Lack of access to specialists is a critical gap in quality care for vulnerable populations. With too few specialists, patients experience longer wait times, which can be costly in both medical and financial terms. Health Affairs recently published an article that examined the first three years that Los Angeles County’s safety-net program used eConsult, an electronic system in which all requests from primary care providers for specialty assistance were reviewed by specialists. The eConsult system was rapidly adopted and decreased wait times to see specialists, according to the Health Affairs article. The California Health Care Foundation’s Health Innovation Fund last year made a $750,000 investment in RubiconMD, which provides the eConsults technology platform. With this investment, CHCF supports an innovative approach to improving access to specialty care that implements eConsults for primary care providers in Medi-Cal managed care plans. The following was written in response to the Health Affairs report.
I commend and thank Michael L. Barnett, Hal F. Yee Jr., Ateev Mehrotra, and Paul Giboney for documenting their implementation of an electronic consultation system between primary care clinicians and specialists in Los Angeles County.
Partnership HealthPlan of California (PHC) is a not-for-profit Medicaid managed care plan serving 570,000 members in rural Northern California. For the past 18 months, PHC has had a slowly growing eConsult program using the same platform as Los Angeles County. Although lack of specialty access is a widespread issue in our service area, the uptake of the eConsult program has been variable. Our experience helps give additional context to the success in Los Angeles County and has several critical lessons that will help other organizations seeking to use this service in their delivery systems.
We have identified a key element required for rapid adoption that is not present among sites that have poor uptake: a requirement that primary care clinicians use eConsult to initiate consultations for certain specialties.
Encouraging Greater Use
As noted in the article, in Los Angeles County, the use of the eConsult system replaced other methods of requesting consultation; it became the default option. Similarly, in one primary care organization served by PHC, referral coordinators were instructed to not process traditional referrals for certain specialties until an eConsult was performed. This organization has seen a strong and steady increase in adoption of eConsult. However, two other early-adopting primary care organizations served by PHC trained their staff on the use and benefits of eConsult but left the decision to use eConsult to the discretion of individual clinicians. The result was scant use of the eConsult system.
Unlike in Los Angeles County, not all specialties are available by the eConsult system in our service area. Use is more concentrated in nonsurgical specialties, especially dermatology, endocrinology, rheumatology, and neurology. Like the experience in Los Angeles County, more than 50% of eConsult specialist requests were completed without a conventional patient-specialist consultation. In other words, unnecessary office visits were prevented. This effectively increases the capacity and efficiency of delivering specialty services, which helps patients avoid needing to travel long distances to visit scarce specialists in person or to take up additional resources for a specialist telemedicine visit.
In our interviews of primary care clinicians who tested eConsult, we found that the amount of primary care effort necessary to initiate a traditional consultation was less than the work involved in a back-and-forth eConsultation. Even though eConsult was vastly more efficient from the patient, specialist, and health system perspectives, it is the comparative effort of the practicing primary care clinician that led to continued use of traditional consultation instead of adopting eConsult where eConsult was not required.
Extra Effort Produces Results
In contrast, specialists found eConsult to be more efficient, resulting in better uptake in a voluntary environment. In Los Angeles County, all of the specialists consulted were employees of the same health system as the primary care network, so acceptance and adoption on the specialist side was universal. At PHC, specialists participated voluntarily, both from the communities and as part of a contracted multispecialty telemedicine group.
For health systems that are interested in using eConsult to reduce costs and improve efficiency, it’s important that they account for the extra effort eConsult takes for primary care clinicians and that they consider requiring them to use eConsult before a traditional referral is permitted. With a modicum of extra work, primary care clinicians will help expand the availability of specialty care for a patient population that desperately needs the improved access.
Dr. Robert Moore serves as chief medical officer of Partnership HealthPlan of California, a county-organized health system providing Medi-Cal managed care services to 570,000 members in 14 Northern California counties. He is a graduate of the University of California, San Francisco School of Medicine, the Columbia University School of Public Health, Western Governor’s University Graduate Business School, and the family medicine residency at Ventura County Medical Center. Moore serves as a managing partner for CHCF’s California Improvement Network.