iHT² CMIO Symposium Beverly Hills – eConsult: A Model for Integrated Care – Rob Bart, CMIO, Los Angeles County Department of Health Services Closing Presentation "eConsult: A Model for Integrated Care" The rate of outpatient specialist referrals has nearly doubled over the past decade. Increased utilization, along with documented variation in referral rates, has raised concerns about worsening fragmentation of care and the appropriateness of referrals. Access to specialists by primary care providers representing their patients has always been a challenge within safety-net healthcare delivery; fulfilling the dual imperatives of timely access and rational triage drove the implementation of eConsult. eConsult links primary care providers and specialists, with the goals of increasing access to care, improving dialogue, optimizing the efficient use of specialty resources, and enhancing primary care capacity. Learning Objectives: ∙ A new paradigm for primary care-specialty interface ∙ A technology tool supporting a move away from visit-based care Rob Bart, MD Chief Medical Information Officer Los Angeles County Department of Health Services

1. eConsult – a Model for Integrated Care
- making it easier to behave like a system
Rob Bart, MD
Chief Medical Information Officer
Los Angeles County Department of Health Services
with contributions from Paul Giboney, MD & Hal Yee, MD

2. Background

3. Background – ACA & Work force
 32 million Americans newly insured
 10,000 Americans turn 65 daily through 2033
 MD shortage of 91,500 by 2020
 Underserved populations will bear the greatest
burden of workforce shortage

4. Background – ACA & Work force
 Projected physician shortages

5. Background – ACA & Work force
 Projected first-year enrollment growth

6. Los Angeles County
 Population >10 million
 Largest homeless population in US @ > 48,000
(2010)
 10% undocumented immigrants

7. Los Angeles County

8. Los Angeles County

9. Los Angeles County
Department of Health Services
 2nd largest municipal health system US after NYHHC
 US$3.5 billion budget (17% county funded)
 800,000 unique patients served 2012
 Volume of Services
 Ambulatory - >2.6 million
 Emergency - >300,000
 Inpatient - ~75,000
 Healthy Way LA (LIHP) – 252,379 enrolled

10. Los Angeles County
Department of Health Services

11. Goals for Today
 3 Responses to Specialty Care Need

The use of Workgroups to bring together a fragmented
specialty care delivery system.

The use of technology (eConsult) to transform the way we
understand specialty care services.

The implementation of a centralized specialty appointment
scheduling system to improve customer satisfaction and
reduce no shows.

12. The Challenge
 Mario receives primary care at CP or DHS
42 year old with Ulcerative Colitis
 He has a flare in his condition
 His PCP would like GI specialist input for the flare

 The Problem
Long wait time for GI clinic appointment
 No good way for PCPs to communicate with specialists
about possible consults or patients needing expedited
attention


13. The challenge
• How does a large, historically fragmented health
care system address the issues of:
•
Long wait times for specialty services
–
Lack of coordinated care between County and Community
Providers
–
–
High no-show rates to specialty clinics
Large variation in care delivery processes

14. The “Black Hole”
 350,000+ referrals to specialty care annually
 Long Wait times for specialty clinic visits(2011)
Gastroenterology – 162 days
 Nephrology – 86 days
 Podiatry – 222 days
 Urology – 208 days
 Cardiology – 140 days
 Dermatology – 208 days
 Gynecology – 109 days
 Neurology – 225 days

 Access to specialty care is consistently recognized as one of the
top problems in the safety net.

15. Fragmented Care
Hal Yee, 2013

16. Fragmented Care
Hal Yee, 2013

17. Patient Centered Medical Neighborhood
Hal Yee, 2013

18. Principles
Effective Practice
Practical “real world” improvement

19. Disruptive Innovation
 Investment in Patient Centered Medical
Neighborhood (PCPs and Specialists).


Specialty Primary Care Workgroups
eConsult – in partnership with local Medicaid plan and FQHCs
 Investment in Patient Centered Specialty
Scheduling



Reduction in process variation
Reduction in no-show rates
Improved patient experience

20. Specialty Primary Care Workgroups
 Effective Practices
 Collaboration across facilities and disciplines
 Triple Aim
 Equity/Reduced variability

21. eConsult
• HIPAA secure, web-based “clinical conversation”
portal.
• Advantages
–
PCP and Specialist collaboration
•
•
•
–
–
–
Improved PCP clinical capability
Relationship building
Troubleshooting of system issues
Improved responsiveness to requests for specialty assistance
Reduction in avoidable specialty visits
Improves effectiveness of specialty clinic visits (when they are
indicated)

22. eConsult – Primary Care

23. eConsult – Primary Care

24. eConsult – Primary Care

25. eConsult – Primary Care

26. eConsult – Primary Care

27. eConsult – Primary Care

28. eConsult – Primary Care

29. eConsult – Specialty Care

30. eConsult – Specialty Care

31. eConsult – Specialty Care

32. Impact - eConsult
 eConsult
 14 Specialty Services



Cardiology, Dermatology, Diabetes, Endocrinology, Gastroenterology,
Gynecology, Hematology, Hepatology, Nephrology, Neurology, Obstetrics,
Ophthalmology, Podiatry, Urology
1,300+ PCPs using system
130 PCP Sites (40 DHS, 90 Community Partner)
 110+ Specialty Reviewers

Average Time to Respond to Initial Request = 2.5 days

A primary measure of impact is that 100% of specialty requests are
answered promptly by an expert who is able to provide assistance.

33. Impact - eConsult

34. DHS Appointment Service Center (ASC)
 The old way – “Mail and Pray”
 The new way - Patient Centered Specialty Scheduling
 For patients identified through eConsult
 ASC has the ability to schedule anywhere in the system
 Appointments are scheduled only after personal patient
contact

GOALS –
 Improved patient experience
 Quick scheduling turn around times
 Less variation in process
 Lower „no show‟ rate
 More effective work, not just more efficient work

35. Impact - ASC
 Patients Scheduled – 16,000+
 Successfully Scheduled Rate – 84%

For unreached patients - phone message left, letter sent and PCP
notified via eConsult
 No show rate – 13.5% (historically 35 - 40%)

36. Overall Impact
 Community Partner Medical Director –
 “eConsult
has been a blessing and the providers
are thoroughly enjoying the opportunity to
learn new patient management strategies from
the specialty providers. The best part is our
patients aren‟t waiting over 6 months for
consultations!”

37. Summary
 The power of collaboration to overcome the
challenges of a large and fragmented system.
 The power of conversation (via eConsult) to bring
specialty services into the medical home.
 The power of a scheduling process that focuses on
effectiveness and patient engagement.

38. Future – DIRECT Project

39. Future – DIRECT Project

40. Thank you!
rbart@dhs.lacounty.gov