Using E-Consults to Prevent Unnecessary Referrals: A PCPs Guide

In today’s world, Primary Care Providers (PCPs) have the monumental task of managing 100s’ of specialty provider relationships and understanding over 150 specialties and sub-specialties.

Did you know there are 21 sub-specialties just for internal medicine alone?

With this type of challenge, how do PCPs guide patients to the most appropriate doctor for further treatment under their care when they do not know the best options available.  What’s worse, 55% of the time patients should not even go to another provider and can remain under the PCPs care if provided with guidance from their specialty care counterparts.

What is an E-Consult

Electronic consultation (e-consult), a telehealth modality, is a mechanism that enables primary care providers to obtain specialists’ inputs into a patient’s care treatment without requiring the patient to go to a face-to-face visit.

The primary care provider (or other continuity provider) initiates the econsult through a traditional referral pathway, ideally supported by clinical checklists. The specialist then gives advice or renders an opinion that the primary care provider (PCP) receives and acts on.

An e-consult can be as simple as a “curbside” opinion between the specialist and PCP that is intentionally general, often undocumented, and can not only delay treatment for the patient, but carry a large malpractice risk. Did you know that 80% of all serious medical errors involve miscommunication during care transitions to different care settings.

Considering in the United States that more than a third of patients are referred to a specialist each year, the need for solutions to improve communication is greatly needed.

Despite the frequency and the importance of the specialty-referral, the process itself has been a long-standing source of frustration for both primary care physicians (PCPs) and specialists due to only 45 percent of patient referrals being necessary.

Oftentimes, the clinical question is answered solely via e-consult, although the specialist will sometimes eventually see the patient in a face-to-face encounter. The rate of conversion to face-to-face depends on the clinical condition. When a face-to-face is required, only one visit will often be needed thanks to the pre-visit preparation completed via e-consult.

Viewing diagnostic images at a time after data collection is another store and forward telehealth application with radiology, dermatology and ophthalmology (retinal scanning) being common examples. The line between this telehealth application and e-consults is somewhat blurry, as e-consult platforms are also able to store and forward images attached to the e-consult.

 

Why is Provider Communication a Problem Today?

Poor access to specialist care can be detrimental to patients’ health. Excessive wait times and delays in care can cause anxiety in patients and their families. They can also reduce patients’ ability to carry out day-to-day activities and lead to deterioration in patient’s’ overall health as important diagnoses are delayed. In addition, 3 out of every 10 tests or services are duplicated needlessly, causing frustration for patients and providers alike.

The most significant gap identified with EHR is that vendors lack common functionality or the ability to customize e-Consult functionality within the EHR to meet the unique needs of each client.

While use of Direct messaging is available amongst EHR systems, the drawback of using this as a sole means of e-Consult functionality is the lack of closed-loop tracking, reporting and reconciliation of electronic consultations back to the patient chart in a fluid manner. Agnostic platforms like ReferralMD meet this capability very clearly, providing bi-directional data integration to maximize data flow for clinicians.

 

How do Primary Care Doctors Get the Advice They Need?

Unfortunately it can takes years to develop specialty care relationships through a combination of networking, and recommendations from other physician partners, or outreach campaigns from specialist looking to drum up referral business.

In the past a PCP had little control and found it hard to find great specialty care partners to seek advice about their patients. This is all changing now with technologies such as ReferralMD, a referral network management platform.

Quick Takes:

• Improving the interface between primary and specialty care requires a new perspective on care delivery by providers. In-person referrals have developed as the mechanism for primary care providers to get assistance from specialists, but there are other ways to access this expertise and co-management support E-consults eliminate the language of “denials? and “approvals” and instead is focuses on collaboration to find the best facility for a patient to receive care.
• Providers are concerned that the patients will perceive innovations such as e-consults as barriers to care if they do not result in a face to face visit. To address this concern, PCPs should discuss the positive attributes of electronic referral and consultation systems, which include closer collaboration between PCPs and specialists in co-management of patients and the convenience to the patient associated with avoiding additional specialty clinic visits.
• Respecting the patient’s desire to see as specialist in person is important. If the referral is necessary or the patient requests a visit, ReferralMD allows for all information including the patient medical records to be sent over electronically without need to fax.
• Collaboration between primary care and specialty care providers offers an opportunity for informal training and for providers to practice their full scope. With the Advent of EHRs, the old-fashioned curbside console has been lost, but he E-consults bring back this opportunity for dialogue.  EHRs are not necessarily developed to encourage dialogue and interaction, both of which come from people using the tool.
• Selecting the right specialist is critical, as is providing constructive feedback to both PCPs and Specialists about the quality of their communication with one another.

Thanks to the California Improvement Network

Make a List and Check it Twice

Since it is getting close to Christmas, I wanted to share a very nice report that you can use to identify who you should align yourself with as a PCP.

The report is simple to use and can be filtered by city, specialty, organization name, provider name and more, and is available from the ReferralMD platform.

Apply now for a demo.

In order to steer patients to the most appropriate, high-quality doctor, you need an updated physician directory that shows which doctors in you area work with you employed/contracted providers or the competition (in/out of-network affiliations) based on important criteria such as…

• Accepted insurance
• Proximity to patient
• Wait times
• Experience
• and much more

Your care coordinators will love the immediate access to information at the point of care as they send referrals out or request consults.

