How eConsults Can Offer a Virtual Care Connection to Specialists

Using a telemedicine platform to connect primary care providers with specialists can improve care management and care coordination for patients.  These services, called eConsults, can serve as a cost-effective way to expand access to care and improve outcomes, as well.

The connected care service is most often used by PCPs in Federally Qualified Health Centers (FQHCs) or other organizations that serve safety net populations - patients who often lack the money or the means to make appointments with specialists. But it’s also proving popular with solo doctors and small medical practices who want to improve their care delivery without losing track of their patients and their complex needs.

eConsults also offer an intriguing opportunity for specialists who want to extend their services beyond their office, as well as those of retirement age who want to keep their hand in the game and continue to treat underserved populations.

A 2017 report prepared by the Association of American Medical Colleges (AAMC) predicts that the shortage of non-primary care specialists will surge to between 33,500 and 61,800 by 2030.

“As we face increasing demand alongside the shift to risk-based reimbursement models, a distinct advantage of this model is that it improves access, promotes high-quality care at lower costs, and increases satisfaction for providers and patients,” Scott Shipman, MD, MPH, the AAMC’s director of primary care affairs and workforce analysis and the Project CORE’s principal investigator, said in the AAMC profile.

Ensuring that specialists have a convenient, low-investment way to continue seeing patients part time could help to mitigate this impending crisis.

As telehealth and remote care options become more popular, how can providers leverage this technology to provide eConsults in an efficient, effective, and low-cost manner to populations in need?

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What is an eConsult?

eConsult services are most often conducted on an asynchronous, or store-and-forward, telemedicine platform, enabling both the primary care provider and the specialist to work at their own pace within a specified time period.

For primary care providers and specialists connecting through a typical store-and-forward platform, the process of consulting on a case is relatively straightforward:

1. Through an online portal, the PCP will present the patient case along with any necessary data, such as images or test results.
2. The specialist gets an alert (such as a text message) that an eConsult is available in the portal. He or she reviews the case and makes a diagnosis, consulting other decision support resources if necessary. That diagnosis is then sent back to the PCP.
3. In cases where the specialist has answered the PCP’s concerns, the PCP can then treat the patient more confidently and effectively – eliminating the need for an appointment with the specialist.

In cases where a diagnosis can’t be rendered online, the PCP then makes an appointment for the patient to be seen by a specialist in person. The eConsult lays the groundwork for that office visit, giving the specialist access to all the information he/she needs prior to the meeting.

eConsults offer convenience to providers as well as to patients.

In safety net populations, patients often can’t afford to see specialists or face significant barriers to access, such as long wait times, transportation problems, or distance to the specialist’s office. Without a telehealth option, these patients would not get the care they need, putting them at a greater risk of negative health outcomes.

Safety net providers are generally the only source of care for this population – they’re tasked to do a lot within the limited time frame of a clinic visit. These patients don’t have the time, money or resources to seek specialist care, so the PCP has to find a way to bring specialists into the clinic. That’s where eConsults come in.

Connecticut-based Community Health Center, Inc., has been seeing success with an eConsult service for FQHCs launched in 2015. The service was developed by Darren Anderson, MD, CHC’s vice president and chief quality officer and director of the Weitzman Institute, a community-based research center founded to help FQHCs improve primary care services for the underserved.  Anderson also worked with Safety Net Connect (SNC), a California-based digital health company.

Following a one-year pilot program in which Anderson reported 90 percent success in using the erConsult platform to facilitate specialist consults,  the Centers for Medicare & Medicaid Services announced in 2016 that it would reimburse CHC for its eConsult platform through the state’s Medicaid program.

“With limited specialty providers available to treat Medicaid patients, appointment wait times can be as long as a year, leading to healthcare disparities, higher rates of disability and complications in chronic diseases,” officials said in a press release announcing the decision. “SNC’s eConsult system has been proven to increase access to timely, cost-effective specialty services for underinsured and underserved patients, many of whom live in rural areas with limited access to specialty care.”

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How an eConsult Program Translates Into Cost Savings

While the goal of an eConsult is to improve clinical outcomes, the platform also proves quite adept at saving money – for both providers and patients.

In what was billed as the first study of the platform’s economic benefits, researchers at CHC and the University of Connecticut Health Center found that the telemedicine platform yielded lower mean adjusted total costs of $655 per patient, or lower mean costs of $466 when adjusted for non-normality, compared to those using face-to-face consults over a six-month span.

In addition, the eConsult group reported reduced costs of $81 per patient for outpatient cardiac procedures, as well as improving access to care for underserved patients and reducing the rate of no-shows for providers.

“The results of our analysis show for the first time that when [primary care providers] are given an option to use eConsults for Medicaid beneficiaries, the total costs and the cost of outpatient cardiac tests and procedures at 6 months are significantly lower, by $466 and $81, respectively, compared with the traditional [face-to-face] approach,” the study, which appeared in the January 2018 issue of the American Journal of Managed Care, reported.

