iHT² CMIO Symposium Beverly Hills – eConsult: A Model for Integrated Care – Rob Bart, CMIO, Los Angeles County Department of Health Services
Closing Presentation "eConsult: A Model for Integrated Care"
The rate of outpatient specialist referrals has nearly doubled over the past decade. Increased utilization, along with documented variation in referral rates, has raised concerns about worsening fragmentation of care and the appropriateness of referrals. Access to specialists by primary care providers representing their patients has always been a challenge within safety-net healthcare delivery; fulfilling the dual imperatives of timely access and rational triage drove the implementation of eConsult. eConsult links primary care providers and specialists, with the goals of increasing access to care, improving dialogue, optimizing the efficient use of specialty resources, and enhancing primary care capacity.
Learning Objectives:
∙ A new paradigm for primary care-specialty interface
∙ A technology tool supporting a move away from visit-based care
Rob Bart, MD
Chief Medical Information Officer
Los Angeles County Department of Health Services
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iHT² CMIO Symposium Beverly Hills – eConsult: A Model for Integrated Care – Rob Bart, CMIO, Los Angeles County Department of Health Services
1. eConsult – a Model for Integrated Care
- making it easier to behave like a system
Rob Bart, MD
Chief Medical Information Officer
Los Angeles County Department of Health Services
with contributions from Paul Giboney, MD & Hal Yee, MD
3. Background – ACA & Work force
32 million Americans newly insured
10,000 Americans turn 65 daily through 2033
MD shortage of 91,500 by 2020
Underserved populations will bear the greatest
burden of workforce shortage
9. Los Angeles County
Department of Health Services
2nd largest municipal health system US after NYHHC
US$3.5 billion budget (17% county funded)
800,000 unique patients served 2012
Volume of Services
Ambulatory - >2.6 million
Emergency - >300,000
Inpatient - ~75,000
Healthy Way LA (LIHP) – 252,379 enrolled
11. Goals for Today
3 Responses to Specialty Care Need
The use of Workgroups to bring together a fragmented
specialty care delivery system.
The use of technology (eConsult) to transform the way we
understand specialty care services.
The implementation of a centralized specialty appointment
scheduling system to improve customer satisfaction and
reduce no shows.
12. The Challenge
Mario receives primary care at CP or DHS
42 year old with Ulcerative Colitis
He has a flare in his condition
His PCP would like GI specialist input for the flare
The Problem
Long wait time for GI clinic appointment
No good way for PCPs to communicate with specialists
about possible consults or patients needing expedited
attention
13. The challenge
• How does a large, historically fragmented health
care system address the issues of:
•
Long wait times for specialty services
–
Lack of coordinated care between County and Community
Providers
–
–
High no-show rates to specialty clinics
Large variation in care delivery processes
14. The “Black Hole”
350,000+ referrals to specialty care annually
Long Wait times for specialty clinic visits(2011)
Gastroenterology – 162 days
Nephrology – 86 days
Podiatry – 222 days
Urology – 208 days
Cardiology – 140 days
Dermatology – 208 days
Gynecology – 109 days
Neurology – 225 days
Access to specialty care is consistently recognized as one of the
top problems in the safety net.
19. Disruptive Innovation
Investment in Patient Centered Medical
Neighborhood (PCPs and Specialists).
Specialty Primary Care Workgroups
eConsult – in partnership with local Medicaid plan and FQHCs
Investment in Patient Centered Specialty
Scheduling
Reduction in process variation
Reduction in no-show rates
Improved patient experience
20. Specialty Primary Care Workgroups
Effective Practices
Collaboration across facilities and disciplines
Triple Aim
Equity/Reduced variability
21. eConsult
• HIPAA secure, web-based “clinical conversation”
portal.
• Advantages
–
PCP and Specialist collaboration
•
•
•
–
–
–
Improved PCP clinical capability
Relationship building
Troubleshooting of system issues
Improved responsiveness to requests for specialty assistance
Reduction in avoidable specialty visits
Improves effectiveness of specialty clinic visits (when they are
indicated)
32. Impact - eConsult
eConsult
14 Specialty Services
Cardiology, Dermatology, Diabetes, Endocrinology, Gastroenterology,
Gynecology, Hematology, Hepatology, Nephrology, Neurology, Obstetrics,
Ophthalmology, Podiatry, Urology
1,300+ PCPs using system
130 PCP Sites (40 DHS, 90 Community Partner)
110+ Specialty Reviewers
Average Time to Respond to Initial Request = 2.5 days
A primary measure of impact is that 100% of specialty requests are
answered promptly by an expert who is able to provide assistance.
34. DHS Appointment Service Center (ASC)
The old way – “Mail and Pray”
The new way - Patient Centered Specialty Scheduling
For patients identified through eConsult
ASC has the ability to schedule anywhere in the system
Appointments are scheduled only after personal patient
contact
GOALS –
Improved patient experience
Quick scheduling turn around times
Less variation in process
Lower „no show‟ rate
More effective work, not just more efficient work
35. Impact - ASC
Patients Scheduled – 16,000+
Successfully Scheduled Rate – 84%
For unreached patients - phone message left, letter sent and PCP
notified via eConsult
No show rate – 13.5% (historically 35 - 40%)
36. Overall Impact
Community Partner Medical Director –
“eConsult
has been a blessing and the providers
are thoroughly enjoying the opportunity to
learn new patient management strategies from
the specialty providers. The best part is our
patients aren‟t waiting over 6 months for
consultations!”
37. Summary
The power of collaboration to overcome the
challenges of a large and fragmented system.
The power of conversation (via eConsult) to bring
specialty services into the medical home.
The power of a scheduling process that focuses on
effectiveness and patient engagement.