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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
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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.
DISCUSSION

Poor communication between primary care and specialty care can lead to care gaps, avoidable care, and, ultimately, adverse patient outcomes.24,25 Also, in markets where there is limited supply of specialty care, a lack of access can further contribute to worse patient outcomes.26,27 Asynchronous communication and interaction between primary care and specialty care, enabled by an efficient and reliable electronic communication tool, can potentially be a solution to such problems. This study provides empirical evidence that such a system—in this case, AAD—was associated with reductions in ED and physician visits, which also appeared to have led to significant total cost reductions. To our knowledge, this is the first study that has shown such evidence using a large cohort of patients across multiple specialties.

Comparing the baseline statistics (Table 2) with the postintervention statistics, particularly those in month 1 (Table 3), reveals that there appear to be large jumps in total cost and care utilization that coincided with the AAD consult. Similar patterns were observed among the comparison group (as indicated by the expected values in Table 3). This suggests that AAD consults might have been used by PCPs in response to some major clinical events requiring quick input from specialists.

PCPs may have used AAD either to address clinical urgencies or simply to obtain specialist input in routine encounters without formal referrals. The reductions in ED and specialist visits during month 1 relative to the expected values (based on the comparison group), coupled with the observation that AAD consults appear to have coincided with large jumps in cost and utilization relative to the baseline period, are consistent with PCPs using AAD for the former purposes rather than the latter. Alternatively, it may be that the reductions in cost and utilization are detectable only when AAD is used for the former purposes rather than the latter. Further research is necessary to explore this mechanism.

One potential criticism of programs such as AAD is that they may simply “delay the inevitable”—that is, rather than causing actual reductions in inefficient care, they merely delay care to later periods. The results of this study confirm that at least some of this might be true: There appear to be small but statistically significant increases in both primary care and specialty care visits during the second month of follow-up. However, these increases are more than offset by the decreases during the first month of follow-up. Moreover, there is no statistically significant difference by the third month, suggesting that there is no long-term impact of the AAD program beyond the first 2 months.

AAD is designed to be scalable in other health systems with mature EHR capabilities. On the asker side (primary care), it allows timely, reliable, and documented assistance from specialists that is easy to invoke and is costless to their patients. On the answerer side (specialty), it is configured to reward providers for their service via RVUs while improving access by effectively increasing the specialist’s capacity. AAD therefore provides benefits for all the key stakeholders, including not only the physicians but also the patients and the payers. Even for other health systems not structured similarly to Geisinger (eg, those that do not have their own health plans), the findings from this study imply financial justifications for AAD from the third-party payer’s perspective.

Limitations

This study is subject to several limitations. First, because this study relied on observational data, a causal link cannot be established. As shown in Table 2, the AAD intervention group appears to be sicker and costlier than the comparison group at the baseline. Therefore, these results are likely to be conservative estimates of the true effect. Second, it is not possible to determine how much of the reductions in care utilization reflect care that was avoidable or unnecessary. Future research may examine the appropriateness of such reductions in care utilization and cost. Third, the AAD impacts may be different depending on the severity and acuity of the patients’ conditions (ie, there may exist interaction effects between AAD and patient characteristics). In addition, there may be differential AAD impacts across the participating specialties, as well as those that have not yet participated. Although the current study did not explicitly examine such interaction effects and specialty-specific impacts, they are topics of future inquiry.

CONCLUSIONS

Geisinger’s AAD program was associated with reduced ED visits and physician visits, leading to significantly lower total cost of care. This suggests that a reliable and efficient asynchronous communication system between primary care and specialty care providers can potentially lead to reductions in acute care and more efficient use of specialty care.

Acknowledgments

The authors would like to thank the Medlink Scheduling Team for their excellence in message processing, Wayne Swink for AAD software development, and Jesse Chubb for database and dashboard development.

Author Affiliations: The Medicine Institute (EDN, PFS, SMV) and Department of Information Technology (CMC), Geisinger, Danville, PA; Department of Psychiatry, University of Rochester Medical Center (DDM), Rochester, NY.

Source of Funding: None; all work related to this study was done as a part of the authors’ employment with Geisinger.

Author Disclosures: Dr Maeng was an employee of Geisinger at the time this study was conducted. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (EDN, PFS, CMC, DDM); acquisition of data (EDN, PFS, SMV, CMC, DDM); analysis and interpretation of data (EDN, PFS, SMV, CMC, DDM); drafting of the manuscript (EDN, DDM); critical revision of the manuscript for important intellectual content (EDN, PFS, CMC); statistical analysis (SMV, CMC, DDM); provision of patients or study materials (EDN, PFS, CMC); administrative, technical, or logistic support (EDN, CMC); and supervision (EDN).

Address Correspondence to:  Eric D. Newman, MD, Geisinger, 100 N Academy Ave, Danville, PA 17822. Email: enewman@geisinger.edu.
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