Three years ago, when a primary care provider in the Santa Clara County safety net referred someone to a specialist for follow-‐up care, they relied on the patient to set up the appointment, a system that ultimately didn’t work. Within six months of being referred, 50 percent of patients had not seen a specialist.
The process failed for a variety of reasons, recounts Kent Imai, medical director for Community Health Partnership (CHP), a consortium of nonprofit community health centers San Mateo and Santa Clara Counties.
Some referrals were simply lost by patients or staff or patients had trouble reaching specialists’ offices by phone, with calls put on endless hold or dropped entirely. In some cases, mailings to patients went to the wrong addresses. Sometimes language barriers compounded these problems. Ultimately, delays in patient or staff follow-‐through meant that the authorization period for appointments lapsed.
In addition to this broken referral process, wait times were increasing because of increased demand. “There were significant access issues to specialty clinics,” noted Dolly Goel, chief medical officer at Valley Health Plan in San Jose. “The Affordable Care Act helped so many patients get access to care, and there were so many more demands in the clinics, it couldn’t be business as usual.”
“It was unacceptable,” explained Imai.
Kent Imai, MD, Medical Director Community Health Partnership
Finding a Solution in E-‐Consult
To remedy this situation, Imai and other officials in the Santa Clara safety net began looking for a solution in 2016. During a visit to Zuckerberg San Francisco General Hospital, a team of these officials learned how clinicians used e-‐consult to collaborate and change how care was delivered.
High levels of provider and patient satisfaction with this approach convinced Santa Clara leadership that e-‐consult was the right course. To begin the transition to e-‐consult, they formed a steering committee of providers which continues to play a critical role in e-‐consult adoption. Each time a specialty is added to the e-‐consult program, a clinician “champion” is appointed to lead provider training and participate this steering committee.
With support from the Blue Shield of California Foundation, CHP, Santa Clara Valley Health and Hospital System and Valley Health Plan have collaborated over the past two and a half years to ensure that patients are seen as quickly as their health demands.
E-‐Consult Fixes Referral Process and Decreases Wait Times
E-‐consult has helped Santa Clara make the most of its resources to address an imbalance of supply and demand for specialists. Between September
2016 and March 2017, in the first six months of e-‐consult use, the flow of referrals improved considerably. E-‐consult referrals are triaged
in less than 24 hours, notes Imai and wait times for in-‐person visits have decreased significantly.
“We are now seeing patients within three weeks, down from in some cases
… six to eight months,” said Dolly Goel, chief medical officer at Valley Health Plan in San Jose.
So far, 18 specialties are participating in e-‐consult, with about 10 more yet to be phased in. Of the 1800 e-‐consults submitted to specialists by primary care doctors thus far, 16 percent resulted in “advice only” interactions to address patient issues and did not require a face-‐to-‐face appointment with the specialist, up from nine percent. In that same time period, only five percent of the referrals were identified as having an “incomplete workup,” down from eight percent.
Dolly Goel, MD, Chief Medical Officer, Valley Health Plan
Addressing the Challenge of Changing Workflows
Dr. Tin Ngo, medical director for urology at the Santa Clara Valley Medical Center in San Jose said wait times for patients to be seen by urologists, which had been as long as three or four months, are now down to a just a few weeks in a lot of cases.
Adopting a system change as big as e-‐ consult can be a challenge. Providers and staff in the urology clinic expressed doubts to Ngo. With a constant stream of patients and phone calls coming in, staff members can feel overwhelmed and may dislike the idea of taking on new work processes, he said.
To address this issue, every five weeks, specialists in his department rotate handling e-‐consults and are training other providers to handle them
as well. “You go through the work queue and look at incoming referrals,” he explains. “It maybe takes 30 minutes a day. We are training a nurse practitioner
to do a first pass.”
Ultimately, e-‐consult has made work more efficient for the staff.
“E-‐consult changes the work flow of staff. When the doctor is in charge of the triage process, instructions are clearer to staff,” Ngo explains.
Tin Ngo, MD Medical Director, Urology, Santa Clara Valley Medical Center
Challenges: Technology and Reimbursement
Implementing e-‐consult was not without challenges, however. Santa Clara had to address technical, practice and reimbursement issues.
Ideally, all providers in an e-‐consult system would use the same electronic health record. In Santa Clara, however, specialists use Epic and clinic providers use NextGen. Fortunately, it is possible to provide outside users with access to Epic through a link, which has been critical to supporting e-‐ consult communications between primary care providers and specialists.
Another major hurdle is the inability to bill specifically for e-‐consult work. “Everybody is still thinking of billing for time and fee for services,” Goel said. “Are you going to pay us to do this? If the new model of payment is value-‐based, some of the specific things that help, like e-‐consult, are not billable.”
However, with a change of attitude, e-‐consult can be seen as part of good business practice and not just a task that requires reimbursement. In addition, the transparency and accountability of the e-‐consult system motivates providers to participate at their fullest, Ngo pointed out.
“There is meta data in the referrals,” he said. “You can tell what percentage of patients are scheduled, what the turnaround time is for responses from providers. Everything is visible, reportable and transparent. Doctors see their data compared to peers, and doctors are competitive. They are going to want to match that level.”
A Culture of Cooperation Supports Better Patient Care
E-‐consult promotes a culture of cooperation because it requires a close working relationship, partnership and openness to doing things differently, explains Goel.
It took some time for providers to feel comfortable with this new level of collaboration. “Primary care doctors don’t want to be seen as asking dumb questions,” Goel said. To help prepare and support primary care doctors using e-‐consult, every specialty developed clinical guidelines for about three to five of the most common conditions referred to clinicians.
The results show that when the specialist is thoughtful and provides good input, the collaboration works well, she added. With this increased collaboration, primary care providers learn how to manage some common conditions for patients with the advice and guidance from specialists, saving patients and doctors time and unnecessary visits.
But the biggest reward has been improved patient care and greater job satisfaction. With e-‐consult interactions, specialists are much more efficient and effective with their time.
“Clinic is a real pleasure for us now,” Ngo said. “Everyone who sees us needs some kind of intervention.”