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Telemedicine Closes the Gap in Specialty Referrals

Community health clinics in San Diego are using telemedicine to facilitate near-real-time consults with specialists, improving diagnoses and cutting down on referrals.

- A San Diego-based health system is expanding its telemedicine platform after a four-month pilot showed that more than 60 percent of patient visits requiring a specialist consult could be done virtually, without the need for an extra visit.

North County Health Services, a not-for-profit community health provider with 13 clinics around the city, found that 65 percent of its patient visits could be augmented by AristaMD’s eConsult platform, giving patients and their doctors near-real-time access to a specialist. Through that collaboration, doctor, patient and specialist were able to successfully conclude the initial visit without the need for a second appointment.

Denise Gomez, MD, clinical director of adult medicine at NCHS, says the telemedicine platform not only saves the patient a lot time, effort and worry, but guides the clinician toward a better diagnosis.

“The system has two components that are helpful for physicians: First, it has clinical work-up checklists for more than 200 conditions that help the provider validate his or her diagnosis, or prompt the provider with diagnoses or treatment paths to consider if they’re uncertain of the diagnosis,” she said. “Second, the eConsult platform provides the primary care provider with the ability to communicate with specialists in an asynchronous exchange, enabling them to facilitate specialty care for many of their patients.”

“In our pilot, nearly two-thirds of these eConsults enabled patients to receive specialty care from that primary care provider vs. having to make an in-person follow-up appointment with a specialist,” she added.

“The platform improves access to specialty care and saves our patients time – waiting to see a specialist, visiting a specialist or worrying about what might be wrong until they can get in with a specialist,” Gomez said.

Telemedicine consults are one of the fast-growing uses of the technology platform, enabling primary care and front-line clinicians to get real-time support from specialists to make a correct diagnosis and choose an appropriate care plan. The most commonly noted example is in stroke care, where ER doctors – sometimes even EMS providers in ambulances – can connect with a neurologist to diagnose a stroke well within the time limit needed to begin life-saving treatment.

Another example is in dermatology, where clinicians can gain access to a dermatologist to identify a strange rash or lesion or more quickly identify such issues as melanoma and Lyme disease, where quick treatment is vital.

Earlier this year, Shriner’s hospitals in Philadelphia, Salt Lake City and Galveston, Texas, launched a pilot to connect doctors in those hospitals by video with pediatric orthopedic specialists, whose numbers are small and access is difficult. In New York City, meanwhile, NewYork-Presbyterian added a Digital Second Opinion service to its NYP OnDemand platform to give both doctors and patients access to specialists for further information on a diagnosis.

And in Connecticut, The Centers for Medicare & Medicaid Services (CMS) is allowing the state to reimburse Community Health Center’s more than 200 clinics through Medicaid when they use Safety Net Connect’s eConsult platform for telemedicine consults with specialists.

“With limited specialty providers available to treat Medicaid patients, appointment wait times can be as long as a year, leading to healthcare disparities, higher rates of disability and complications in chronic diseases,” officials said in a press release announcing the CMS decision. “SNC’s eConsult system has been proven to increase access to timely, cost-effective specialty services for underinsured and underserved patients, many of whom live in rural areas with limited access to specialty care.”

In San Diego, NCHS officials said their four-month pilot at three clinics worked so well – nine out of 10 providers said they’d recommend the platform to other clinicians, and 91 percent said the service “had a significant influence on their patients’ care plan” – they opted to roll the platform out to all clinics.

“Our providers felt that the clinical work-up checklists helped them ask more specific questions that generated more informative and helpful responses from the specialists,” Gomez said. “We would gain greater efficiency by integrating into our EHR. After a successful pilot, this is our next step.”

Before turning to telemedicine, NCHS clinicians would generate a referral in the patient’s EHR, which would pass through a second database to create an appointment request. That request would then be faxed to the specialist, while the patient would get an e-mail or phone call to schedule a referral visit.

With the eConsult platform, a clinician logs in and enters the patient’s information, along with any lab results or imaging studies, and uses condition-specific guidelines to determine a diagnosis and treatment path. If a specialist is needed, the clinician requests a consult. If the consult can’t be done immediately, a response from a specialist is guaranteed within 24 hours, though NCHS officials said the average was four hours in the pilot.

The most common referrals, NCHS officials, said, were for dermatology, cardiology and orthopedic surgery.

Gomez said the system doesn’t eliminate the need for referral visits, but studies have shown that 60 percent of all such visits could be resolved in the initial doctor’s visit if that doctor had access to specialists.

“Obviously there are some types of referrals that require a face to face - for example, if a patient needs a procedure,” she said. “Our use will be to enhance the support of our providers not only through access to specialty care but also through the utilization of the guidelines.”

In addition, Gomez said clinicians could, in the future, be required to use the platform first before referring a patient to certain types of specialists. 

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