ereferral A New Model for Specialty Care

Transcription

1 ereferral A New Model for Specialty Care Alice Hm Chen, MD, MPH Chief Integration Officer Director, Center for Innovation in Access and Quality San Francisco General Hospital Associate Professor of Medicine University of California San Francisco No Disclosures to Report

2 Overview Contextual background ereferral system Impact of ereferral Policy implications

3 Trends in Specialty Referrals Visits, millions OVERALL Community Practices Hospital Practices National Ambulatory Medical Care Survey (NAMCS), National Hospital Ambulatory Medical Care Survey (NHAMCS); Barnett ML, Song Z, Landon BE. Trends in physician referrals in the United States, Arch Intern Med 2012;172:

4 Difficulty with Specialty Access Felt-Lisk S, McHugh M. Examining Access to Specialty Care for California s Uninsured. CHCF Issue Brief, May 2004

5 San Francisco Safety Net Primary Care 5 hospital-based clinics 11 DPH community clinics 10 non-profit community clinics skilled nursing facility 2 county jails ereferral EMR Specialty Care SFGH/UCSF Salaried Academic Faculty Comprehensive Specialty Services >579,000 ambulatory visits annually 35% specialty care, 20% diagnostics 37% uninsured 35% Medicaid 17% Medicare SFGH Annual Report, Fiscal Year

6 Primary Specialty Interface Paper, telephone, and fax based referral system Clerical process of first referred, first scheduled Significant inefficiencies referral to wrong clinic unnecessary referrals premature referrals inability to discern referral question lack of equitable triage Wait times up to 11 mo

7 ereferral Development HIPPA compliant, web-based referral system Tightly integrated with hospital EMR Auto-population of demographic, clinical data Free text consultative question New model of primary-specialty care collaboration Individualized review and response by designated specialist reviewer (MD or NP) Iterative communication between referring and reviewer clinicians until issue is addressed with or without a specialty clinic visit

8 ereferral Workflow PCP submits electronic referral Consult reviewed electronically by specialist Includes all relevant clinical data from EMR not scheduled and more information requested Appropriate specialty referral AND Pre-referral work-up complete Nonurgent Urgent Consult question unclear Pre-referral work-up incomplete PCP can manage with guidance Schedule Next Available Overbook Eventually Scheduled Never Scheduled

9

10

11

12

13 PCP initiates referral request July 2011-June ,604 new submissions Specialist reviews Appropriate and complete consults 60% (16,466) Consult inappropriate or incomplete or clinic visit not needed 40% (11,138) Scheduled need to be seen in clinic 50% (13,783) Non urgent routine appointment 10% (2,683) Urgent overbook appointment Not initially scheduled specialist responds to request more information and/or make recommendations 20% (5,641) Iterative communication as needed PCP provides information, initial evaluation complete, visit needed No appointment 6 months after last exchange 20% (5,397) Scheduled Never Scheduled

14 Impact Overview Primary Care Reduced wait times Quick access to specialist expertise Primary specialty dialogue is recorded in real time in EMR Case-based CME Virtual co-management keeps patients in PCMH, reduces need for external care coordination More balls in PCP court Specialty Care Reduced wait times Avoidance of incorrect referrals Ability to clinically triage Improved clarity of consultative question Increased efficiency of inperson visits with preconsultative guidance Opportunities to educate, learn Increased case-mix of clinics

15 Impact on Wait Times

16 Impact on Primary Care Kim Y, Chen AH, Keith E, Yee HF, Kushel MB. Not perfect, but better: primary care providers experiences with electronic referrals in a safety net health system. Journal of General Internal Medicine 2009; 24(5):

