For Central Valley Residents, eConsults Are a Technological Lifeline

Dr. Joel Ramirez
Dr. Joel Ramirez, chief medical officer at Camarena Health Center in Fresno and Madera Counties, is a key member of a group that shares eConsult best practices with area health centers. Photo: Gary Kazanjian

Health centers across California depend on electronic consultations known as eConsults to improve patients’ access to specialty care. The use of eConsults is especially important to people in rural areas, like the Central Valley, who face many challenges accessing health care specialists such as dermatologists, neurologists, and rheumatologists. These electronic dialogues, a key component of comprehensive telehealth, allow primary care physicians to seek advice from geographically distant medical specialists through a digital platform. The consultation results in guidance to the primary care physician, physician’s assistant, or nurse practitioner on diagnosis and specialty treatment. This reduces or eliminates the need for many patients to travel for face-to-face visits with specialists.

Electronic consultations enable primary care providers to ask clinical questions of a network of specialists and get an answer within hours. Studies have shown that eConsults decrease wait times for specialist visits and prevent unnecessary referrals. In the safety net, where specialists are difficult to find and access, the impact on a patient’s ability to get needed care is substantial.

Unlike other telehealth services, however, primary care providers cannot be reimbursed for eConsults, according to Medi-Cal guidelines set by the California Department of Health Care Services. Currently, only the medical specialists’ time is reimbursable. Senate Bill 365, authored by California State Senator Anna Caballero, would change that by requiring Medi-Cal to reimburse primary care providers — doctors, nurse practitioners, and physician assistants — including those working for Federally Qualified Health Centers or rural health clinics.

I recently had a Zoom conversation about eConsult with Dr. Joel Ramirez, chief medical officer at Camarena Health Center, one of several rural Central Valley community health centers bringing eConsults into their workflow. Camarena serves more than 50,000 patients in Fresno and Madera Counties and the mountain communities of Coarsegold and Oakhurst. Our conversation has been lightly condensed and edited for clarity.

Q: Why are eConsults so important to improving patient care, especially in rural areas?

A: The use of eConsults helps to fill the gaps in health care services that we face in rural communities. We are located in Madera County and serve a primarily Medi-Cal population comprised mostly of farm laborers and monolingual Spanish speakers. These traits create challenges in the delivery of health care for many who must overcome obstacles to access a doctor’s visit. It’s not uncommon for our patients to live in households with only one or no vehicle. They may need to use public transportation, and they may need to ask for rides. Sometimes we even see them walking to our health centers.

In a rural area, specialists are few and far between, contributing to poor outcomes and limited access to health care for our patients. The use of eConsults gives our medical provider staff the ability to obtain input from specialists in a way that does not burden patients trying to access health care by forcing them to seek out childcare or requesting time off from work. In our health center, we found that it reduces in-person specialty care visits by as much as 80%.

Q: Can you describe an example of a successful use of eConsults and how it helped a patient?

A: A physician assistant in one of our clinics had a patient with progressively worsening diabetes. The patient did not have the means to transport herself to her medical appointments. The provider explored ways to get the patient to appointments and ultimately decided to submit an eConsult to a specialist. Within three days, he had a report back that guided him on initiating continuous glucose monitoring and an insulin pump. The provider had a conversation with the patient, and together they decided to follow those recommendations. Since then, the patient’s diabetes has improved. She also lost weight in the process, and that made her happy. The provider benefited because he learned how to initiate this process. Without an eConsult, this would have fallen on the specialists to do in their office.

Q: So eConsults are beneficial not only to patients?

A: The benefits of eConsults to patients are numerous. I think the most palpable for them is that eConsults reduce wait time. With some specialties, the wait time for an initial consultation visit can be months. With eConsults, the primary care provider can receive guidance from the specialist and implement the care plan within several days. We’ve seen enhanced patient outcomes. Patients who may struggle with transportation and accessing health care see those problems eliminated, because there’s no need to travel to the appointment. Because we’re able to reduce or eliminate these challenges, patients end up having a better experience, and we see that reflected in our patient satisfaction surveys.

Providers tend to have a better experience because they do not have to respond to all those phone calls and questions like “When’s my appointment? You told me you were sending me this specialist, but I don’t have an appointment yet. This is getting worse — what do I need to do?”

For specialists, no-show rates are reduced because they do not even need to schedule those appointments. When patients have to travel great distances or get an appointment in the distant future, they might just decide not to attend the visit at all, which can lead to higher no-show rates. A high no-show rate costs providers money and time.

Q: Do you think eConsult reimbursement for primary care providers would lead to additional providers using it?

A: I believe it would. For many health centers and other offices, part of the hesitation to use the technology may be that it is a reimbursable activity for the specialist but not for the initiating provider. Primary care providers are also apprehensive because they wonder about the time they’re going to spend placing the eConsult, receiving and digesting the guidance, following up with the patient, and accounting for the process with management.

Q: Can eConsults prevent patients’ conditions from worsening?

A: For many rural patients, eConsults could be a lifeline. The delay in timely access to specialty care can lead to a deterioration of medical conditions, poor outcomes for patients, and a negative impact on the community’s overall health. The innovative processes provide an electronic response to the physician, nurse practitioner, or physician’s assistant, which broadens their knowledge base and speeds the next steps. Whether it’s starting a patient on medication, ordering a specific test, understanding how to interpret results, or knowing when appropriate follow-up should occur, all of that can lead to better patient outcomes.

Q: You are a key member of the Central Valley eConsult Coalition, which brings health centers together to share best practices and strategies in using eConsult technology. Why do you put so much energy into spreading this innovation?

A: The Central Valley holds a very dear place in my heart. I was raised here, and I’m raising my family here now. Some programs that you can find in more urban areas are nonexistent in the Central Valley. I would like patients of the Central Valley to have access to the same type of specialty care as patients elsewhere. It’s important to me, to Camarena, and to other health centers to see patients better manage chronic conditions like asthma, diabetes, hypertension, and hyperlipidemia through the increased use of eConsults and other technologies.

Q: What’s next for eConsults and telehealth in general in the Central Valley?

A: The COVID-19 pandemic has brought telehealth to the forefront, allowing patients to access health care safely from any location. I can’t predict what’s going to happen with eConsults, but I hope the number and types of specialists who are reimbursed for eConsult service will expand. This would greatly help health centers and doctors’ offices to adopt routine use of eConsults and increase access to health care, promote better health outcomes, and potentially save lives.

Learn more about CHCF’s investment in eConsult company RubiconMD and related grant work.

Gary Kazanjian

Gary Kazanjian is a Fresno, California-based photojournalist who has worked for the Associated Press for more than two decades. He has captured news images for the New York Times, Fresno Bee, Los Angeles Times, San Francisco Chronicle, Time, People, Sports Illustrated, Working Mother, The Economist, and many others. Gary has been a longtime photography instructor at the College of Sequoias and has taught photography at Fresno City College and California State University, Fresno.

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