Overview

Development of an eConsult system across the Los Angeles Department of Health Services

Organization Name

Los Angeles County Department of Health Services

Organization Type

• Community hospital
• Community organization
• Community outpatient clinic
• Integrated healthcare system/network
• Public Health System
• Safety net hospital

National/Policy Context

• The Department of Health Services (DHS) in LA consists of four medical centers, 2 large multispecialty ambulatory care centers, 17 DHS Health Centers, 180 community partner sites (contract with LA County to use DHS specialty care), 14 Department of Public Health Clinics, 14 Juvenile Courts Health Services Clinics, 9 Sheriff’s Department clinics, and the Department of Mental Health.
• It is the second largest public health system in the United States, serving 670,000 patients annually.
  • While there is a central leadership for the Department, each of the institutions within the DHS has its own leadership (i.e. the community partners are separately run nonprofits).
• Prior to 2011, specialty care was underperforming.
  • There was no single process for making a specialty request even within a facility (i.e. referrals could be made via fax, paper, mail, in person, etc.).
  • Many specialists had wait times of 9-12 months. Large numbers of specialty referral requests were never processed.
  • There were no uniform criteria about which patients warranted specialty care.
• In this setting, the Affordable Care Act in some ways created a mandate to improve specialty care. With the passage of the ACA, Medicaid patients had the option to choose other providers. In order to survive in a more competitive marketplace, the DHS LA had to improve access to specialty care.
• It chose to improve specialty care access via an eConsult system.

Patient Population Served and Payor Information

• Ethnically and racially diverse population. 65% are of Hispanic ethnicity. 58% of patients are white, 15% black, 5% Asian, 1% two or more races.
• About half of DHS patients speak a primary language other than English. 42% speak Spanish.
• Of the patients served by DHS LA, 23% are uninsured, 65% have Medicaid, 6% have Medicare, 5% have third-party insurance, and 1% have unknown insurance status.
• DHS also provides healthcare to inmates, children in foster care, youth in the juvenile justice system, among many underserved populations.

Research + Planning

• eConsults were rolled out across DHS LA in a staged fashion (sequentially across primary care practices and specialties) from 2012-2015.
• Expected Practice Development
  • For each specialty, a Specialty Primary Care Workgroup was created. One of their many care improvement tasks was to launch eConsults for the specialty.
    • Each workgroup consisted both of specialists and a few primary care doctors. 30 workgroups were established across DHS.
  • These workgroups were tasked with deciding how would apply same evaluation criteria to all requests of a certain type
    • i.e. which murmurs should a PCP work up further before referring versus refer right away.
  • Many workgroup discussions were codified into “Expected Practices” which described the unique DHS wide approach for patients seeking care and the resources that would be brought to bear for a certain problem, bearing in mind the medical literature and standards of care.
    • Development of an Expected Practice takes 2-3 meetings.
    • At the first meeting, the workgroup decides whether an Expected Practice should be developed for a certain topic.
    • A few members of the workgroup are delegated to draft the Expected Practice.
    • A follow-up meeting is spent talking about the nuances and decision-making reflected for a specific expected practice.
    • Expected Practices that overlapped with those developed by another workgroup had to be reconciled.
    • If applicable, Expected Practices were also reviewed by Pharmacy and the Managed Care workgroup.
  • Joint development of standards by PCPs and specialists made both parties feel ownership over the process such that by the time eConsults was launched in a particular specialty area, all parties wanted the eConsults to succeed.
  • There are currently 200 Expected Practices, which are downloaded 3000 times a month.
  • Notably, there is an Expected Practice on eConsult use.
    • This Practice specifies that eConsults need to have a response within 4 calendar days (including weekends and holidays)
• Policy Setting & Compensation
  • Setting expectation that eConsults be used for all non-urgent non-emergent requests for outpatient specialty care assistance was crucial to success of process.
    • Emphasized that once a specialty went on eConsults and PCPs had access to eConsults, all other modalities were unplugged
  • With regards to payments, had to make clear that eConsults were considered patient care and reimbursed as such.
    • eConsults are part of salary for salaried physicians. In high volume specialties like gastroenterology, if eConsults reviewers are getting a particularly high volume of eConsults, clinicians may cancel an hour or two of clinic to do eConsult work.
    • If contracted, the contractor makes whatever their usual hourly rate is (ex. $200 per hour).

Tools or Products Developed

• SafetyNetConnect eConsults system
  • Web based platform into which consult information is entered
  • Needed to be separate from the EMR as not all DHS facilities use the same EMR
• Specialty web-pages
  • Each specialty has a home page that describes the ideal information to include in an eConsult request. It also contains links to a library of Expected Practices for the most commonly addressed conditions for that specialty

Training

• Every time EConsults were rolled out to one of the DHS LA organizations, the central eConsults team would have 3 interactions with them
  • The first meeting was meant to introduce eConsults and ask the organization about their process for asking for consults
  • A second meeting focused on how to design a new workflow integrating eConsults
  • A third meeting involved on-site training for EConsults.
• All specialties and primary care practices were trained between 2012-2014

Tech Involved

• Web-Based Portal
• Safety Net Connect
• Website

Team Members Involved

• Physicians

Workflow Steps

• eConsult question submitted via SafetyNetConnect portal (online portal for eConsults that is separate from EMR).
• eConsult reviewed by specialist within 4 calendar days.
  • eConsults from a certain PCP always reviewed by same specialist.
• Dialogue ensues between PCP and specialist.
• Patient either referred for specialty care or further workup requested prior to referral.
  • If visit is necessary, specialist reviewer forwards request to a DHS-wide scheduling service for appointment booking.

