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The American Journal of Managed Care January 2019
The Gamification of Healthcare: Emergence of the Digital Practitioner?
Eli G. Phillips Jr, PharmD, JD; Chadi Nabhan, MD, MBA; and Bruce A. Feinberg, DO
From the Editorial Board: Rajesh Balkrishnan, PhD
Rajesh Balkrishnan, PhD
The Health Information Technology Special Issue: New Real-World Evidence and Practical Lessons
Mary E. Reed, DrPH
Inpatient Electronic Health Record Maintenance From 2010 to 2015
Vincent X. Liu, MD, MS; Nimah Haq, MPH; Ignatius C. Chan, MD; and Brian Hoberman, MD, MBA
Currently Reading
Impact of Primary and Specialty Care Integration via Asynchronous Communication
Eric D. Newman, MD; Paul F. Simonelli, MD, PhD; Shelly M. Vezendy, BS; Chelsea M. Cedeno, BS; and Daniel D. Maeng, PhD
Patient and Clinician Experiences With Telehealth for Patient Follow-up Care
Karen Donelan, ScD, EdM; Esteban A. Barreto, MA; Sarah Sossong, MPH; Carie Michael, SM; Juan J. Estrada, MSc, MBA; Adam B. Cohen, MD; Janet Wozniak, MD; and Lee H. Schwamm, MD
Understanding the Relationship Between Data Breaches and Hospital Advertising Expenditures
Sung J. Choi, PhD; and M. Eric Johnson, PhD
Organizational Influences on Healthcare System Adoption and Use of Advanced Health Information Technology Capabilities
Paul T. Norton, MPH, MBA; Hector P. Rodriguez, PhD, MPH; Stephen M. Shortell, PhD, MPH, MBA; and Valerie A. Lewis, PhD, MA
Alternative Payment Models and Hospital Engagement in Health Information Exchange
Sunny C. Lin, MS; John M. Hollingsworth, MD, MS; and Julia Adler-Milstein, PhD
Drivers of Health Information Exchange Use During Postacute Care Transitions
Dori A. Cross, PhD; Jeffrey S. McCullough, PhD; and Julia Adler-Milstein, PhD

Impact of Primary and Specialty Care Integration via Asynchronous Communication

Eric D. Newman, MD; Paul F. Simonelli, MD, PhD; Shelly M. Vezendy, BS; Chelsea M. Cedeno, BS; and Daniel D. Maeng, PhD
Geisinger’s Ask-a-Doc program, which enables direct asynchronous communication between primary and specialty care, was associated with lower healthcare utilization and cost, implying more efficient care.
ABSTRACT

Objectives: To describe and evaluate the impact of primary and specialty care integration via asynchronous communication at a large integrated healthcare system.

Study Design: In January 2014, Geisinger’s primary care providers (PCPs) were given access to an asynchronous communication tool, Ask-a-Doc (AAD), that enabled direct communication with specialists in 14 medical specialties and 5 surgical specialties. Internal data were collected to assess PCPs’ acceptance and use of the tool, as well as satisfaction. Insurance claims data were obtained to assess the impact on healthcare utilization and cost.

Methods: A retrospective analysis of health plan claims data was conducted among those patients who had at least 1 specialist visit with 1 of the participating specialties between January 2014 and December 2016. A set of difference-in-differences multivariate linear regression models with patient fixed effects was estimated, in which those who were not exposed to AAD served as the comparison group.

Results: Acceptance and use of AAD among PCPs gradually increased over time but varied by specialty. AAD was associated with an approximately 14% reduction in total cost of care during the first month of follow-up and a 20% reduction (P <.001) during the second month. These reductions in cost of care appeared to be driven by reductions in emergency department visits and physician office visits.

Conclusions: Geisinger’s AAD experience suggests that the integration of primary and specialty care via the use of a highly reliable and efficient asynchronous communication system can potentially lead to reductions in avoidable care and more efficient use of specialty care.

Am J Manag Care. 2019;25(1):26-31
Takeaway Points

Poor communication between primary care and specialty care can lead to care gaps, avoidable care, and adverse patient outcomes. Such problems can be exacerbated by inadequate access to specialists.
  • Asynchronous communication and interaction between primary and specialty care providers, enabled by an efficient and reliable electronic communication tool embedded within a mature electronic health records system, can be a potential solution to these problems.
  • The results of this study provide empirical evidence that such an intervention, as embodied by Geisinger’s Ask-a-Doc program, can lead to more efficient care by reducing avoidable care and cost.
Healthcare is evolving, and new care models are being tested to improve quality while reducing costs. In 2007, the patient-centered medical home (PCMH) model was proposed, founded on the principles of primary care and patient-centered care combined with payment reform.1-3 Although care coordination implied effective information exchange, it quickly became evident that effective electronic connectivity was extremely challenging.2

In 2008, Fisher et al introduced the concept of a medical home “neighborhood,” where specialists could interact with the PCMH.4,5 Two years later, the American College of Physicians published a comprehensive white paper outlining this concept in greater detail.6 However, their tactical approach focused predominately on traditional face-to-face referral interactions,7 rather than on electronic or other forms of communication. Additionally, even the most rudimentary form of communication (ie, sending basic patient information) was deemed unreliable.8-10 In an attempt to improve communication between primary and specialty providers, other large healthcare systems have developed electronic consultation, or e-consult, programs.11-14 These programs vary in their implementation, but most have demonstrated success in improving the quality of communication and access to care.15-17 However, very little information is published with regard to their process reliability, effectiveness, and cost impact.18-20