ReferralMD Example:

 

Another option, think about who advises your patients before they end up in one of your examination rooms and begin your list with those names.

Continue your list with the non-competing clinics in your area you can think of (even if you think their loyalty lies with another doctor)—basically, any other office in town that treats people or provides any sort of medical advice. Make your list as long as you possibly can without self-editing.

Once your list is exhaustive, refine it by asking yourself these questions:

1. Who do you already know and get along with well? (This is obvious, but you would be surprised how many facilities do not discuss their relationships fully with other staff or clinicians they work with)
2. Which clinics are on top of their marketing?
3. Keep your eyes open for ads on TV and in local publications.
4. Also try web searches to see who’s proactively taking advantage of online traffic. To review your competitors website utilize tools like
5. Are there any impressive new doctors in town that are already doing a lot of business—or whom you would consider an up-and-comer? (Which doctors have full schedules and can’t fit in many new patients?)

Recommend taking a look at your local county clerk’s office and review new doctors that have just received their business licence. May be a great way to build solid relationships early on and offer assistance to a up and coming doctor.

Are any doctors breaking off to build a new practice of their own? (Again, keeping your eyes open for advertisements or announcements in local publications will help here.)

Of the clinics whose loyalty lies with your competitors, do they have any competing clinics you can reach out to?

With the answers to these questions, you can establish the top targets to invite into your mastermind group. You may want to create a first choice and second choice list. The two lists will help you determine who to spend time on, if a doctor is already at the top of his or her respective positions you may want to eliminate that person from the list. Targeting the people who will be initially receptive to an invitation will be an important time-saver.

Additional Information on:  How to Build a High-Performing Physician Referral Network from Scratch

E-Consult Benefits

A number of factors are leading to rapid adoption of e-consults in certain areas of the healthcare marketplace, particularly where specialty access is challenging and pressures to increase value are more acute. The set of common experiences in ambulatory specialty practice described below illustrate opportunities where e-consults could be used to improve physician satisfaction, patient experience, quality of care and utilization of specialty services.

• Incomplete work ups. Specialists often enter an examination room to see a patient referred by a PCP and find that not all of the tests needed to assess the question or problem have been done.
• Low value visits. Studies suggest that a significant percentage of referrals, depending on venue and specialty, are actually for issues that could be resolved and managed at the primary care practice level.  (examples: neurology 17 percent, cardiology 36 percent, hematology 48 percent, nephrology 63 percent).
• The referral is directed to the wrong specialist. Much to the frustration of all involved, specialists sometimes see a patient for an initial consultation and discover the question or problem is not appropriate for their specialty practice.
• Poor access. PCPs and patients are often faced with long wait times to see a specialist.
• Feedback delayed/disconnected. In many systems, the results from a specialty consultation can take weeks or months to be returned to the PCP, decreasing the chances that the PCP will learn from each referral and, over time, make fewer referrals for the same clinical question.

E-consults are designed to address and mitigate each of these negative experiences.

 

E-Consult Challenges

E-consult implementation is not without challenges such as:

• Dual documentation. Providers are sometimes required to document in dual systems and are legitimately concerned about dual entry being time consuming and a potential source of errors.
• Lack of payment models. Payment models for e-consults vary. Using e-consults in a value based payment system is optimal. Those at risk need to be confident that if specialists are paid for e-consults, face-to-face visits will actually decrease.
• Transitions of care from remote specialists. E-consults allow a specialist outside of a strained local network to provide access, but if there is a later transition to an in-network, in-person visit based on acuity, the transition can be challenging and can create redundancies and, therefore, must be monitored.
• Workflow consistency within practices. Using e-consults for some patients and not others (for instance by payer) is difficult and may inhibit adoption.
• PCP adoption. Some referring providers will resist change and want their patients to be seen face-to-face. Identifying physician champions who understand the value of e-consult is essential to the success of the model.

 

E-Consult Market Developments

Evidence for the effectiveness of e-consults in safety net healthcare is building. Several articles detailing outcomes in a safety net environment have begun to emerge. These studies show high satisfaction among primary care providers, reductions of in-person consults of 40 percent, and overall cost savings.

This growing evidence is also translating into payment. The State of Connecticut’s Medicaid program has just begun paying for econsults initiated by PCPs at federally qualified health centers (FQHCs). Colorado and Oklahoma have pilot payment programs and Washington is planning a pilot. In California, where providers bear more risk than providers in other states (including risk for FQHCs in the near future), econsults have been implemented or are currently being implemented in a number of arrangements. The 1115 Waiver Global Payment Program in California specifically calls out econsults under a service category example. Continued dissemination of econsult use should be expected as local departments of public health begin to respond to the global budgets.

E-consultation is a telehealth solution that is gaining more widespread use. Companies have emerged to fulfill the need, offering SaaS models and pre-designed clinical checklists for referrals, as well as additional specialist capacity to address access problems. Market need, proven results, and commercially available products are likely to bring about rapid adoption in settings where specialty access is limited.

Conclusion

Building a referral network has gotten much easier due to technology allowing PCPs to work more closely with their specialty care counterparts.  If you have not made the leap yet, we highly recommend that you do, the ROI and benefits to your patients are massive.

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