Budget

• $500K to $1M

Budget Details

• DHS just renewed the eConsult agreement with their vendor (SafetyNet Connect) for $1 million a year.
• This does not include salaries for the 550 specialists who provide eConsult reviews

Where We Are

• The intervention is currently ongoing, as part of standard care.

Outcomes

• 17,000 eConsults are processed monthly. 4,000 providers from across 450 clinics use the eConsult program.
• The average response time from the initial eConsult request is 2.5 days
• In terms of dispositions of eConsults
  • 71% are resolved via a face to face visit or a directly scheduled procedure
  • 13% of eConsults address patient needs adequately without a visit
  • 5% result in PCP/specialist dialogue and extended co-management
  • 5% are cancelled/have resulted in no activity in 6 months
• As of 2015, median time to appointment for any eConsult request requiring a specialty visit decreased 17.4% from 63 to 52 days (p < 0.001)
  • Percent of appointments scheduled within 30 days increased from 24% to 30.2% (p < 0.001)
• Hospital based practices and community primary care practices more likely than multispecialty practices to resolve eConsult requests without a visit.
• Significant within-specialty variation in number of requests resolved without a visit (for example ranging from 5.9% to 93.1% across 26 endocrinology reviewers).

Benefits

• Improved timeliness of specialty input, as above.
• Enables PCP and specialist collaboration across a large, often fragmented system and provides educational value to dialogue with specialists.
  • Feedback has shown that eConsults improve PCP clinical capabilities, build PCP-specialist relationships, and help troubleshoot system access issues.
  • PCPs feel less isolated because they are connected to a larger system of care.
• Continuity of relationship of one PCP with one specialist makes PCPs feel like they have a “friend on the inside” and incentivizes optimal behavior on both the part of the PCP and the specialist.
• Improves effectiveness of specialty clinic visits because the patient arrives more prepared with appropriate testing already performed.
• Reduced no-shows for specialty care
• Creates a platform by which to send consult notes back from the specialty visit (not all of the organizations in the eConsult network uses the same EMR).
• In addition to having to wait less time for specialty care, patients reap benefits by having to travel less to specialty care, take fewer days off work, and arrive at specialists visits with more of pre-visit testing completed

Unique Challenges

• PCPs perceive that eConsults have shifted some of the work of specialty care to them
  • This is a particular challenge for primary care practices who don’t yet have an effective medical home model and continue to do care coordination, population health management, etc. themselves
• If PCPs are co-managing patients, they often have a harder time ordering specialty labs or diagnostics
• Submitting a high-quality eConsult takes time for PCPs
• It took time and experience to make specialists feel more comfortable with giving advice about a patient they had never seen.
• The patients who end up seeing specialists are often more complex
• A proportion of PCPs viewed eConsults as an obstruction that slowed access to care. They felt that for anything that had to be resolved very expeditiously, they would page someone on the appropriate service or send patients to the ED because there wasn’t a guarantee of how quickly they’d have an eConsult reply.
• Occasionally, PCPs felt like they had to find workarounds for certain reviewers if they knew a particular reviewer was unlikely to accept a patient to be seen in person. PCPs sometimes felt they had to embellish their language in eConsult requests.

Glossary

Metrics

Key Quality Metrics: 

MIPS: CAHPS for MIPS scores measure patient satisfaction and are included as measures that practices can submit for MIPS’ quality program.  E-Consult implementation is likely to help healthcare systems improve on some of these domains such as Getting timely care, appointments, and information, Access to Specialists, and Care Coordination.  More information can be found here.

MSSP ACOs: ACOs participating in the Medicare Shared Savings Program (MSSP) must contract with a vendor to administer the CAHPS for ACOs survey.  Quality scores calculated from completed surveys are used to determine an ACOs overall quality performance.  As with MIPS, implementing an e-consult program may help ACOs improve on domains such as Getting timely care, appointments, and information, Access to Specialists, and Care Coordination.  More information about the survey can be found here, and more information about its role in the MSSP can be found here.

Other Opportunities: By decreasing wait times for specialist appointments (as described above), specialists may be able to reduce their no-show rates.  In addition, specialists can ensure that low acuity patients who can be managed more appropriately in primary care do not make unnecessary appointments, potentially lowering avoidable costs.  Finally, while most insurers do not yet allow providers to bill for time spent on e-consults, a number of insurers and state Medicaid programs are exploring the possibility.