By Adam Darkins, August 2018.
The Increasing Importance of Primary Care
An aging population, the rising incidence and prevalence of obesity and other chronic conditions such as diabetes, heart failure and anxiety/depression, and the wide variety of information sources for patients are factors radically altering the healthcare landscape. These drivers are shifting a previously physician-centric and hospital-focused healthcare system toward one that is increasingly patient-focused and primary care centered. In this new environment primary care physicians (PCPs) play a pivotal role in the team management of patients with complex chronic conditions. They are skilled in factoring biopsychosocial considerations with traditional disease-based approaches to give a holistic response to the health needs of their patients, in ways that reflect individual patient and care giver preferences. Long-term relationships with their patients, and service providers across the continuum of care, position PCPs to best help individualize care in the most appropriate setting; thereby increasing both patient and provider satisfaction, while enhancing the quality and cost-effectiveness of care delivery.
Embracing the PCMH Model
Such holistic patient-centered care, which places a premium on patient engagement and self-management, requires consistent, coordinated and team-based approaches. Policy-makers and payers (both public and private) have recognized the importance of these attributes and are encouraging primary care to explore new inter-disciplinary team work practices to deliver effective care management. In response primary care teams are adopting evidence-based models, such as the patient-centered medical home (PCMH). The Agency for Healthcare Research and Quality (AHRQ) defines a medical home as an organizational model for primary care that delivers the core functions of primary healthcare with improvements focused on providing access to high quality, comprehensive, patient-centric and coordinated care.
In coordinating care across the broader healthcare system, including specialty care, hospitals, home health care, and community services the PCMH model enables primary care to meet the population health challenges it faces. Such coordination is particularly critical during transitions between sites of care, such as when patients are discharged from the hospital or a rehabilitation center. Care coordination is facilitated by building clear and open communication among patients and families, the medical home and members of the broader care team.
Building the Information Infrastructure for Care Coordination
Unlike the episodic models of care it is replacing, team-based care requires ongoing input from across the continuum of care to ensure the right care is provided to the right patient, in the right place at the right time. Health information technology (HIT) offers a vital tool for team communication and care coordination and creating this “just-in-time” care environment. An electronic health record (EHR), essentially a digital version of a patient’s paper chart, offers real-time, patient-centered records that makes information available instantly and securely to authorized users. EHR systems consolidate, normalize and present standard clinical data such as patient medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images and laboratory and test results to support patients’ care. EHR technology has the potential to facilitate an information-rich exchange between the primary care team and support specialist referral across the continuum of care.
In their current state of maturation EHRs can enhance the care of individual clinicians but are often ill-adapted for use across the continuum of care, having generally arisen from legacy systems that were designed to meet the needs of distinct silos of care within individual practices and hospitals. Lack of interoperability and poor alignment with workflows across the continuum of care can make the EHR a cause of frustration and contribute to clinician burnout. Systems that support a multi-disciplinary team working, need to offer evidence-based tools to providers making clinical decisions to automate and streamline provider workflow.
The Challenges of Specialist Referral
An area where it has been particularly challenging to provide access to high quality, comprehensive, patient-centric and coordinated care is making specialist referrals from primary care. Referral rates from PCPs to specialist physicians have more than doubled since 19991, reflecting increased demand for care from aging baby boomers. Shortage of specialists, especially in rural areas, mean the supply of consultations hasn’t kept pace with this demand. Wait times for specialty care visits lengthened by 30% between 2014 and 2017, to an average of 24 days.2
Referrals from primary care to specialist care will yield one of three results: the specialist assumes care for the patient; the patient is referred back to primary care, or the patient will receive co-management from both physicians. Determining the course of care management requires primary and specialist physicians to each evaluate a patient’s case including complaints, symptoms and medical history. In some cases, specialist input is needed to assure a PCP that specialist care is not required and that proper care management can remain in the primary care setting. Likewise, a specialist consultation can effectively verify cases for which advanced care is needed. Information sharing is the key to care coordination in this, as in other areas of primary/secondary care collaboration and in interfacing with the PCMH.
