To improve access to specialty care in our large public system, we implemented an eConsult process that offers rapid review of clinic referrals and allows specialists to provide clinical guidance to the referring provider when appropriate. In the initial pilot, 30% of referrals were either appropriate for management by the referring provider or required additional workup prior to being seen by the specialist.
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Participating specialty clinics must prepare for an eConsult workflow by designating a “specialist reviewer” to review and triage each referral and by allocating resources for patient communication and scheduling.
Successful eConsults require primary care and specialty providers to collaborate on the best plan of care for each patient and to set clear expectations on communication and co-management.
Demand for specialty care in the United States is high; patients and primary care providers face multiple challenges in accessing timely, affordable specialty care. The asymmetry between demand for services and access to care is heightened in safety-net settings, where access to specialists is frequently cited as a major concern. Nationwide, roughly half of all specialists accept Medicaid, with wide variation across geographic areas. For uninsured patients, barriers to access are higher and the choice of specialists is far more limited.
NYC Health + Hospitals, the municipal health system for New York City, is a major provider of ambulatory specialty care services for patients with Medicaid or no insurance. In 2015, we provided more than 2 million visits to specialty clinics, with wait times of several months for some routine appointments. Changes in the health care landscape, particularly an increase in the number of uninsured patients, will make access to specialist care in the safety net more challenging for patients. Improving our ability to deliver specialist expertise in lower-cost settings for more patients is critical to our mission as a safety-net health system.
To expand our ability to meet current and future demand for specialty care, we shifted our focus from specialty care visits to specialty care expertise. That is, we sought ways to ensure timely access to the expertise of a specialist, whether or not the patient is seen by a specialist. Lessons from other health systems facing similar challenges — including San Francisco General Hospital’s trailblazing eReferral system and Los Angeles County Department of Health Services’ development of expected practices to guide clinical practice — pointed us toward specific innovations at the interface of primary care and specialty care.
At NYC Health + Hospitals, we identified three areas of opportunity for innovation:
- Identify instances where the patient’s needs can be met in the primary care setting in conjunction with specialist input and guidance.
- Improve preparedness for specialty visits by ensuring prerequisites, e.g., labs are complete and available in advance of the visit.
- Increase our ability to provide access to care aligned with the urgency of the patient’s need.
Progress in these areas relies on improving communication and information flow between primary care and specialty care providers. Because our facilities share an electronic health record (EHR) system, we chose interventions that focused on supporting bidirectional communication guided by best practices and clear expectations around the role of the primary care and specialty care providers.
eConsult, sometimes termed eReferral or eCR, emphasizes provider-to-provider communication, making it easier for primary care providers and specialists to communicate about and co-manage patients when appropriate. Many eConsult systems are integrated into the EHR and require the specialist to review all incoming referrals, responding electronically when appropriate and requesting the patient to be scheduled for a face-to-face visit if needed.
Based on successes and lessons from implementations in other safety-net health systems, we sought to develop an eConsult system that would integrate into our existing workflows with minimal disruption.
Beginning in 2015, we assessed supply, demand, and operational nuances in our specialty clinics. We reviewed referral tracking and management strategies guided by the 2014 Patient-Centered Medical Home (PCMH) standards and worked with our local IT team to build strategic enhancements into our commercial EHR to support closed-loop referral tracking and management, which enables staff to follow up on referrals as needed and receive specialist reports for review. We also expanded a routine data collection process to include staffing and wait times in individual specialty clinics.
In early 2016, we built on this technology and programmatic infrastructure to launch a pilot eConsult initiative. Based on existing best practices in referral review and triage, both within our facilities and in the literature, we developed an integrated eConsult/referral workflow that we built into the EHR for four specialty clinics at a pilot hospital outpatient department that volunteered to participate. Each participating specialty clinic was required to designate a “specialty reviewer” to review and triage each referral. (See workflow in Figure.)
Several clinical and administrative champions of eConsult emerged as we developed and implemented the pilot model. Enthusiasm for eConsult among facility leadership led outpatient departments at two more hospitals to join the pilot; eConsult was subsequently implemented in two specialty clinics at one facility and in four specialties at the second.
Early data and feedback from pilot clinics show that the eConsult workflow is contributing to improved access to specialty care expertise for our patients. Since pilots began, 6,324 referrals have been placed to an eConsult specialty clinic and triaged by a specialist; of these, 4,411 (70%) were determined to be appropriate and ready for an in-person visit, triaged by urgency, and contacted by specialty clinic scheduling staff. The remaining 1,913 (30%, range 8%–75%) referrals were determined to be appropriate for eConsult. On average, specialists reviewed and triaged each referral in approximately one week; previously, patient charts were not reviewed by a specialist prior to the first in-person specialty visit, often several weeks or months after the initial referral.
NYC Health + Hospitals routinely collects and monitors time until Third Next Available Appointment (TNAA) for primary care clinics; in our pilot, we also began doing so in specialty clinics. While clinic-specific factors, including changes in the number of providers, greatly affect appointment availability, eConsult appears to contribute to improvements in TNAA. In conjunction with other access improvement efforts, one pilot clinic saw a substantial reduction in TNAA (from 37 days to 8 days) over the first 6 months; TNAA at other pilot clinics either remained at similar levels or showed a trend toward decreasing over the first 3 months.
We expect eConsult to result in improved TNAA for specialty clinics, though the magnitude of the change will depend on the proportion of referrals that can be managed electronically and the proportion of patients newly referred from ambulatory care clinics versus established patients or patients referred from the emergency department.
Three key operational domains substantively affect eConsult’s success:
- eConsult requires shifts in expectations for all involved. Clear and consistent communication are required so that:
- Primary care providers consistently review eConsult responses and follow up with patients as needed.
- Specialty clinic staff schedule only those referrals that have been triaged appropriately.
- Specialists use the eConsult process as an opportunity for ongoing education for referring providers and for co-managing patients.
- Patients expect to be contacted by the specialty clinic if an appointment needs to be made.
- Specialist support. The time needed to triage all incoming ambulatory care referrals and respond via eConsult when appropriate can be significant; while we expect eConsult to improve our ability to match supply and demand over time, specialists can experience short-term increased workload. Our specialists are employed, so their compensation is not affected by this transition. As we move to prioritize workflows that emphasize specialist value and expertise, we expect to provide ongoing support to manage the transition process.
- Administrative support. The eConsult workflow shifts scheduling responsibilities away from primary care clinics (which typically book patients into specialties) to the specialty clinic, increasing the workload for administrative staff there. Anecdotally, the eConsult process can create stronger communication channels between specialists and clerical staff; however, not all facilities are able to consistently dedicate specific staff to one specialty clinic.
Learning from our pilot and drawing inspiration from successful eConsult implementations elsewhere, we continue to refine our eConsult model to better target the opportunities we see in our system, with emphasis on patient communication and improved scheduling processes. This year, we are beginning a more formal rollout to medical specialties at 17 facilities. We plan to partner with an academic evaluator to assess the progress and results of eConsult in a selection of specialties.