This presentation demonstrates a novel methodology to unpack the black box of provider to provider communication using empirical, video-recorded telemedicine sessions. We present preliminary findings related to the overall organization of the sessions, an activity analysis of consults, and the types of questions generalists ask during consults.

1. Preliminary SDP Findings
How does SCAN‐ECHO facilitate
communication between primary and
specialty care providers?
CJ Koenig et al.
Christopher.Koenig@va.gov
September 18, 2015

2. Authors
Christopher J. Koenig, PhD San Francisco VA
Matthew Wenger, MD San Francisco VA
Glenn Graham, MD San Francisco VA/VISN
Susan Kirsch, MD Office of Specialty Care
Thom Taylor, PhD Palo Alto VA
Steve Asch, MD, MPH Palo Alto VA
Catherine Rongey, MD, MPH San Francisco VA
Supported by VA HIV/Hepatitis QUERI SDP #12‐550
(PIs: Rongey & Asch)

3. Consultations
Consults enable cross‐provider collaboration.
• Written consults are traditional.
• Communication quality is variable
• Inappropriate referral
• Incomplete and partial information
• Outcome uncertainty
Sewell, et al., 2013 AM J Med

4. Health Information Technology
HIT proposes additional solutions.
• E‐Consults
• Video teleconferencing
• Project ECHO
• VHA’s SCAN‐ECHO
Arora et al., 2011 N Engl J Med
1. Foster general & specialist communication
2. Create knowledge networks
3. Improve patient health outcomes

5. Knowledge Gap
How does SCAN‐ECHO facilitate
generalist‐specialist
communication and collaboration
for specialty care needs?

6. Research Questions
1. What organizational features
characterize SCAN‐ECHO consults across
sites?
2. What types of questions do generalists
pose during
SCAN‐ECHO consults?
3. How might generalist’s questions
demonstrate familiarity with specialty
care concerns?

7. Data Collection
Qualitative Data
Scale
Data Types
SCAN-ECHO
sessions
n= 2 VAMC sites
Video
recordings
n= 32 sessions
Site 1 = 17
Site 2 = 15
~45-60 minutes
~1440-1920 min
Verbatim
transcripts
20-30
pages/session
~640-960 pages

8. Analysis
Discourse analysis
• Sociolinguistic, qualitative methodology
• Naturalistic paradigm
• Analyzes language in use in real‐world settings
• To describe recurrent activities and social
actions
• To evaluate social practices for potential
improvement

9. Research Question #1
What organizational features
characterize SCAN‐ECHO
consults across sites?

10. SCAN‐ECHO Session Organization
Team Work Logistics Consults Didactic
Sessions
Recorded
Average Session
Duration
Site 1 15 45 min
Site 2 17 63 min

11. SCAN‐ECHO Consult Types
Site 1 Site 2
Full Case n= 39 (71%) n= 47 (78%)
Update
(Generalist‐led)
n= 15 (27%) n= 2 (3%)
Summary
(Specialist‐led)
n= 1 (2%) n= 11 (19%)
TOTAL n= 55 (100%) n= 60 (100%)

12. Full Case Consult Activities
Site 1
GEN Presentation 1m, 48s
Discussion 6m, 42s
TOTAL 8m, 30s
Site 2
GEN Presentation 0m, 54s
SP Re‐Presentation 3m, 24s
Discussion 6m, 42s
TOTAL 11m, 00s
8%
31%
61%

13. Full Case Consult Organization
Next
Speaker
Full Case
Presentation
Discussion
Social
Talk
Consult
1+n
Consult
1
Consult
Question
Assessment &
Action Plan

14. Research Question #2
What types of questions do
generalists pose during
SCAN‐ECHO consults?

15. Verbatim Consult Question
(Site 1, ID#131112, Case 3, Question 1)
So, he’s a 60‐year‐old guy, hepatitis C, phenotype I. He
has been told that he has a diffusely nodular liver. And
I don’t think he had a history of a biopsy prior. As he was
getting his housing and his other stuff stabilized, he had a
series of follow‐up appointments. He had three things to
do: an education class, which he completed; and two, he
needs more psychosocial stuff; and then third thing is to
complete the MRCP. So, he has this MRI result, and I just
need feedback on how we’re interpreting it for him.

16. Data transformation
Verbatim
Question
Standard
Question
Generalizable
Question
What is the meaning of test finding X?
So, he’s a 60‐year‐old guy, hepatitis C, phenotype I. He has
been told that he has a diffusely nodular liver. And I don’t
think he had a history of a biopsy prior. As he was getting
his housing and his other stuff stabilized, he had a series of
follow‐up appointments. He had three things to do: an
education class, which he completed; and two, he needs
more psychosocial stuff; and then third thing is to complete
the MRCP. So, he has this MRI result, and I just need
feedback on how we’re interpreting it for him.
How do I interpret this MRI result?
Inductive Category: Interpreting Results

17. Standardized Consult Questions
0
5
10
15
20
25
30
35
40
45
Site 1 (n=61)
Site 2 (n=64)

18. Research Question #3
How might generalist’s questions
demonstrate familiarity with
specialty care concerns?

19. Data transformation
Verbatim
Question
Standard
Question
Generalizable
Question
What is the meaning of test finding X?
So, he’s a 60‐year‐old guy, hepatitis C, phenotype I. He has
been told that he has a diffusely nodular liver. And I don’t
think he had a history of a biopsy prior. As he was getting
his housing and his other stuff stabilized, he had a series of
follow‐up appointments. He had three things to do: an
education class, which he completed; and two, he needs
more psychosocial stuff; and then third thing is to complete
the MRCP. So, he has this MRI result, and I just need
feedback on how we’re interpreting it for him.
How do I interpret this MRI result?
Category: Interpreting Results

20. Generalizable Consult Questions
Generalizable Question Site 1 Site 2 TOTALS
1 How do I access information about patient's history? 1 1
*2 How do I order a non‐standard test X? 1 1
3 How should I treat finding or disease X? 1 1
4 What is condition X the cause of test finding Y? 1 1
5 What is the cause of physical finding X? 1 1
*6 How do I communicate situation X to patient? 3 3
7 Is drug X indicated in situation Y? 2 1 3
8 Could this patient have disease or condition X? 1 3 4
*9 Is condition X the cause of test finding Y? 2 5 7
*10 NO QUESTION 1 8 9
11 What is the drug of choice given situation Y? 9 2 11
12 Is test X indicated in situation Y? 6 9 15
*13 How should I respond to patient request for treatment X? 9 6 15
14 What is the cause of test finding X? 3 11 14
15 How should I manage disease or finding X? 9 8 17
*16 Should I start/dis/continue with drug X? 14 8 22
TOTALS 61 64 125
* Questions not identified in prior research

21. Limitations
Limits to generalizability
• Two high‐performing sites
• One disease condition (HCV)
Questions are one aspect of the consultation
New methodology opens the black box of
provider‐to‐provider communication

22. Conclusions
Provider‐to‐provider verbal communication is largely
unexplored and under‐researched.
SCAN‐ECHO consults have an advantage over standard
consults.
• Provide clinical, psychological, and social contexts in a
narrative format that can be tailored to the situation.
• Interactive feedback according to unique concerns.
Novel methodology can be used to
• Evaluate complex (HIT) interventions
• Develop recommendations for improving
communication between providers

23. Thank you!
For questions or comments please contact:
Christopher.Koenig@va.gov