17 Specialist Reviewer Perspective Communication Yes because we really didn t have an interaction in the past. So this ability to interact, to send a note back to the referring physician who then sends you back a note, you know, there s like a paper trail of what s going backwards and forwards or computer trail let s call it of what s going backwards and forwards. So it makes much better interaction. Education I think most of the ereferral people spend a fair bit of time explaining why we re asking for tests or doing things, and through that I think it helps providers learn how to deal with some of these problems better on their own. Workflow the major downside is just that it creates a shared management system that pushes some of the responsibility for the consult on the referring physician they re in a very busy primary care practice, many don t have really great infrastructure. Co-management That s another advantage for some of these patients who just won t come to our clinic; at least there s a mechanism where you can provide some support for the primary care provider who s stuck dealing with the problem. Straus SG, Chen AH, Yee H, Kushel MB, Bell DS. Implementation of an electronic referral system for outpatient specialty care. AMIA Annu Symp Proc. 2011; 2011:

18 Kim-Hwang JE, Chen AH, Bell DS, Guzman D, Yee HF, Jr., Kushel MB. Evaluating electronic referrals for specialty care at a public hospital. J Gen Intern Med 2010;25: Impact on Clinic Efficiency HOW DIFFICULT WAS IT TO IDENTIFY the reason for the consultation or clinical question before interviewing and examining this patient today? Percentage of specialists responding somewhat difficult or very difficult. * p-value <0.05 1A. Medical Subspecialty Referrals 1B. Surgical Subspecialty Referrals Difficult (%) * Difficult (%) * 0 Paper-based ereferral 0 Paper-based ereferral N = 618 (413 medical, 205 surgical)

19 Impact on Clinic Complexity Endocrinology

20 Facilitators and Challenges Facilitators Closed network Investment in pilot Intuitive design Academic, salaried specialists committed to underserved patients Implementation team responsiveness through surveys, outreach, suggestion box Challenges Home grown system requires tending Variability among specialist reviewers Variability in workflow and clinical expertise among PCPs Integration with new ambulatory EMR

21 Policy Implications Potential for HIT to improve communication and efficiency of primary-specialty care interface Primary care and co-management support (versus gatekeeper role) enhances medical home model Useful model for accountable care organizations Role of specialists in reducing variations in clinical care, promoting evidence-based medicine Need for financial reimbursement mechanism Selection of appropriate specialist reviewers is key

22 Specialist Reviewers Protected time Experienced clinician Respect for primary care providers Enjoys educating colleagues Committed to value/waste reduction Attuned to overall responsibilities of specialty service in context of larger system

23 ereferral Team ereferral Steering Committee Director: Alice Chen Specialty Director: Lisa Murphy Evaluation: Delphine Tuot, Justin Sewell IT Specialist: Kjeld Molvig ereferral Medicine Reviewers Cardiology: Mary Gray Diabetes: Mimi Kuo, Audrey Tang Endocrinology: Lisa Murphy Gastroenterology: Justin Sewell Hematology: Brad Lewis Liver: Mandana Khalili Oncology: Judy Luce Pulmonary: Adithya Cattamanchi, Antonio Gomez Renal: Sam James Rheumatology: John Imboden ereferral Women s Health Reviewers Breast Evaluation: Diane Carr, Mary Scheib w/judy Luce Gynecology: Rebecca Jackson and faculty Obstetrics: Rebecca Jackson and faculty ereferral Surgery Reviewers Breast Surgery: Kelly Ross-Manashil with Peggy Knudson ENT: Christina Herrera with Andrew Murr General Surgery: Danielle Evans with Bob Mackersie Orthopedics: Diane Putney, Dorothy Christian, Brenda Stengele with Ted Miclau Neurology: Sean Braden with Cheryl Jay Neurosurgery/Neurotrauma: Sean Braden with Geoff Manley Plastics: Erin Fry with Scott Hanson Urology: Ben Breyer and fellow Podiatry: Erika Eshoo ereferral Radiology Radiology lead: Alex Rybkin MRI, CT, U/S, fluroscopy: Nancy Omahen SF DPH Community Clinics Lisa Johnson San Francisco Community Clinic Consortium David Lown

24