ADVANCING THE PRIMARY/SPECIALTY CARE INTERFACE THROUGH ECONSULTS AND ENHANCED REFERRALS

As academic health centers (AHCs) respond to value-based purchasing, they are embracing a transformed role for primary care. As a case in point, 5 AHCs have formed a collaborative organized by the Association of American Medical Colleges (AAMC) to extend a model developed at the University of California, San Francisco (UCSF) that addresses the referral process between primary care and specialty care providers. This program, known as Coordinating Optimal Referral Experiences (CORE), incorporates 2 EMR-based innovations into the clinical workflow: (1) specialty- and problem-specific templates that provide pre-referral decision support to the primary care physician and establish a co-management agreement between providers,¹ and (2) “eConsults” which involve provider-to-provider asynchronous messaging.

With eConsults, the primary care physician sends a focused clinical question to a pre-identified subspecialist who then responds within 48 to 72 hours. The eConsult allows the primary care physician to provide care for the patient directly, provides specialist input in a convenient and timely manner for the patient, and reduces expensive specialty-driven care for minor issues, which in turn frees up the specialist for more complicated patients. Upon completion of each eConsult, both the primary care physician and the specialist receive a productivity (RVU) credit for their efforts. Overall, the model emphasizes and supports the role of the primary care physician as the primary provider for the patient, and emphasizes the rational use of services.

The AAMC received a Health Care Innovations Award from the Center for Medicare and Medicaid Innovation (CMMI) to disseminate this model in partnership with UCSF across 5 partner institutions (University of Wisconsin, University of Iowa, University of California San Diego, University of Virginia, and Dartmouth-Hitchcock). With the 3-year grant, each AHC will implement the program in 15 or more medical and surgical specialties. Departments of Family Medicine are deeply involved in this program, and have identified several early learnings.

Joint Learning and Defining “Borders” Between Primary and Specialty Care

Learning goes 2 ways between specialists and primary care physicians. For instance, cardiologists thought they were seeing all patients with palpitations, unaware of how many were being managed in family medicine and not referred. Primary care physicians receive education on best practices for common problems with a focus on “just-in-time” education. This educational effect is being extended through several efforts including newsletters featuring best eConsults; face-to-face inservice meetings between primary and specialty care faculty and residents; and through development of a searchable “best eConsults” archive.

More Effective Referrals

The program is facilitating more effective referrals as both the primary care physicians and specialists learn and clarify what information needs are present and which situations benefit from referral, continued monitoring, or management by the primary care physician.

Patients

Patient dissatisfaction with eConsults has not been a challenge. Providers are encouraged to give patients the option of seeing a specialist rather than having an eConsult placed if they prefer it. Most patients prefer the convenience and savings of avoiding an extra appointment, as well as the rapid receipt of specialist input via eConsults.

Payment

RVU credits for each completed eConsult are paid internally by the health systems. Additionally, UCSF and 2 of the new AHCs have already initiated pilots to have commercial payers and/or their own health plans reimburse for eConsults. Long-term, the model is best suited to value-based payment systems.

Health System Buy-In

Obtaining buy-in from health system leadership is essential to lay the necessary ground work, align priorities across many of the silos common to AHCs, and to provide payments. Valuing this exchange of cost-effective coordination and communication in the ambulatory setting aligns financial incentives with good medicine.

Low Threat

Subspecialists must see enough patients face-to-face for eConsults to succeed in the current funding environment. The study sites report that their specialists are not threatened because demand is still substantial. Since eConsults provide for greater efficiency, specialists feel like they waste less time on referrals of marginal value.

The concept of improving communication between specialists and primary care physicians to achieve better care coordination and more appropriate use of specialty services is not new, but it has been hard to implement among busy clinicians whose incentives are not well aligned. To date, the CORE Program appears to be effectively working across a wide range of specialties. It is a user-friendly, scalable, and mutually beneficial method carried out in the current EMR environment. Greater alignment between primary care and specialty care is critical to building value-based health care systems. The CORE model supports the development and continual adjustment of this provider interface, and can serve as a real-time continuous educational source for the best practices of medicine. Evaluation of this innovation is ongoing across the collaborative, but published evidence on similar models has been promising.²