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eConsult– “Innovations in Health Care
How to Impact Access, Quality and Cost”
By Sajid Ahmed, Director Health Information
Technology & Innovation Strategies
L.A. Care Health Plan
iPad hands on review: Fits in your white coat and is fast enough for
Medical point of care use…
Create Something Before People Know
They Need It!
Here's a juicy definition of innovation
from the almost omnipresent Guy
Kawasaki.
Where does telehealth (eConsult) fit in the
Health IT equation?
What is Telehealth?
Telehealth is the delivery of health-related services and
information via telecommunications technologies.
Telehealth is an expansion of telemedicine, and unlike
telemedicine (which more narrowly focuses on the
curative aspect) it encompasses preventive, promotive
and curative aspects.
What is Telehealth?
WHAT
What is eConsult?
• It is a process and a technology
• The electronic clinical information and
consultation exchange between providers (e.g.
primary care provider (PCP) and specialist)
• An electronic “curbside consults”
• A peer to peer communication and referral
management system
eConsult Goals
• Improve quality and communication:
• Typed notes
o HIPAA-secure website
• Case-based learning
o Expansion of primary care practice scope
• Improve access:
• Timeliness standards
• Improve efficiency:
• Decrease unnecessary visits
• Improve pre-visit work-up
The Problem: Specialty Access
• Patients:
• Long wait times
• Need for multiple specialist visits
• High rate of no shows
• Linguistic, communication and transportation barriers
• Providers:
• Partial/incomplete work up (resulting in poor use of
specialist time)
• Onerous, unreliable referral system
• Notes illegible, not timely
• Poor communication between PCPs and specialists
• <60% of PCPs get report from specialist
The Problem: Specialty Access
• SynerMed/L.A. Care
• Authorization process seen as adversarial
• Misalignment of financial incentives
• PCP is typically paid capitation and specialist is paid fee
for service
• Co-management process between PCP and
specialist is eConsult goal
• Poor and incomplete clinical notes available for utilization
review
• Lack of medical triage
• New DMHC standard about access w/in 15 days
eConsult Training & Support
• All of the PCPs, PCPs’ office staff and specialists
received in-service training.
• PCP and specialist (Derm, Endocrine,
Nephrology and allergy and immunology)
provide feedback and suggestions to improve
the platform
• PCP and Specialist rate each other’s consults
and responses
L.A. Care eConsult Pilot Project
Preliminary Findings
Data from 3/25/2009 to 10/26/2010
PCP Offices Using the eConsult System
40 PCPs Trained: 33 Angeles, 7 EHS
35
30
0
10
25
3
10
20
3
15
5
10
2
5
10
9
10
0
0
1
2
3
14
4
Returning
29
18
5
New
22
23
6
7
8
383 (half) of the eConsults generated resulted communication
between the PCP and specialist with up to 48% deferred
Potential eConsults
=829 (100%)*
Non-eConsult
=446 (54%)
eConsult
=383 (46%)
425**
95 (%)
Face-To-Face
185
(48%)
N/A
eConsult Closed
(No Face to Face)
185
(48%)
N/A
eConsult In Process
7
(2%)
5
(5%)
Admin FTF
6
(2%)
*Base EXCLUDES: Duplicates, errors, cases where Dr. isn’t trained, no camera, wrong group or specialty, Dr. doesn’t want
to participate, specialist is ill/on vacation. Manual count differs from automated count by 10 eConsults
**104 noted as follow-ups where pt. already seeing specialist
Over Time PCPs Choose to Use
eConsult More Frequently
200
180
160
140
120
100
80
60
40
20
0
Non-eConsult
eConsult
n = 15
n = 45
n = 60
Q1
Q2
Q3
n = 131 n = 193 n = 181
Q4
Q5
Q6
On Average, PCPs and Specialists Exchanged
Four Communications per eConsult.
50.0%
47.1%
• Total Number of Notes:
1,253
• Average per eConsult: 4
• Most Frequent #: 3
• Min-Max: 2-12
45.0%
40.0%
35.0%
30.0%
25.0%
18.5%
20.0%
15.0%
10.0%
10.4%
7.1%
6.8%
5.0%
4.5%
1.9% 2.3%
0.0%
2
3
4
5
6
7
8
9
0.6% 0.3% 0.3%
10
11
12
Example of eConsult in Process
• #528: PCP Note/Question 4/16/10: HPI: white discoloration
around lips. Patient has hypopigmented discoloration around lips. As
a 14 y/o this bothers her. Please advise rule out vitiligo.
