- A first-of-its-kind telehealth program launched in Connecticut two years ago is reducing unnecessary spending, improving care coordination for the hard-to-reach Medicaid population and making primary care doctors more confident in their abilities, simply by using online messaging to determine if specialist referrals are necessary.
The eConsult program developed by Community Health Center in 2015 is now being used in some nine states, from Maine to the Pacific Northwest, and has spawned a network of similar programs across the country. Its premise is simple: Give doctors an online resource to ask a few questions and perhaps get a little reassurance that they’re doing the right thing.
“This thing makes people happy,” says Darren Anderson, MD, CHC’s vice president and chief quality officer and director of the Weitzman Institute, a community-based research center founded to help Federally Qualified Health Centers improve primary care services for the underserved.
Speaking at the Northeast Telehealth Resource Center’s recent “Taking Telehealth Mainstream” conference at the University of Massachusetts in Amherst, Anderson explained that the eConsult program was initially designed to make life easier for the referral coordinator.
The referral coordinator’s job is to link Medicaid patients in need of a specialty consult with specialists – not an easy task, for several reasons. First, Medicaid typically serves low-income populations, often with access issues. They’re not particularly interested in seeing a specialist, and would often have to travel some distance, often by bus, cab or train, to see one.
Second, specialists by their nature are hard to find and in high demand, so there are few slots on their calendar for appointments. For that reason, they often limit new appointments and shy away from Medicaid patients who would more often than not skip or miss an appointment. As well, any available slots for a Medicaid patient might be several months distant.
So it’s up to the referral coordinator to chart a “squiggly line path” from a Medicaid patient who needs a specialist to a specialist who can see that patient. And that’s where the eConsult program comes into play.
Working with the Weitzman Institute and Safety Net Connect, a California-based developer of online care coordination services, CHC launched its eConnect pilot in 2015. Working at first with cardiac care patients, the program routed all specialist referrals from CHC providers through an online system that allows the specialist to review the case online. This includes access to the patient’s medical record and any questions the primary care doctor may have about his/her diagnosis and treatment so far.
According to Anderson, that pilot program produced “no negative outcomes.” In fact, it found that almost 70 percent of the specialty referrals didn’t require an appointment with a specialist. Instead, the specialist would review the case, confirm the primary care doctor’s diagnosis and make suggestions on treatment and medications.
“There was a statistically significant reduction in cost,” added Anderson, both for cardiac care treatment and in the overall cost of care.
Furthermore, Anderson said the telehealth platform proved an interesting point: Sometimes primary care doctors just need a reassuring word or two from a specialist to let them know they’re on the right track for treatment.
Based on that success, Anderson said, CHC and the Weitzman Institute created a non-profit to manage the program, then used a grant to expand it to other specialties and other states around New England.
The success of the project also drew the attention of the Centers for Medicare & Medicaid Services, which approved the eConsult program for Medicaid reimbursement.
“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,” CMS officials said in a 2016 press release. “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.”
The results since then have been equally impressive. According to Anderson, a health center in Bangor, Maine, using the eConsult platform for dermatology consults was able to resolve 108 of 109 specialty consults without a face-to-face meeting. And in Washington and Oregon, the Yakima Valley Farm Workers Clinic has resolved 788 of 938 specialty consults without needing to send the patient to a specialist.
Anderson says the platform simplifies the process for primary care providers – many of them in crowded FQHCs or clinics – by giving the specialist the responsibility for deciding if a consult is needed. The referral coordinator routes the case to an appropriate specialist, who reviews it and often responds within hours, if not a day or two.
“We’ve largely taken the decision … out of the hands of the clinician,” he said.
The program’s success has also spawned other eConsult platforms. In San Diego, North County Health Services launched the service in its 13 clinics, using a platform developed by AristaMD, and found that 65 percent of its specialty referrals could be avoided through the online consult.
“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,” Denise Gomez, MD, NCHS’ clinical director of adult medicine, 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.”
“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,” she added.
It has also prompted some concern among researchers who say the platform could add to providers’ workloads instead of easing that burden.
In a study published in Health Affairs last December, Lori Uscher-Pines and Ateev Mehrotra wrote that a telehealth program can increase the workload for specialists and healthcare providers in underserved areas simply because the increase in quick consults at the front end may add to the number of in-person visits at the back end. This could stress overworked doctors and nurses and add to the wait time for an in-person visit, particularly in health systems that aren’t managing their traffic effectively. And it could keep underserved populations from getting the care they need.
Mehrotra, a hospitalist at Beth Israel Deaconess Medical Center and healthcare policy expert at Harvard Medical School, and Uscher-Pines, a researcher for the RAND Corporation, studied two programs - the Medical Alumni Volunteer Expert Network (MAVEN) and Direct Dermatology (DirectDerm) - and found more problems than progress.
Those programs “offer telehealth capabilities to primary care providers who are frustrated that local specialists won’t take their patients or have long wait times,” the researchers wrote. “In the environments in which these two programs operate, telehealth seems to have so much promise. However, we learned in our evaluations that bringing in telehealth won’t reduce the burden on the dysfunctional healthcare system. By identifying problems that require longitudinal care, telehealth may actually stress the healthcare system further.”
They also wrote that a telehealth platform like eConsult can work if it’s mapped out properly.
“Prior work has highlighted that roughly 20 percent of all consultations can be resolved with just an electronic exchange between a primary care provider and specialist,” Uscher-Pines and Mehrotra wrote. “A larger fraction could likely be resolved with a videoconference between a patient and specialist. The hope is that deterring a large fraction of in-person consultations will free up specialists for the patients who most need them. As such, the introduction of telehealth can increase efficiency and help a community serve a greater number of underserved patients without adding more providers.”
At the NETRC conference, Anderson said CHC’s eConsult program is working just fine. When asked if such a platform would result in more consults and a heavier workload, he said primary care physicians are actually using the service to become better doctors.
“They’re learning” he said, adding that doctors will use those specialists’ consult to improve their own decision-making, so that next time they might be able to handle a patient’s diagnosis without going to a specialist for guidance.