguish between low and high volume sites, learning from the ways in which high volume sites ensured compatibility, communications, training, and access to information.

Impacts:
Implementation research has identified dozens of factors that potentially influence the successful implementation of new programs. Through applying the CFIR to analyze interview data, a limited number of key factors where time, energy, and resources should be expended to achieve ideal implementation results were identified.