Overview

CHCN engaged RubiconMD to implement their eConsult platform and eConsult specialist network for their primary care providers in an effort to enable more efficient and comprehensive primary care

Organization Name

8 CHCN member health centers: Asian Health Services, Axis Community Health, La Clinica de la Raza, LifeLong Medical Care, Tiburcio Vasquez Health Center, Tri-City Health Center, West Oakland Health.

Organization Type

• Community health center
• Community outpatient clinic
• FQHC
• Safety net hospital

National/Policy Context

• The healthcare specialist referral process is complex, requiring referral accuracy, appointment scheduling, and information exchange.
• Referral processes and pathways are often inefficient and ineffective, and this has an amplified negative impact on Medicaid patients, who at baseline have decreased access to specialty care given that over 30% of physicians do not see Medicaid patients.
• These patients are often sicker, with increased comorbidities, and they are more likely to lack the financial resources needed to be able to get to appointments when compared with the general population.

Local/Organizational Context

• Community Health Center Network (CHCN) is a Medicaid managed care organization consisting of 90 locations in the East Bay area of California, including more than 40 primary care sites.
• It serves predominantly Latino, Asian, and African American communities with a large proportion of non-English speaking patients.
• CHCN identified issues with their referral system in 2015. In particular, they had many recently graduated primary care providers, their specialty network was spread thin and specialists were frustrated.
• In addition, patients were not showing up to appointments due to inability to access transportation for financial reasons. All of these elements led to breakdowns in the referral process.
• In an effort to improve and streamline the referral system, CHCN decided to bring in RubiconMD, an organization that specializes in facilitating electronic consults (eConsults) through their eConsult platform and network of specialists.
• The Chief Medical Officer at CHCN, Dr. Laura Miller, and CHCN’s Director of Operations, Ella Schwartz, initially reached out to RubiconMD about engaging them for  their providers to have access to same-day eConsults with top specialists.
• The two organizations have had weekly or bi-weekly check-ins since the project’s initiation to discuss user engagement and program development.

Patient Population Served and Payor Information

• CHCN’s patient population predominantly consists of underserved people, including African American, Asian and Latino patients. Over 70% of CHCN’s patients live under the federal poverty line, and a large portion are non-English speaking.
• About 50% of CHCN health centers’ 290,000 patients receive care through the Medicaid managed care organization, thus there is a clear incentive for CHCN to improve efficiency and effectiveness in the referral system. The other 50% of patients receive care through various payment schemes, including commercial health insurance or other medical assistance programs.

Leadership

• Clinical operational leadership at CHCN made the decision to pursue eConsults as a solution to the broken referral system; it was very important to have a clinical champion engaged in the process to help eConsult rollout and implementation, and provide feedback to RubiconMD for continued program improvement.

Research + Planning

• RubiconMD had lengthy discussions with CHCN about the organization’s structure and specific needs for an eConsult service.
• They shaped the services for CHCN’s use, deciding how the eConsult platform should be integrated into existing workflows, if CHCN wanted to tap into RubiconMD’s extensive specialist network, etc.

Tools or Products Developed

• RubiconMD has developed an intuitive eConsult platform, which can be used as a stand-alone web-based platform through the web / mobile apps or integrated into existing EHR.

Training

• Prior to rollout members of the RubiconMD team presented in-person at all-provider meetings alongside CHCN organization leadership where they explained the impact of eConsults, addressed pain points, and provided examples of when this tool can be useful (ex. certain behavioral health cases, which providers may not have considered consults for in the past).
• Additionally, RubiconMD offers  one-on-one training with providers and can train new providers individually as well. They also have videos and tutorials that are available to providers.
• Overall, the eConsult platform is intuitive and much less difficult to use than other programs providers are using for care.

Tech Involved

• Desktop computer
• eConsult/eReferral
• Electronic medical record

Team Members Involved

• Physicians
• Primary Care Physicians
• Specialists
• Support Staff

Workflow Steps

• The PCP sees a patient in the clinic and determines the need for an eConsult
  • Sometimes, PCPs determine the need for an eConsult prior to seeing a patient and can submit the eConsult without a patient visit
• The PCP inputs patient data into the eConsult platform, including the background of the patient’s medical issue and the specific clinical question, and submits the eConsult; this is the most important step, as it generates the value for the eConsult. The case can be started on the provider’s iPhone, this is especially useful if pictures are needed of physical findings.  
• The eConsult is received by the specialist, and the specialist provides recommendations via the eConsult platform within 12 business hours (although most cases take under 4 hours)
  • The specialist can either be within the healthcare organization’s network or a part of RubiconMD’s specialist network. CHCN used a hybrid approach where some specialists were within their network at Highland Hospital, a local public hospital, and other specialists were part of RubiconMD’s network.
• The PCP receives recommendations and, if necessary, can ask follow-up questions of the specialist. Otherwise, the PCP (or another member of the primary care team) reaches out to the patient with recommendations. These recommendations, depending on the case and clinical question, can include a medication change, scheduling a follow-up appointment with the PCP to discuss options, diagnostic assessments, confirmation of a treatment plan, reassurance, and/or scheduling an appointment with a specialist in the community.
  • Note: almost 70% of eConsults can be resolved without the patient having a face-to-face visit with a specialist (Olayiwola, 2015).
• After eConsults, the PCP rates the quality of the interaction (out of 5 stars). If interactions receive a low rating, the RubiconMD clinical and operations teams looks into what went wrong and acts on it. Additionally, the RubiconMD clinical team takes a sample of exchanges and evaluates the quality of the clinical guidance provided in order to ensure clinical accuracy.