• Specialist 4/19/10: This is a difficult case because the
hypopigmentation is very minimal as seen on the photos. Are there
any other areas of hypopigmentation on the body? eyelids, genitals,
etc? This may be early vitiligo. Patient needs an autoimmune
workup: CBC with diff, SMA20, ANA, TSH, T4, RPR, thyroglobulin and
thyroid microsomal antibodies. Let's start there and look for more
areas of hypopigmentation and reevaluate prior to initiating tx
• PCP 4/22/10: I will call the pt. to come in for lab.
• PCP 6/9/10: I spoke w/ pt’s mom; she will bring her in tomorrow
for labs.
• Spec 6/11/10: Please followup labs…waiting for labs
Good eConsult
Summary eConsult Benefits
• Improved communication and coordination
(everything is time-stamped and notes are typed)
• Speed and co-ownership for consult
• No health plan/IPA review and patients calling to
wait for an appointment
• Patients did not have to go anywhere unless PCP
forgets to take photo or spec. recommends tests
• Quality/efficiency when pt arrives at specialist’s
office already triaged and with labs done
Lessons Learned
• Project management; hands-on training and support
• Work with PCP and specialist (to help with integration)
• Need patient volume (LA Care and HealthNet patients)
• Oversight/Workflow: Providers are not always the people
putting in the clinical information
• SynerMed system is NOT an EHR
•
•
•
•
Specialist needs laboratory and pharmacy information
Payment/Reimbursement and other incentives
Photo should be standard practice
Need backup for vacations and volume surge.
Safety-Net eConsult Program
WHO
WHY
WHEN
WHAT
HOW
WHO
The Stakeholders
L.A. County, Department of Health Services
Health Care LA, IPA
MedPOINT Management, MSO
Community Clinic Association of Los Angeles County
L.A. Care Health Plan
WHO
The Teams
Stakeholder Committee
Physician Core Working Group
Technical Core Working Group
Staff Core Working Group
Physician Advisory Group
Service Partners
Technology Developers
Trainers and Supports
Dedicated Project Management Staff
WHAT
What is eConsult?
• It is a process and a technology
• The electronic clinical information and
consultation exchange between providers (e.g.
primary care provider (PCP) and specialist)
• An electronic “curbside consults”
• A peer to peer communication and referral
management system
WHAT
Safety-Net eConsult Program
• L.A. Care community benefit funded program
to expand eConsult to the Safety-Net
• $1.5 Million
• 18 Months Program
– Development, process redesign, workflow training,
support and implementation
• 30 Safety-Net Private Non-Profit Clinic SITES
for up to 10 Clinic Organizations
• 17 DHS Clinic SITES and 4 DHS on site Clinics
• Replace the County’s referral system “RPS”
• Interface with HCLA/MedPOINT’s EZCap
Authorization System
WHEN
eConsult Milestones
• Q1 2011
• Initial Planning and Program Design
• Q2 2011
• Stakeholders recruited
• Funding Procured
• Q3 2011
• Vendor Selection and Contract
• Staffing and On site visits
• Q4 2011
• Workflow and Process Redesign
• Clinic Selection Process
• Technology Development and Testing
HOW
How Does It Work?
• eConsult is initiated by a PCP’s office
• Generated automatically by authorization request
• Background information entered
• Photos & labs uploaded
• PCP enters “eConsult” clinical question
• Consultation Question is entered by PCP and sent to Specialist as
part of the referral or authorization process
• eConsult Specialist reviews and responds to PCP
• PCP manages/treats member or orders tests
PCP Office Staff uses
a HIPAA secure
web portal
Specialist reviews
eConsult from PCP
PCP enters eConsult
Face-to-Face
Patient
Why
eConsult is in the News!
• eConsult system press release went out on August 2
to about 165 media outlets.
• Generated 35 news stories, some of which included
interviews with our spokespeople, Dr. Batchlor or
Sajid Ahmed.
• Since August we have had 5 contacts for more
information and meetings on eConsult from other
health plans, counties and physician groups
eConsult is going VIRAL
Lessons Learned & Challenges
• Project management; hands-on training and support
• Work with PCP, staff and specialist (to help with process
integration)
• Need patient volume (Not a problem unless its is not
standard use with referral and authorizations)
• Oversight/Workflow: Providers are not always the people
putting in the clinical information
• Specialist needs laboratory and pharmacy information
• Payment/Reimbursement expectations
• Photo should be standard practice
• Need backup for vacations and volume surge.
L.A. Care’s Safety Net
eConsult Program
• L.A. Care is project managing the program
• L.A. Care is funding the program up to $1.5M
• There are 3 workgroups and 1 advisory group:
–
–
–
–
Stakeholder Workgroup
Technical Workgroup
Physicians Workgroup
Physicians Advisory Group
• Convening a referral coordinator workgroup
• Quarter 1 2012 Go-live
Collaboration = Success
Primary Care
Physicians &
Office Staff
eConsult
Specialists
Referral
Specialists
Questions & Discussion