Gaining popularity across specialties
Delphine S. Tuot, MD, a nephrologist who directs the ZSFG e-consult system, said that the notion of preconsult triage is gaining popularity in all medical specialties. For example, the Blue Shield of California Foundation is funding implementation of e-consult systems across many of California’s safety net health care delivery systems. “We have many health care plans that are interested in this process as well, because it improves access to specialty care, particularly in rural areas or in areas where the specialist workforce is limited,” said Dr. Tuot, who is codirector of the UCSF Center for Innovation in Access and Quality at ZSFG. Such efforts are also being promoted by the Public Hospital Redesign and Incentives in Medi-Cal Program (PRIME), which is part of California’s Medicaid waiver. PRIME “is encouraging health systems to look at innovative ways to deliver specialty care,” Dr. Tuot said. “E-consults and other non–face-to-face ways to deliver specialty care, including telemedicine encounters, count toward that metric for the Medicaid waiver.”
Dr. Delphine S. Tuot
At the national level, the Association of American Medical Colleges has collaborated with more than 20 academic medical centers in 14 states, including Dartmouth-Hitchcock and Yale University, to implement tools built into the electronic medical record system through a program known as Project CORE (Coordinating Optimal Referral Experiences). According to Scott Shipman, MD, MPH, director of clinical innovations for the AAMC, nearly all of the current CORE sites have either gone live with the model in rheumatology or are planning to do so. “Better communication and coordination between primary care providers and specialists is important for all specialties, but because of the complexity of evaluation and management of problems in rheumatology, there is a tremendous opportunity for the CORE model to help get providers on the same page,” Dr. Shipman said in an interview. “We do this through simple decision support that we build into the referral order in the EMR, available at the point of care. Additionally, given the workforce challenges facing rheumatology in most regions of the country and consequent access barriers, offloading some of the demand via e-consults holds great promise.” Current focus areas for Project CORE, he said, include continued support of current CORE sites in their implementation and scaling efforts to maximize impact, advocacy to promote payer engagement in support of e-consult reimbursements, and working to extend the model to additional academic medical centers.
Dr. Scott Shipman
Dr. Tuot emphasized that performing e-consults “takes time and effort on behalf of specialists, so if you’re by yourself in solo practice it probably does not make sense to implement,” she said. “You need to spend your time seeing patients as much as possible. For primary care providers who are asking for curbside consults, it’s probably best to have things in writing from the specialist, such as in an e-consult, to make sure there’s no misunderstanding.”
As demand for rheumatology services increases, clinicians “have to figure out a way to see patients in most urgent need of our services,” Dr. Yazdany said. “That requires that we use technology like the e-consult system to prioritize the patients that we’re seeing. As we look at the rheumatology workforce shortage, especially in some geographic regions, it’s going to be absolutely critical. There are some diseases that no other specialists have experience caring for. In those situations, those patients need to get in to see rheumatologists in a timely fashion.”