Weitzman2013: eConsults: Using Technology to Enable Smart Referrals and Improve Access to Specialists

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Nwando Olayiwola, Daren Anderon, Ianita Zlateva and Nicole Jepeal present about eConsults: Using Technology to Enable Smart Referrals and Improve Access to Specialists at the 2013 Weitzman Symposium

Nwando Olayiwola, Daren Anderon, Ianita Zlateva and Nicole Jepeal present about eConsults: Using Technology to Enable Smart Referrals and Improve Access to Specialists at the 2013 Weitzman Symposium

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  • Is this a demographic?
  •  0.431883  1.540155  0.132636  3.256  0.00113 **
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  • 1. eConsults:Using Technology to Enable Smart Referrals andImprove Access to SpecialistsJ. Nwando Olayiwola, MD, MPH, FAAFPDaren Anderson, MDIanita Zlateva, MPHNicole Jepeal, BA
  • 2. From: Wright, MeganSent: Thursday, May 10, 2012 12:51 PMTo: Pitt, Elizabeth; Dorbuck, Paula; Lostocco, Lynn; Tarantello, Maria;Novo, Mayra; Paddock, TeresaCc: Joseph, SharonSubject: New Britain GH ENTI just spoke with Luz at NBGH ENT and as of today they are no longeraccepting ENT patients. The doctor there is not renewing hiscontract. She does not know if they will be accepting patients in thefuture.Meg WrightMedical Records Clerk/Referral CoordinatorCommunity Health Center, Inc.575 Main Street, 2nd FloorMiddletown, CT 06457860-347-6971 ext. 3659wrightm@chc1.com
  • 3. From: Dorbuck, PaulaSent: Friday, January 20, 2012 10:08 AMTo: Paddock, Teresa; Pitt, Elizabeth; Lostocco, Lynn; Wright, Megan;Tarantello, Maria; Joseph, SharonCc: Farb, Alan; Dudley, Robert W.Subject: ccmc opthalmologyJust as an FYI ccmc ophthalmology is not currently taking any newhusky patients.Paula Dorbuckreferral coordinator575Main street2nd floormiddletown ct860 347 6971 ext 3512
  • 4. From: Paddock, TeresaSent: Wednesday, June 13, 2012 3:20 PMTo: Joseph, SharonSubject: RE: Orthopaedic and DermatologyHere is the latest greatest news:Dr. Mazzocca—UCONN Orthopaedics—states that ALL orthopaedic referrals from the Shoreline Area areto be scheduled locally. If no local orthopaedics, then they are to be referred to Yale or St. Raphael’s.Dr. Wolf—Dermatology—states that he will only see patients that live in the following areas, New London,Groton, Mystic, Gales Ferry and Ledyard. No where else.For me, this means I have no where to send a managed healthcare patient when they need to see anOrthopaedic. (Unless they have Medicare as the primary coverage, then Sea Coast Orthopaedics will seethem.)As for dermatology, patients that live in Waterford have no where to go at this time.Can my job get any harder to do???????????Teresa PaddockReferrals/Safety ChairNew London/Groton/ClintonP:860-446-8858F: 860-443-8720
  • 5. • 39% of cardiology referrals were confirmed ascompleted in pilot data• Wait Time to completion over 50 daysIncomplete ReferralsDocumentationGapCommunicationGapAccess GapPilot Data – Cardiology Referrals – Care Gaps
  • 6. Primary careproviders inthe safety netstruggle toobtain accessto subspecialtycare for theirpatientsPaucity ofsubspecialistswho are willingacceptMedicaid leadsto majorimbalances insupply anddemandWait times forpatients toobtainspecialtyappointmentscan be as longas one yearPoor access tospecialty care haspotentially lifethreateningimplications fromthe long waittimes and delaysLimited accessto specialtyservices isnoted tonegativelycontribute toknownracial/ethnichealthdisparitiesAt least a quarterof visits to CHCsresult in referralfor subspecialtycare or diagnosticservices that arenot available inthe primary careofficeThe LandscapeCHCs and other safetynet settings have begunexploring variousmodels to bridge thesegapsHicks LS, OMalley AJ, Lieu TA, Keegan T, McNeil BJ, Guadagnoli E, Landon BE. Impact of health disparities collaboratives on racial/ethnic andinsurance disparities in US community health centers. Arch Intern Med. 2010 Feb 8;170(3):279-86. doi: 10.1001/archinternmed.2010.493.Cook NL, Ayanian JZ, Orav EJ, Hicks LS. Differences in specialist consultations for cardiovascular disease by race, ethnicyt, gender, insurance status,and site of primary care. Circulation. 2009 May 12;119(18):2463-70.Neuhausen K, Grumbach K, Bazemore A, Phillips RL. Integrating community health centers into organized delivery systems can improve access tosubspecialty care. Health Aff (Millwood). 2012;31(8):1708-1716.