Budget Details

• Represents less than 0.5% of CHCN’s expenses for professional specialty services
• The cost for RubiconMD’s services is organization-dependent. Services include the cost of setting up the eConsult platform in the existing system, clinical transformation to set up services, and payment to RubiconMD’s specialists per eConsult.
• For a stand-alone private practice, the cost is $250 per provider per month to subscribe.
  • More information on customized cost: https://www.rubiconmd.com/buy-now

Where We Are

• The pilot began in December 2015 at 6 sites within 2 health center organizations, including 40 PCPs.
• The pilot was deemed successful, prompting expansion of the program to all 450 PCPs in the CHCN network in September 2016.

Outcomes

• Patient Outcomes (reported for about 30% of total cases)
  • PCPs reported that up to 75% of eConsults improved their care plan for the patient.
  • PCPs reported that more than 50% of eConsults were educational and provided value for future patient encounters

• Process Outcomes
  • Almost 70% of clinical questions asked regarding patient care for specialists could be resolved without the patient seeing the specialist for a face-to-face visit, thus reducing the demand for in-person specialty care and improving access for those in need.

• Clinician Satisfaction
  • Improved physician satisfaction
  • PCPs appreciate quick turnaround times and the opportunity to gain knowledge from the eConsult which can serve future patients.
  • Specialists appreciate receiving a comprehensive clinical question and more thorough workup for patients who are, as a result, more likely to be appropriately referred to them.

• Patient Satisfaction
  • Patients enjoy knowing that another more specialized physician is reviewing their case and providing recommendations.

• Cost Savings
  • Savings of $300 to $800 per eConsult, due to avoidance of unnecessary specialist referrals, duplicative testing, etc.
    • Note: this is based on a small-scale study from other RubiconMD partners.
  • Patients saved money by avoiding costs for transportation, childcare, etc. associated with unnecessary in-person specialist appointments.
  • Analysis has shown that eConsults allow for a reduction in overall specialty care utilization. This decreased unnecessary use leads to reduced costs for both the healthcare system and patients. Additionally, providers get high levels of satisfaction, as PCPs endorse educational value and specialists report increased clarity on the consultation question and workup.

Future Outcomes

• There is a plan for further cost savings analysis to understand the long-term financial impact of eConsults.

Benefits

• Significant simplification of the extremely complex and arduous referral process at several pain points:
  • Referral accuracy:
    • The PCP received near-immediate consultant input, allowing for more informed specialist needs assessment by the PCP
  • Appointment scheduling:
    • More accurate triage of specialty referrals reduces the volume of in-person specialist appointments that require scheduling, allowing for those needing referrals to schedule their appointments more easily.
  • Information exchange:
    • The PCP provides the eConsult specialist with a specific clinical question and knowledge of the workup that has been performed to avoid duplicate workup.
    • The eConsult system allows for documentation of the exchange between PCP and eConsult specialist, including decisions and treatment plans, and can incorporate it into the patient’s medical record.
• PCP, specialist, and patient satisfaction has been improved (see Outcomes section above).
• eConsults are thought to be a long-term cost savings tool (see Outcomes section above).

Unique Challenges

• Reimbursement, and thus sustainability, for eConsults is difficult. Self-contained integrated health systems are often willing to absorb the cost of eConsults, particularly those with value-based care contracts.
• However, in other settings where there isn’t a reimbursement mechanism for eConsults, sustainability is an issue.
• Some community health centers, for example, have required grant funding. Private practice PCPs often pay out of pocket. The hope is that CMS will begin reimbursing for eConsults, as this is included in the current CMS payment proposal.

Personnel Challenges

• The program requires busy providers to do more than they are already doing.
• However, providing education around the value of the eConsult platform and making the platform as streamlined and integrated as possible has eased this issue.

Glossary

• Medicaid managed care organization: a healthcare delivery system where patients receive Medicaid health benefits from managed care organizations (MCOs) which have arrangements with Medicaid agencies, receiving a set reimbursement per member per month for the services (capitation). More information at: https://www.medicaid.gov/medicaid/managed-care/index.html