The Problem
Under value-based care, we must ensure that every patient receives the right care at the right time and in the right setting. Both patients and the health system alike suffer when unnecessary care is given (waste) and when needed care is foregone (worsened health). Our goal is to provide exactly the level of care the patient needs, no more and no less.
The DukeE-Consultation program has expanded the scope of primary care and improved efficiency. E-Consults provide PCPs with virtual specialty support and assistance in determining the necessity of a referral.1 Through this program, PCPs have been empowered to care for more complicated patients. Many patients that previously would have needed specialty referral are now treated “in place” in primary care. The E-Consultation program has improved provider-to-provider communication and increased the availability of specialist appointments for higher risk patients.2
However, two unresolved problems remain. First, the E-Consultation program does not address under-treatment, where a patient receives less care than is needed. Chronic kidney disease (CKD) exemplifies this problem. Abundant literature demonstrates the benefits of early detection, treatment and specialty referral in CKD.3 Yet CKD is frequently under-recognized and under-treated in primary care.4 The majority of patients with CKD are unaware they have the illness. Furthermore, patients are often reluctant to see a nephrologist due to fear, denial and/or mistrust of the healthcare system.
Second, the E-consultation program does not provide patient education. When a specialty visit is avoided, the patient loses the benefit of disease specific counseling from the specialist. Existing health education resources available in primary care (e.g., HealthWise) are overly generic and not appropriately tailored to an individual patients’ condition or educational needs.
We need a scalable, population-based approach to CKD that ensures timely recognition and treatment,and enables patients to better manage their illness. This type of care model will improve the value of care delivery, enhance patient engagement, and accelerate development of similar capabilities for many other chronic diseases and conditions.
Our Solution
In Duke Nephrology and select Duke Primary Clinic sites, we will pilot a CKD population health management intervention that utilizes Epic MyChart® and the Xealth digital patient education platform to guide appropriate specialty consultation and deliver tailored patient educational content.
We postulate that proactive management of CKD, resulting in fewer unnecessary admissions, better prevention of CKD progression.
References
- Joschiko J, Keely E, Grant R, et al. Electronic Consultation Services Worldwide: Environmental Scan. J Med Internet Res 2018;(20).
- Schettini P, et al. Keeping Care Connected: e-Consultation program improves access to nephrology care. J Telemed Telecare. 2019;25(3).
- Smart NA, Dieberg G, Ladhani M, Titus T. Early referral to specialist nephrology services for preventing the progression to end-stage kidney disease.Cochrane Database Syst Rev. 2014 Jun 18;(6).
- Diamantidis CJ, Hale SL, Wang V, et al. Lab-based and diagnosis-based chronic kidney disease recognition and staging concordance. BMC Nephrol 2019;20(1):357.
