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The American Journal of Managed Care January 2020
Using Applied Machine Learning to Predict Healthcare Utilization Based on Socioeconomic Determinants of Care
Soy Chen, MS; Danielle Bergman, BSN, RN; Kelly Miller, DNP, MPH, APRN, FNP-BC; Allison Kavanagh, MS; John Frownfelter, MD, MSIS; and John Showalter, MD
Eliminating Barriers to Virtual Care: Implementing Portable Medical Licensure
Pooja Chandrashekar, AB; and Sachin H. Jain, MD, MBA
Trust in Provider Care Teams and Health Information Technology–Mediated Communication
Minakshi Raj, MPH; Jodyn E. Platt, PhD, MPH; and Adam S. Wilk, PhD
The Health IT Special Issue: Enduring Barriers to Adoption and Innovative Predictive Methods
Ilana Graetz, PhD
What Accounts for the High Cost of Care? It’s the People: A Q&A With Eric Topol, MD
Interview by Allison Inserro
Does Machine Learning Improve Prediction of VA Primary Care Reliance?
Edwin S. Wong, PhD; Linnaea Schuttner, MD, MS; and Ashok Reddy, MD, MSc
Health Information Technology for Ambulatory Care in Health Systems
Yunfeng Shi, PhD; Alejandro Amill-Rosario, MPH; Robert S. Rudin, PhD; Shira H. Fischer, MD, PhD; Paul Shekelle, MD; Dennis Scanlon, PhD; and Cheryl L. Damberg, PhD
The Challenges of Consumerism for Primary Care Physicians
Timothy Hoff, PhD
Advancing the Learning Health System by Incorporating Social Determinants
Deepak Palakshappa, MD, MSHP; David P. Miller Jr, MD, MS; and Gary E. Rosenthal, MD
Predicting Hospitalizations From Electronic Health Record Data
Kyle Morawski, MD, MPH; Yoni Dvorkis, MPH; and Craig B. Monsen, MD, MS
Opt-In Consent Policies: Potential Barriers to Hospital Health Information Exchange
Nate C. Apathy, BS; and A. Jay Holmgren, MHI
Currently Reading
e-Consult Implementation Success: Lessons From 5 County-Based Delivery Systems
Margae Knox, MPH; Elizabeth J. Murphy, MD, DPhil; Timi Leslie, BS; Rachel Wick, MPH; and Delphine S. Tuot, MDCM, MAS

e-Consult Implementation Success: Lessons From 5 County-Based Delivery Systems

Margae Knox, MPH; Elizabeth J. Murphy, MD, DPhil; Timi Leslie, BS; Rachel Wick, MPH; and Delphine S. Tuot, MDCM, MAS
This case study of 5 county-based delivery systems finds that existing specialty care relationships and information technology integration are important differentiating factors for e-consult implementation success.

Systems achieved varied success in their e-consult implementation journeys (Table). System 1 achieved sustained implementation success, rolling out e-consults across all 27 specialties and completing more than 8000 e-consults. System 2 achieved fragmented implementation using both integration with an existing EHR platform as well as an external add-on platform for users on different EHRs. System 2 made e-consults available for 9 specialties and completed 880 e-consults. System 3 achieved early implementation by the end of data collection, with e-consults available for 13 specialties and 161 e-consults completed. System 4 piloted e-consults with 2 specialties but was unable to obtain meaningful volume or expand the e-consult program. System 5 chose not to implement e-consult beyond its planning grant phase. Across systems, all organizations faced challenges with consistent project management support and requests from specialists for greater financial or time recognition for e-consult services. Preexisting substantial relationships with specialist networks facilitated implementation, as did EHR compatibility.

System 1

System 1 includes 9 health centers providing primary care, urgent care, and specialty services, as well as a consortium of nonprofit community health centers with 19 primary care clinics. System 1 achieved sustained implementation success, rolling out e-consults across 3 to 4 specialties each quarter from March 2016 through February 2018. System 1 was unique compared with systems 2 and 3 because e-consults were required as part of the workflow for all specialty referrals. From January to June 2018, 8000 e-consults were completed, with about 23% virtually comanaged (ie, patients received care via their PCC without an in-person specialty visit). Prior to e-consult implementation, about 45% of referrals were lost or lapsed longer than 3 months, frustrating patients and their PCCs, and wait times for some specialist appointments were longer than 6 months. In contrast, specialists’ average response time to an e-consult was less than 24 hours, exceeding organizational goals.

Interviews revealed that system 1 specialists—already a part of an internal network within the health system—“really drove this initiative…and helped to identify roadblocks and work through them.” Setting aside time, including some clinical time, was essential to getting e-consults “off the ground.” In addition, clinicians in system 1 are salaried, requiring dedicated time to respond to e-consults.

E-consults were implemented by making changes within the existing EHR system. The implementation process included weekly leadership meetings with the chief medical informatics officer, the director of specialty care, the director of ambulatory care, and a leader from the community health center consortium. In addition, monthly meetings with a steering committee reviewed data, collaboratively decided when to extend e-consult to new specialties, and coordinated workflow and trainings. The ambulatory care director noted, “The real key is getting people together in person to discuss what’s happening with e-consult. What are the ongoing challenges? What are the successes?” Physician-to-physician communication was key, whereas communication from nonphysicians was less effective.

System 2

System 2 includes 5 hospitals and a network of neighborhood-based clinics, including a community health center network. System 2 began rollout in June 2016 and chose a hybrid implementation approach to incorporate both internal (salaried) specialists and external (contracted) specialists. Criteria for early-adopter specialties included a high volume of referrals, a long wait time for in-person specialty care visits, and already-occurring curbside consults. Overall, the system achieved sustained yet fragmented implementation. Implementation began among specialists already using an internal EHR platform, which generated 63% of the e-consult volume (553 of 880 e-consults between January and June 2018). The remaining 37% of e-consult volume (327 of 880) for January to June 2018 was generated from an external e-consult platform. The external platform was added about 1½ years after initial implementation to connect community health centers that rely on a different EHR and also to provide access to specialty expertise not readily available locally.

Of the 9 specialties that implemented e-consult, 3 specialties reported an average volume of greater than 10 e-consults per month: cardiology, endocrinology, and gastroenterology/hepatology. Cardiology received the most e-consult requests, 76% of which were comanaged without requiring an in-person specialist visit. Response times for cardiology ranged from an average of 6 hours in May to 6 days in June (3 days average for January-June 2018).

Although 1 interviewee indicated that e-consult implementation was a top priority for the chief medical officer, another interviewee cited lack of primary leadership focus amid other competing priorities. Both acknowledged leadership turnover as an implementation challenge. Many clinicians viewed e-consults as an additional uncompensated task because contracts had not changed to recognize dedicated time for e-consult completion.

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