  • 7. The Evidence for Electronic ConsultationFace toface visitsAccess toCareQuality CostSFGH/UCSF1 Decreasedby halfWait timesdecreasedby up to90%72% ofprovidersreportedimprovedcareN/AKPCO2 Decreasedby 41%N/A Equal totraditionalvisitN/ANetherlands3 Decreasedby 84%N/A Improvedthe rate ofnecessaryreferralsHas thepotential todecreasecost1. Chen AH, Kushel MB, Grumbach K, Yee HF,Jr. Practice profile. A safety-net system gains efficiencies through eReferrals to specialists. Health Aff (Millwood).2010;29(5):969-971.2. Palen TE, Price D, Shetterly S, Wallace KB. Comparing virtual consults to traditional consults using an electronic health record: An observational case-controlstudy. BMC Med Inform Decis Mak. 2012;12:65-6947-12-65.3. Scherpbier-de Haan ND, van Gelder VA, Van Weel C, Vervoort GM, Wetzels JF, de Grauw WJ. Initial implementation a web-based consultation process forpatients with chronic kidney disease. Ann Fam Med. 2013;11(2):151-156.
  • 8. What Do the Providers Want?
  • 9. Project DetailsFunder: Connecticut Health FoundationPeriod: 2 yearsStudy Location: Community Health Center, Inc.Partners:– UCONN Center for Public Health and Health Policy– UCHC Department of CardiologyAn Evaluation of an Electronic Consultation (“eConsult”) Platform toIncrease Specialist Access for Patients in Underserved Populations:Impact on Wait Times, Cost and Access Disparities
  • 10. Rob Aseltine, PhDeConsults:Using Technology to EnableSmart Referrals and ImproveAccess to Specialists
  • 11. Research Design• Study Design– Randomized controlled design– Randomization at the provider level• Eligible: Any PCP who sees adult patients andvolunteers• Intervention– eConsult pathway within the E.H.R• All consults must use this pathway EXCEPT urgent,existing relationship– Cardiology team recommendations (3 possiblereviewers)– PCPs following up and implementing therecommendations• Control– traditional referral within the E.H.R.
  • 12. Specialistsreviewsconsult within2 businessdaysCase warrants a inperson specialistvisit –appointment madeSpecialist requestsadditionallabs/tests beperformed – infosent to specialistfor reviewSpecialist providesadvice andguidance so PCPcan manage thecase in the primarycare settingPCPelectronicallysubmits consultwith allrelevant clinicalinformation
  • 13. Control InterventionPercent N Percent NGenderFemale 58% 114 47% 51Male 42% 83 53% 58Total 197 109RaceWhite 38% 74 39% 43Black 16% 32 19% 21Hispanic 36% 70 29% 32Other 11% 21 12% 13Total 197 109AgeMean (SD) 53.8 (13.3) 51.9 (15.8)Demographic Characteristics of Study Participants
  • 14. Facility Control InterventionPercent N Percent NBristol 0% 0 9% 10Danbury 2% 3 22% 24Norwalk 4% 8 0% 0Clinton 8% 15 1% 1Enfield 4% 8 0% 0Groton 6% 11 9% 10Meriden 38% 75 11% 12Middletown 9% 17 0% 0New Britain 8% 16 23% 25New London 11% 21 6% 6Stamford 10% 19 9% 10Waterbury 2% 4 10% 11Total 197 109Demographic Characteristics of Study Participants
  • 15. Priority Control InterventionPercent N Percent NRoutine 81% 159 90% 98Stat 1% 2 1% 1Urgent 18% 36 9% 10Total 197 109Type of Referral
  • 16. Coeff Exp(Coeff) SE z Pr(>|z|)Intervention 0.43 1.54 0.13 3.26 0.001 **Age 0.002 1.00 0.005 0.37 0.71Black 0.32 1.38 0.18 1.83 0.07Hispanic -0.11 0.90 0.16 -0.71 0.48Other -0.17 0.84 0.23 -0.74 0.46Cox Regression Results** Significant at .01 level.
  • 17. Coeff Exp(Coeff) SE z Pr(>|z|)InterventioneConsult0.91 2.47 0.16 5.84 .000 ***InterventionTraditional-0.16 0.85 0.20 -0.79 0.43Age 0.002 1.00 0.005 0.37 0.71Black 0.32 1.38 0.18 1.83 0.07Hispanic -0.11 0.90 0.16 -0.71 0.48Other -0.17 0.84 0.23 -0.74 0.46Cox Regression Results*** Significant at .001 level.
  • 18. 24338.50 5 10 15 20 25 30 35 40 45ControlIntervention eConsultIntervention TraditionalMedian Time to First Contact with Cardiologist (in Days)
  • 19. 60%82%47%34%73%26%0% 10% 20% 30% 40% 50% 60% 70% 80% 90%ControlIntervention eConsultIntervention Traditional% of group seen within 2 weeks of referral% of group seen within 31 days of referralTiming of Specialty Consultation following Referral
  • 20. Survival Curves of the Three ExperimentalGroups
  • 21. Intervention Group N=109Traditional Pathway 38 (35%)eConsult Pathway 71 (65%)eConsult resulting in a F2F 10 (14%)Referrals resolved w/out a F2F 61 (56%)Cardiology Referral Data – Intervention Group(Aug 2012-Jan 2013)
  • 22. 2444%56%020406080100120Intervention ReferralsResolvedwithout a F2FVisitRequiring aF2F VisitReduction in Face to Face Visits
  • 23. Summary and Next Steps• eConsults provide dramatic reduction in time to firstcontact with specialist and reduction in face to face visits– Interesting: Those bypassing eConsult pathway due to urgency tooksignificantly longer• Impact on health outcomes = ???– Data from APCD, CHIME, & Vital Statistics will provide answers• Impact on cost– Currently investigating payment models– Early data shows cost savings