While Connecticut is the only state, as of 2018, to reimburse providers for eConsults through its Medicaid program, other payers are taking notice. California’s Blue Shield Foundation, which commissioned a report on eConsults from the Center for Connected Health Policy in 2016, is moving toward reimbursement plan for providers, as are Colorado, Oklahoma and Washington.

“Both specialists and primary care clinicians liked the eConsult system,” the Washington State Telehealth Collaborative noted in its December 2017 report on a pilot program, in which all 40 PCPs in the University of Washington Health System expressed satisfaction with the service.

“One said, ‘I have found it a very helpful way to get answers to my questions and learn at the same time, while getting my patients’ needs addressed,’” the report continued. “From the specialist perspective, one said, ‘it is the future of medicine.’”

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Launching an eConsult Program

Primary care providers looking to establish an eConsult program should follow these eight basic steps:

1. Establish partnerships with the right specialists
2. Choose the appropriate telemedicine platform on which to collaborate
3. Make sure the platform is customizable
4. Ensure that all messaging is HIPAA compliant and secure (including image transfers)
5. Make the workflow as simple as possible for both PCPs and specialists
6. Create separate processes for both completed consults and consults that lead to in-person appointments with a specialist
7. Determine payment and liability
8. Enable feedback from clinical users are well as patients

Conducting quality assurance and workflow testing is extremely important for ensuring that eConsults reduce burdens instead of add to them.

In 2016, Ateev Mehrotra, a hospitalist at Beth Israel Deaconess Medical Center and healthcare policy expert at Harvard Medical School, and Lori Uscher-Pines, a researcher for the RAND Corporation, published a study in Health Affairs pointing out that eConsult platforms could add to the burden on healthcare providers if not planned properly.

The two wrote that eConsults can increase the workload for specialists and healthcare providers in underserved areas simply because the increase in quick consults at the front end may add to the number of in-person visits at the back end. This could stress overworked doctors and nurses and add to the wait time for an in-person visit, particularly in health systems that aren’t managing their traffic effectively. And it could keep underserved populations from getting the care they need.

”We learned in our evaluations that bringing in telehealth won’t reduce the burden on the dysfunctional healthcare system,” the team cautioned. “By identifying problems that require longitudinal care, telehealth may actually stress the healthcare system further.”

But they also wrote that a telehealth platform can work well if it’s mapped out properly.

“Prior work has highlighted that roughly 20 percent of all consultations can be resolved with just an electronic exchange between a primary care provider and specialist,” Uscher-Pines and Mehrotra wrote.

“A larger fraction could likely be resolved with a videoconference between a patient and specialist. The hope is that deterring a large fraction of in-person consultations will free up specialists for the patients who most need them. As such, the introduction of telehealth can increase efficiency and help a community serve a greater number of underserved patients without adding more providers.”

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Using eConsults for Peer Support and Education

Some eConsult services take a different approach to provider-to-provider communications.

One such platform is Project ECHO (Extension for Community Health Outcomes).

Project ECHO was developed in 2003 at the University of New Mexico School of Medicine by Sanjeev Arora, MD, a liver disease doctor based in Albuquerque who wanted to improve care management and coordination for patients with hepatitis C. The platform consists of a hub-and-spoke telemedicine model whereby one health provider – usually a large academic medical center or health system – hosts regularly scheduled online meetings on a specific topic, like substance use disorder (SUD), pediatric behavioral health or chronic care management.

The virtual care framework allows providers in rural and remote locations to connect with their peers through a forum hosted by experts to gain knowledge and discuss specific cases.

The popularity of social media has also given rise to healthcare networking channels. Platforms like Sermo, Doximity, DailyRounds and QuantiaMD give providers the opportunity to, in essence, crowdsource a difficult case, provided they de-identify information to avoid disclosing identifiable health information.

The primary benefit of these social media platforms is immediacy: an online post can generate answers within minutes. But those answers won’t necessarily come from a specialist, and the advice isn’t vetted for accuracy.

Another issue is cost. Community health programs and FQHCs are often resource-thin and cash-strapped, so paying for an eConsult platform might be too much of a luxury.

In 2014, Dr. Laurie Green, a Harvard graduate and San Francisco-based obstetrician and gynecologist, launched the MAVEN (Medical Alumni Volunteer Expert Network) Project. Originally designed to retired and semi-retired doctors an avenue to continue offering their services at their own pace, the platform has now evolved to give FQHCs an affordable resource for eConsults and mentoring.

“We’re here to give these providers support that’s really needed,” Lisa Bard Levine, MD, MBA, the organization’s CEO, told mHealthIntelligence. “A lot of these primary care providers are newly trained, or working for clinics that struggle to provide necessary support for their physicians. A lot of them are realizing that this is a gray area in healthcare.”

At the end of the day, whether it’s to help out a beleaguered community health clinic or to answer a primary care doctor’s nagging concern about a patient, eConsult services are helping to improve care management and coordination for a wide range of providers.

They help to prove several tenets of telemedicine – that an effective connected care platform can bring the right providers with the right skills to the right patient at the right time, improving the care process and leading to better outcomes. They also allow the provider to reach out beyond the constraints of the office or clinic and offer help where it’s most needed.