The Southern California Clinical and Translational Science Institute (SC CTSI) has supported a study showing how technology can give Medicaid patients better access to medical specialists, with less hassle for the patients and lower cost for the providers.
Called eConsult, for electronic consulting, the study used a combination of computer and digital communications tools to allow primary care providers to consult with specialists when in-person meetings are difficult to schedule or perhaps unnecessary.
A team from USC, LA Care Health Plan, SynerMed and Partners in Care Foundation showed how an electronic consulting system provided Medicaid patients greater access to dermatologists, endocrinologists and nephrologists.
A 2011 study of children with Medicaid and coverage under the Children’s Health Insurance Program (CHIP), which was published in The New England Journal of Medicine, found that specialists were five times less likely to accept Medicaid-CHIP than private coverage. Among those who did accept public insurance, wait times for appointments averaged 22 days longer than for the privately insured.
In addition, many traditional specialist referrals result in high rates of no-shows. The limited availability of specialists, especially for Medicaid patients, often means patients must commute farther to see those doctors, leading to conflicts in transportation and work that can prevent them from making it to the appointment.
Susan Enguidanos, assistant professor at the USC Davis School of Gerontology, was eager to evaluate a program that seeks to change and improve the referral process. With the eConsult study, she and research colleagues Alex Li, Sajid Ahmed and Sandy Atkins looked at three specialist referrals in the fields of dermatology, nephrology and endocrinology.
LA Care trained private physicians and staff in the use of eConsult and a new referral workflow system, which included digital cameras and software.
For example, a primary care physician seeking a dermatologist’s consult on a patient’s skin rash would take a digital photograph of the affected area and send it electronically to a dermatologist, along with other pertinent medical information.
Lab reports and other test results would be similarly transmitted to the specialist.
Transmission occurred in seconds, and the specialist response came within days — not the weeks typically required for an in-person appointment.
“This way the specialist can immediately identify and triage the condition without necessarily requiring the patient to make another appointment and another trip to the doctor,” Enguidanos said. “From the photo, the specialist might be able to simply tell the primary care provider how to handle treatment or if they’re more concerned, they can get the patient into their office fast.”
And if it’s nothing serious, Enguidanos added, the specialist can quickly put everyone’s mind at ease and prevent unnecessary appointments or additional tests.
Electronic consults also give specialists more flexibility to review cases before, during or after usual office hours. For the dermatology, endocrinology and nephrology consults in the study, eConsult simplified and accelerated the communication and referral process between primary care physician and specialist.
“We think of it as an electronic ‘curbside consult’ where physicians dialog with their specialist colleagues to virtually address patient needs,” said Ahmed, chief information and innovation officer at Martin Luther King Jr. Community Hospital, who helped design the system and ensure its success while he was director for health information technology and innovations at LA Care.
The outcome of the study resulted in a substantial boost in speed and the number of patients who received specialist care.
“Typically, with eConsult, the specialists involved were turning around cases in three days, versus several weeks for referrals handled the traditional way,” said co-investigator Atkins, vice president at the Institute for Change at Partners in Care.
In one three-month period, 100 percent of the patients referred by primary care providers through the eConsult process were reviewed by a specialist electronically, as compared to only 57 percent of traditionally referred patients. In addition, investigators found the electronic consults resulted in a 71 percent reduction in face-to-face specialist appointments, mainly because of the 55 percent of cases that were resolved electronically without the need for a specialist appointment.
For managed care health providers, this type of store-and-forward telehealth technology can save significant amounts of money: an electronic consultation with a specialist typically carries half the cost of an in-person appointment.
LA Care Health Plan provided $1.5 million to expand eConsult in Los Angeles County, where the system has resulted in more than 45,000 electronic consults in the past 18 months and has been adopted by the Independent Physician Association as well as its member safety net clinics.
SC CTSI provided additional funding to support the evaluation study, enabling investigators to bring aboard health economist Michael Nichol, professor at the USC School of Pharmacy.
“Bringing a health economist into the project allowed us to do a more robust analysis and create a stronger business case for how eConsult could positively impact the quality of care, as well as provide cost savings and efficiencies,” Enguidanos said. “As a result of this analysis, we also better understood the challenges for physicians in electronic consulting, which in turn helped us improve the design of eConsult.”
An article on the study is currently under review for publication in the American Journal of Managed Care.
SC CTSI is a member of the Clinical and Translational Science Awards network funded through the National Center for Advancing Translational Sciences at the National Institutes of Health (grant number UL1TR000130).