Global Lab for Innovation

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1 Global Lab for Innovation Innovation Profile econsults The large-scale implementation of secure electronic communications allows primary care practitioners (PCPs) to initiate and receive electronic consultations from specialists. This results in a 20% to 40% reduction for in-person specialist visits for these patients. PCP-specialist collaboration to establish the protocols and templates for the communication has resulted in high provider and patient satisfaction, shortened patient wait times, and better preparation of patients when an in-person specialist visit is required. Safety net systems in California have reported that between 25% and 50% of consultation requests were resolved without a specialist visit. Applications Profiled Here: (1) L.A. Department of Health Services / L.A. Care Health Plan econsult program and (2) San Francisco General Hospital ereferral pilot Summary Application Profiled: L.A. Department of Health Services/L.A. Care Health Plan econsult program and San Francisco General Hospital ereferral pilot Category Savings Level 1 Access Experience Engagement Outcomes Barriers Reimbursement Technology Culture Documented, Complex NR NR Investment $ to $$ Training EMR Integration Potential for Spread User Sites Moderate Favorable 2 County Medicaid Programs What it is econsult is a web-based portal used by primary care physicians (PCPs) to request advice from specialists in management of their patients. A specialist reviewer responds to requests with suggestions for diagnosis or treatment ( an electronic curbside consultation ) or by recommending an appointment for the patient with a specialist. It is designed to enable peer-to-peer exchange of clinical information between primary care physicians and specialty providers and improve access to specialty care.

2 Problems addressed Patients that can be managed by their PCP are sent for specialist visits resulting in longer wait times for other patients who do need to see the specialist. 1 Patients are sent for specialist visits without appropriate preparation, including necessary laboratory tests and imaging, resulting in repeated specialist visits. Access to specialists is limited for safety net, rural, and many urban populations. How it works Primary care providers (PCPs) fill out a form requesting specialty review, includung patient information and attaching results of diagnostic tests, images and other materials. A specialist may determine that additional information is needed, that the PCP can continue to manage the patient (without continued specialist advice, or with continued consultation), or that an in-person visit to a specialist is required. If the specialist reviewer recommends that the patient see a specialist, the reviewer also decides how soon the patient needs to be seen. In some systems, the specialist reviewer can also make an appointment for patients whose case they have reviewed. Savings are achieved for capitated systems by reducing rates of specialist office visits. Innovators San Francisco General Hospital (SFGH) and SFGH-based UCSF faculty, after an initial pilot in 2005, formally implemented their ereferral program in L.A. Care Health Plan initiated a pilot in 2010, and the L.A. Department of Health Services undertook a system-wide implementation of econsult that extended to a wide range of primary care providers and clinics in Los Angeles in Complexity (How complex are the organizational requirements) Complex. An e-review system can be created in any delivery system where primary care providers refer to a relatively closed set of specialist practices for their referrals. Having a shared pre-existing electronic medical record (EMR) facilitates the adoption of electronic referrals but is not a requirement for implementation of an econsult system. Both SFGH and LA Care report that they were able to build and implement their programs within one year. Both also report beginning the program with a limited number of interested specialties and gradually adding more specialties as interest spread and champions/ reviewers were found. Requirements for adopters include obtaining an e-review infrastructure with capabilities to upload relevant portions of the patient medical record to process the consultation requests and identification of a champion(s) within each specialty practice who is willing to take on the task of reviewing each request to that specialty. 3 The start-up costs for portal development are decreasing as commercial companies and EHRs develop this offering. Success is largely dependent on physician buy-in and engagement. Global Lab Profile 2

