Online Referral Service Reduces Specialty Wait Times

Ken Terry

March 13, 2017

An electronic referral service that enables specialist reviewers to triage referral requests and interact with primary care physicians online reduced the median wait time for specialty appointments in the Los Angeles public health system, a new study has found.

Michael L. Barnett, MD, an assistant professor of health policy and management at the Harvard T. H. Chan School of Public Health and an instructor in the Division of General Medicine and Primary Care at Brigham and Women's Hospital, both in Boston, Massachusetts, and colleagues published their findings in the March issue of Health Affairs.

The Los Angeles County Department of Health Services (DHS) implemented its eConsult system for the provision of specialty care in 2012. In this system, volunteer specialists review all referral requests from primary care providers. By 2015, the system was in use by more than 3000 primary care providers, with more than 12,000 consultations monthly. Nearly 500 specialist reviewers participated across 86 specialties.

In the current study, Dr Barnett and colleagues looked at eConsult requests from primary care providers who were using the system before January 2014 for referrals to 12 specialties available on eConsult before 2014 (cardiology, endocrinology, ear/nose/throat, gastroenterology, gynecology, hematology/oncology, nephrology, neurology, ophthalmology, podiatry, rheumatology, and urology).

The reviewers were expected to respond to referral requests promptly. Either they could forward the request to a DHS scheduling service for appointment booking, or they could engage in a dialogue with the referring physician to address the request without a specialist visit. The researchers devised an "engagement index" to measure variations in reviewers' interactions with primary care providers.

The median time to an electronic response from a specialist was 1 day, and 25% of eConsults were resolved without a specialist visit. Between 2014 and 2015, the median time to an appointment for any eConsult request that resulted in a visit to a specialist decreased 17.4% (from 63 to 52 days; P < .001). The percentage of appointments scheduled within 30 days increased from 24.0% to 30.2% (P < .001).

The researchers found no significant change in the average monthly number of eConsult requests that resulted in a specialist visit. However, there was a significant decrease in the rate of eConsult requests resolved without a visit, from 570 per month (23.1% of all requests) in the first quarter of 2014 to 447 per month (19.3%) in the fourth quarter of 2015.

A side benefit of the eConsult service is that it facilitated the education of primary care providers, which may explain the observed decline in eConsult cases resolved without a visit, the researchers write. Alternatively, the specialist reviewers might have become less engaged over time and approved more specialist visits, they explain.

Rates of requests resolved without a specialty visit ranged from 11.4% in the 10th percentile to 32.3% in the 90th percentile. Hospital-based practices and community primary care practices were more likely than multispecialty practices to make referrals that were resolved without specialty appointments.

The median time to appointment decreased without any increase in specialist staffing. According to the researchers, this implies that the eConsult system decreased the backlog of patients waiting for an appointment.

Clare Liddy, MD, told Medscape Medical News she suspects the primary care physicians in Los Angeles referred out fewer inappropriate cases over time because of the knowledge they had gained from the reviewers.

Dr Liddy is a practicing family physician and a clinical investigator at a research institute affiliated with the Department of Family Medicine, University of Ottawa, Ontario, Canada. She has had experience with and has studied an electronic referral system similar to eConsult used in the eastern Ontario health region, but was not involved in the current study.

In cases resolved without a visit, an average of 3.6 exchanges took place between reviewers and primary care providers. This indicates the reviewers suggested additional tests or a change in medications in many cases, Dr Liddy said.

Most primary care physicians don't have that kind of access to specialists unless they still work in the hospital, she noted. "In the usual referral process, you do your referral and it's one directional." Although the referring physician normally gets a letter back from the consultant, in some cases the specialist's advice is not relevant, she said. In contrast, services like eConsult allow physicians to have live interactions that can yield better results, she explained.

"This communication improves efficiency and improves my ability as your primary care doctor to care for you properly and in a timely manner."

Dr Liddy praised the study, which she said was the largest trial of electronic referral services to date. She was impressed that the service enabled access to care that was previously not an option for the homeless and the uninsured. In addition, she liked the fact that the reviewers performed their service, in many cases for 6 months or longer, without remuneration.

However, the researchers found there were differences in the willingness of the reviewers to spend time educating the referring physicians. They found "a moderate correlation between reviewers' patterns of eConsult resolution and their score" on the engagement index, suggesting that some reviewers approved specialty visits, rather than interacting with primary care providers.

"Not all specialists should be doing this type of work," Dr Liddy commented. "You need to have a group of willing specialists who are diverse and experienced and who are interested in educating and promoting access."

The use of electronic referral services is starting to grow in North America, she added. In the United States, the Mayo Clinic and the Veterans Affairs system are using eConsult, along with San Francisco General Hospital in California. And in Canada, there's a new national collaborative that seeks to spread the use of these services across the country, she said.

This work was supported by the California Health Care Foundation and the Blue Shield Foundation of California. Dr Barnett has disclosed no relevant financial relationships. One coauthor is a cofounder and minority shareholder of Caredination Inc and is on the board of the community econsult network of the Weitzman Institute. One coauthor was supported by an unrestricted gift to Harvard Medical School by Melvin Hall and CHSi. Dr Liddy has disclosed no relevant financial relationships.

Health Aff. 2017;36:492-499. Abstract

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