The Problem
As health systems grow larger and demand for specialty care increases, it is becoming increasingly important to embrace efforts to reduce care fragmentation and enhance the primary care to specialty care interface. Referrals serve as the gateway to specialty care; however, with referrals doubling within the past decade, access to specialists continues to be a common barrier for both patients and PCPs. Patients are often faced with long wait times, along with cost and travel burdens to see specialists, whichcontribute to poor patient satisfaction and outcomes. Barriers to access are especially a problem for patients with chronic diseases who suffer from increased rates of morbidity and mortality due to delayed referrals. PCPs may be forced to refer patients to out-of-network specialists with quicker access, which can in turn increase care fragmentation. When patients are seen by specialists, communication breakdowns still exist, which can result in duplicate diagnostic testing, polypharmacy, and confusion about conflicting care plans. For specialists, concerns also exist about the appropriateness of referrals and lack of pre-requisite workup.
Our Solution
As access to specialists becomes increasingly more difficult for patients and primary care providers (PCPs), health systems are seeking innovative solutions to improve specialty care access. Several stakeholders from Duke health system leadership, nephrology, primary care, and health informatics, convened to develop a Nephrology eConsult program. The program contributors designed an eConsult workflow imbedded within EPIC that would use existing functionality for ordering, documentation, and messaging.
Using the “E-Communication to Nephrology” order, PCPs have the option to request remote evaluation and management recommendations from a Duke Nephrology provider based on chart review, without a face-to-face visit. Nephrology is ideally suited for an eConsult model since timely nephrology referral is crucial for patients with high-risk chronic kidney disease (CKD), and yet many new patients referred to nephrology have low-risk CKD and do not require in-person specialist visits. Our quality improvement study sought to characterize the demand for nephrology and identify the areas where eConsults could most improve the referral process.
We hypothesized that eConsults would promote closing the specialty referral loop, reduce nephrology care wait times, and increase referral completion rates for patients within our primary care network.
Impact
- The time for eConsult note completion was approximately 10 to 18 minutes, as measured by the nephrologist. The median response time for eConsults was one day; 45% were completed on the same day and 80% were completed within 2 days.
- The nephrologist did not recommend a face-to-face visit for 67.5% of patients. For the 32.5% of patients for whom a face-to-face specialist visit was recommended, wait times and visit outcomes were measured. The median wait time was 40 days (compared to the 61-day median appointment wait times for traditional Nephrology referrals).
- Approximately three quarters (73.1%) of the visits were completed, 15.4% were canceled, 7.7% were scheduled, and 3.8% were no shows. The 26 in-person visits were scheduled among 8 different Duke Nephrology providers. An appointment status and wait time were available for all in-person visits that followed an eConsult.
E-Consults significantly improved closure of the specialty referral loop,increased referral completion rates, and reduced nephrology care wait times.
We sent an online survey to measure PCP satisfaction at the end of the pilot.
- A majority (86.6%) of the PCPs who responded rated their overall satisfaction with the program as a9 or 10 out of 10 (“highly satisfied”) and 100% were “extremely likely” to continue using eConsults.
- Similarly, a majority (80%) of PCPs indicated that they would have sent an ambulatory referral to nephrology with or without additional diagnostics prior to referral for most patients for whom they submitted eConsults.
- The remaining 13.3% of PCPs indicated that they would have simply managed the patient in primary care, and 6.6% would have contacted a nephrologist via phone, email, or staff message.
PCPs were asked to provide free text about what the biggest benefits were of using eConsults.
- A majority (78.6%) said that the quick turnaround time by the nephrologist was the biggest benefit (“Timeliness of consults and ability to handle “simple” issues without a formal consult”; “Speed and ease of consult, quick response”).
- The remaining 21.4% described the efficiency for providers and patients as the greatest benefit (“Efficiency for provider and patient; triage of referrals–PCPs not always sure when to refer to nephrology”; “Patients do not have to travel to Duke for evaluation”).
- Recommendations about how to improve the program included using eConsults for follow-up specialist visits and making eConsults available to all primary care practices and other specialties. The other specialties included rheumatology, neurology, cardiology, gastroenterology, endocrinology, and dermatology, along with several other specialties.
Other outputs:
- Our work was presented at the12thAnnual Duke Health Patient Safety and Quality Conference (March 23, 2017) andthe 2017 Annual Scientific Session of the North Carolina Chapter of the American College of Physicians (February 24, 2017).
- We will also be submitting a manuscript to the Journal of Telemedicine and Telecare entitled “Keeping Care Connected: E-Consultation Program Improves Access to Nephrology Care”.
Although a financialmodelfor eConsult reimbursementhas not yet been created, department leadership in other specialties, including Urology and Rheumatology,have begun discussing how to implement an eConsult program for their patient populations, who have similar challenges compared to those referred to Nephrology. These specialties are likely to pilot the next eConsult programs at Duke, so much discussion has taken place about how to best structure those pilots, taking into consideration the limitations of the Nephrology pilot (i.e. having one specialist reviewer and a small sample size of primary care clinics and patients). Various eConsult platforms have been considered including AristaMD and Wisercare, which incorporates patient preferences into the decision making and could allow for more widespread implementation of eConsults.