3 Savings Yes. Although formal studies of cost effects have not been concluded, a significant savings is likely because of the reduction in in-person specialty visits and the improved preparation of patients for their specialty visits, if needed. L.A. County Department of Health Services pilot studies found that between 25-46% of consultation requests were resolved without a patient visit.4 SFGH reported a substantial drop (50%) in face-to-face specialty consultations. 5 Access Yes. SFGH reports an up to 90% decline in wait time for non-urgent specialist visits. 6 L.A. Care /L.A Department of Health Services reports a 60% drop in average waiting time for appointments with participating specialist practices. 7 SFGH also reports that roughly 10% of referred cases are found to be urgent, and are therefore given expedited face-to-face specialist appointments. 8 Patient experience Likely, but not documented. The e-review systems respond to patients reported preferences for seeing a limited number of physicians, continuity of care, and brief wait times for specialist consultations. Engagement No information was available concerning impact on patient engagement. Outcomes No information was available for patients clinical or functioning status outcomes. Spread In 2014, UCSF received funding to develop a dissemination program to support adoption of econsult programs across all the UC campuses. Also in 2014, AAMC was awarded a CMMI Innovation Challenge grant that funds UCSF to coordinate implementation of econsult programs across a number of academic health centers. SFGH reports that roughly 13 delivery systems have developed their own econsult programs. 9 In California, Orange and San Diego Counties have ereview systems. Several VA centers have also implemented an econsult system. Global Lab Profile 3

4 Barriers and Drivers Barriers Reimbursement: Specialty reviewers cannot currently bill for their time spent reviewing electronic consultations. (In a capitated system with specialist employees, the delivery system may recoup substantial savings by averting specialist visits that offset or more than offset the cost of specialist reviewers time.) Additionally, econsult requires a greater investment of time by the PCP, who is also not reimbursed for this effort. Technology: Implementation will be difficult and incur additional systems costs where there is not a shared EMR between the clinicians involved. Delivery system must have IT resources available to build an e-review program, ideally overlaid with their EMR. Culture: In some specialty practices there may not be MDs willing to assume role of reviewers. Time allocation to econsult work requires a re-thinking (by both specialist and PCP) of what it means to provide specialty care access to their patients. Drivers Workforce Shortage: Shortage in many specialty areas that create long wait lists for visits. Cost of Care: In capitated systems, savings are achieved by reducing rates of specialty visits and having more patients managed in primary care. Similar innovations A number of innovations in tele-health are focused on making virtual specialist consultations available to patients in their PCPs offices. These differ from ereferral and econsult in that they are services limited to a single specialty and extend specialist consultations through the PCP during PCP office visits and generally require follow-up visits to the PCP for specialty consultation findings. Examples include tele-dermatology and tele- eye exams for diabetics. Innovation contact Alice Chen, MD, MPH, Chief Integration Officer, San Francisco General Hospital, Associate Professor of Medicine, Division of General Internal Medicine, University of California, San Francisco. Paul Giboney, MD, Director of Specialty Care, Department of Health Services, Los Angeles, California Address Website dhs.lacounty.gov/wps/portal/dhs/ Global Lab Profile 4

5 Endnotes 1 AHRQ Innovation Exchange, Electronic Specialist Consultations Reduce Unnecessary Referrals and Wait Times for Specialty Appointments. AHRQ posting July, The LA Care program was modeled on the SFGH program. They are similar in many respects, but the SFGH program uses ereferral exclusively for all specialty consultation requests, whereas the LA Care/DHS system has an econsult system in addition to a traditional consultation system. SFGH ereferral is embedded into the EMR, whereas econsult is independent of the EMR. Interview with SFGH ereferral program manager, January, SFGH ereferral program manager reported that their decisions concerning which specialties to include in the system were determined largely by which specialties had internal champions who would assume the reviewer role. Interview with SFGH ereferral program manager, January, SFGH and LA Care reports the following specialties as participating in their programs. Neurology; Rheumatology; Physical Therapy; Endocrinology; Nephrology; Cardiology; OB/GYN; Gastroenterology; Oncology; Ophthalmology (Ophthalmology is e-scheduling, not ereferral at SFGH); Podiatry; and Urology. 4 AHRQ Ibid. 5 Paul Karon, Electronic Consultations Break Down Barriers for Medicaid Patients in LA County, Printmore Share Services, November, SFGH Ibid. 7 A.Chen, Improving the Primary-Specialty Care Interface, SFGH Annual Report, Fiscal Year Chen, op. cit. 9 Both programs report that the rate of requests resolved without a specialist visit varies by specialty and over time. Presumably, e-communications between PCP and specialist eventually reduces PCPs requests for consultations because they learn how to treat some cases without consulting a specialist. Neither program has reported change in rates of PCP requests for consultations. Global Lab Profile 5

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