Without easy and automated means of electronic information sharing to assist with care coordination between PCPs and specialists to help manage the increasing traditional face-to-face visit workload, it’s not surprising many PCPs and specialist physicians are dissatisfied with this process. In order to provide the right care, in the right place at the right time, timely and accurate information must be available to support patient assessment, diagnosis and treatment planning. Current referral workflows often lack complete medical workups, are sent to the wrong specialist or are inappropriate for specialist attention. Long delays for PCPs to receive results from specialist visits decrease a PCP’s ability to optimize the patients’ care. Most importantly, referral issues may delay necessary patient treatment and decrease satisfaction with the care process. Furthermore, wide variations in referral patterns demonstrate underuse and overuse of specialist referrals, both of which compromise optimal care and may add significant costs.
eConsultations as a Case Study in HIT Support for the PCMH
To address the challenge of expanding the capacity of specialist referral from primary care, electronic consultations (eConsults) are a care delivery model that is rapidly gaining traction in the market due to its effectiveness in reducing variations in referral practice, increasing access to specialist care consultation, reducing wait times for specialist visits and increasing clinician satisfaction. eConsultation is an interesting case study in building HIT resources that support the PCMH by focusing on the patient and aligning technology support to workflows that focus on serving clinicians and the decisions they have to make for their patients.
eConsultation systems enable appropriate information exchange between EHR systems to support rapid decision-making by the primary care provider based on specialist input. Also, eConsults drives the standardization of referral best practice. Systematic review suggests PCPs find eConsults often allow ongoing management of patients in primary care who would otherwise have been referred to specialists. Effective implementation of eConsult technology is driving high levels of provider satisfaction, especially in safety-net systems and integrated healthcare systems3 such as Kaiser Permanente and the Department of Veterans Affairs.
eConsult programs are becoming an indispensable tool for communication and care coordination for the wider PCMH model. Historically, EHRs and care planning tools have not been designed with the patient-focused and relationship-building imperatives that are driving the development of emerging eConsults systems. The National Committee for Quality Assurance (NCQA) acknowledges the importance of creating more effective referrals in their 2017 PCMH metrics (Closing the Referral Loop: Receipt of Specialist Report).4 Moreover, in medical home pilot programs, primary practices have a financial incentive to track referrals and to provide decision support to guide compliance with referral best practice.5 Also, referral guidelines have been promoted as a means of improving the appropriateness of referrals.6
A key element of the PCMH model is the ‘huddle.’ Team huddles, guided by pre-visit planning, have been reported to assist in role delegation, consistency of information collected from patients and structured communication among team-members. When a patient’s care is co-managed by a specialist physician, the specialist would ideally participate in the huddle – a process that presents logistical, practical and medico-legal hurdles. However, with eConsults there is a viable future scenario for structured involvement of the specialist physician in a virtual huddle.
Exactly how eConsults will factor into patient and family-centered care planning needs careful consideration. Data exchange, quality management, reimbursement and privacy/confidentiality considerations are among the many important issues to address. But, as more health systems look toward creating PCMH models to better manage the health of their patient population, methods of improving care coordination and communication will be essential to success. It is likely that future development of the eConsultation will not be limited to a bi-directional exchange between PCP and specialist, but as a tool to coordinate between the primary care team and their specialty care counterparts with the patient at the center. In such a future scenario, patients may become increasingly interested in receiving structured digital information on the outcome of the eConsult.
1 Barnett ML, Song Z, Landon BE. Trends in Physician Referrals in the United States, 1999-2009. Arch Intern Med. 2012;172(2):163–170.
2 Merritt Hawkins. Survey of Physician Appointment Wait Times. 2017.
3 Vimalananda VG, Gupte G, Seraj SM, et al. Electronic consultations (e-consults) to improve access to specialty care: A systematic review and narrative synthesis. Journal of Telemedicine and Telecare. 2015;21(6):323-330. doi:10.1177/1357633X15582108.
4 Quality Measures Crosswalk for PCMH 2017. NCQA PCMH 2017 Recognition Credit: CC 04C QI 02A. https://www.ncqa.org/portals/0/Programs/Recognition/PCMH/Quality_Measures_Crosswalk.pdf
5 Bitton A, Martin C, Landon BE. A nationwide survey of patient-centered medical home demonstration projects.
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6 Rodriguez HP, Scoggins JF, von Glahn T, Zaslavsky AM, Safran DG. Attributing sources of variation in patients’ experiences of ambulatory care. Med Care. 2009 Aug; 47(8):835-41.