This study describes a novel model of asynchronous communication between primary care providers (PCPs) and specialists, referred to as the Ask-a-Doc (AAD) program, developed and implemented by Geisinger. Geisinger is a large integrated healthcare delivery system located in central Pennsylvania serving more than 2 million patients; it has approximately 500 employed PCPs, who include physicians, nurse practitioners, and physician assistants, and 2000 employed specialists. This study also tests the hypothesis that implementation of AAD was associated with lower total cost of care and reductions in healthcare utilization due to improved primary care and specialist communication.

Background

In 2010, Geisinger senior leadership established a work group to improve the integration of primary and specialty care. The first step was to analyze the existing relationships and interactions, which revealed 4 key areas for improvement: (1) trigger (when/why a specialist was consulted), (2) care pathway (what plan of care was selected by the specialist), (3) mode of care (face-to-face, phone call, other), and (4) communication (process and expectations). Table 1 describes these components in relation to AAD in detail.

An integration work group designed and tested the initial AAD program using PCP groups as “askers” and rheumatology and pulmonary medicine specialty groups as “answerers.” To ask a question, the PCP clicked an AAD link within Geisinger’s electronic health record (EHR) system, launching a web-based AAD tool. The PCP selected a specialty department and was then presented with an AAD form. The form was prefilled with information on the patient, PCP, and AAD specialist. The PCP then added their callback number, selected a time frame (1 hour, 1 business day, or 3 business days) and a mode (chart review or phone call), completed a formulated question, and clicked “send” to complete the process.

The AAD consult was received by a group of schedulers, who processed and retransmitted the message to the EHR AAD in-basket of the on-call specialist. They also text-paged that specialist if the requested time frame was 1 hour or 1 business day. The specialist reviewed the chart, called the PCP (if requested), documented their response in the EHR using the AAD structured response template, and routed the answer back to the requesting PCP. The process was tracked in a database that followed the process from start (form sent) to finish (answer routed). Any messages that failed to meet the requested time frame, failed to use the correct documentation tool, or were incorrectly routed would appear on a task management report that was addressed via a project manager. PCPs could ask a question 24/7, but the messages were processed only Monday through Friday, 8:30 am to 4:30 pm.

Based on positive assessments from the pilot phase of the program, administrative approval was given to expand AAD across Geisinger. To further provider engagement, specialty directors received quarterly reports with physician-level detail about provider performance and time spent. There was no predefined incentive—financial or otherwise—for PCPs to use AAD. PCPs could use AAD at their discretion for any patient they deemed appropriate. For specialists, relative value units (RVUs) were assigned for the time spent on AAD requests but only for those answered completely and correctly (ie, answered within requested time frame, had correct documentation, and routed to the asker).

The program was officially rolled out (post pilot) on January 1, 2014. All PCPs (primary care physicians, physician assistants, and nurse practitioners) were trained to use AAD. Participating specialties included 14 medical specialties (addiction medicine, cardiology, comprehensive care clinic, dermatology, endocrinology, hematology, infectious disease, laboratory medicine, nephrology, neurology, palliative medicine, psychiatry, pulmonary medicine, and rheumatology) and 5 surgical specialties (orthopedics, thoracic surgery, transplant surgery, urology, and vascular surgery).

Chart review, rather than phone call, was the most commonly requested mode of consultation (87% vs 13%). Four percent of time frame requests were for 1 hour, 33% were for 1 business day, and 63% were for 3 business days. Scheduler turnaround time for processing an AAD consult averaged 3 minutes and 3 seconds. In terms of specialist performance, the average AAD consult took 11 minutes to complete, and the average specialty turnaround time to answer the question was 6 hours and 19 minutes. The specialist answered the question within the requested time frame 98% of the time, the documentation tool was used correctly 98% of the time, and the consult was correctly routed 95% of the time. A project manager helped providers correct the remaining process errors for a consultation completion rate of 99.9%. Finally, the PCPs rated their satisfaction with the AAD service at 4.3 on a scale of 0 to 5, with 5 being excellent.

AAD use by PCPs increased steadily over time (Figure 1). In the most recent data available (third quarter of 2018), 84% of Geisinger’s PCPs are either consistent (at least 1 question per quarter for the last 4 quarters) or periodic (at least 1 question per quarter for 3 of the last 4 quarters) users of AAD. Additionally, 10% of all primary care referrals to participating specialties are now AAD consults.

Access to specialty care also appears to have improved with AAD. The average time for a new patient to be seen face-to-face was compared pre-AAD and post AAD, controlling for the total amount of clinical time available to see new patients. With AAD, the time to new patient face-to-face visit (defined as days from referral placed to patient seen) improved more than 16% for the 5 specialties evaluated (Figure 2). There was wide variation noted among specialties, ranging from a 50% improvement in infectious disease to a 3% worsening in nephrology.


 
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