Los Angeles Safety-Net Program eConsult System Was Rapidly Adopted And Decreased Wait Times To See Specialists

Barnett ML, Yee HF, Megrotra A, Giboney P
Source: Health Affairs
Publication Year: 2017
Patient Need Addressed: Other
Population Focus: Vulnerable/disadvantaged
Demographic Group: Urban
Intervention Type: Technology/innovation
Study Design: Other Study Design
Type of Literature: White
link: https://www.healthaffairs.org/doi/10.1377/hlthaff.2016.1283
Abstract

Lack of timely access to specialty care is a significant problem among disadvantaged populations, such as those served by the Los Angeles County Department of Health Services. In 2012 the department implemented an electronic system for the provision of specialty care called the eConsult system, in which all requests from primary care providers for specialty assistance were reviewed by specialists. In many cases, the specialist can address the primary care provider’s question via an electronic dialogue, thereby eliminating the need for the patient to see a specialist in person. We observed rapid growth in the use of eConsult: By 2015 the system was in use by over 3,000 primary care providers, and 12,082 consultations were taking place per month, compared to 86 in the third quarter of 2012. The median time to an electronic response from a specialist was one day, and 25 % of eConsults were resolved without a specialist visit. Three to four years after implementation, the median time to a specialist appointment decreased significantly, while the volume of visits remained stable. eConsult systems are a promising and sustainable intervention that could improve access to specialist care for underserved patients.

Insights Results

Overview of article

  • This study examines the first 4 years of the LA Department of Health’s eConsult system, specifically assessing: 1) The sustainability of long-term improvement in access; 2) Change in provider use of eConsult systems overtime; and 3) Identification of patterns of varied uses of the eConsult across primary care providers and specialist reviewers
  • With the eConsult system, providers must request all non-emergency specialty assistance electronically. To do this, providers submit an eConsult request to a given specialist, including the patient’s clinical background, nature of the problem, and images when necessary. Each request is then read by the assigned reviewer for that specialty, who can engage in a secure, electronic, iterative dialogue with the provider. Depending on the situation, the reviewer either recommends that the patient sees a specialist or resolves the eConsult request without a visit by providing relevant input on treatment or diagnosis electronically
  • The eConsult system could improve access to primary care services in numerous ways: 1) Primary care providers can provide advice quicker than an expert specialist; 2) Demand for visits decreases because many eConsult requests are resolved without an in-person visit; and 3) The eConsult system can ensure that the patient sees the right specialist and has the appropriate previsit evaluation

Methods of article

  • Authors performed a retrospective observational analysis of the eConsult program using a database of all eConsult requests for a 4 year period
  • Outcomes of interest include volume of eConsult requests across the entire LA County health system, and proportion of patients with specialty appointments within 30 days or less (measures urgent access)

Results

  • By the end of 2015, eConsult was in use by 3,060 primary care providers and 479 specialist reviewers across 86 specialty services
  • In 2015 the median time to first response for an eConsult request was slightly less than 24 hours (0.99 days), and 25.0 % of the requests were resolved without a visit
  • There was no significant change in the average monthly number of eConsult requests that resulted in a specialist visit. In contrast, there was a significant change in the average monthly number of eConsult requests resolved without a visit
  • There was significant variability across both primary care providers and specialist reviewers in the outcomes of their eConsults. Rates of requests resolved without a visit for primary care provider ranged from 11.4% in the tenth percentile to 32.3% in the ninetieth percentile
  • The study found no evidence that there was a significant among of pent-up demand for specialty care of that primary care providers began to refer patients to specialty care more frequently

Key takeaways/implications

  • The implementation of this system suggests that even in a large, underserved urban population, specialty access is not an intractable problem, and that a shift in the model for specialty care can provide rapid electronic input for thousands of patients in need.
  • The study suggests there is a “learning effect” from the use of eConsult over time as eConsult can facilitate the education of primary care provider through eConsult discussions
  • Future research should examine changes in the clinical questions asked in eConsult over time and specialists’ responses to them
  • Room for improvement for eConsult include opportunity to reduce wait time more, addressing the wide variation in the rate of eConsult requests resolved without a visit across specialist reviewers
  • An eConsult system may realize its true potential only with engaged specialist reviewers who are willing to engage primary care providers in dialogue due to the variation in requests resolved between the 2 provider groups
  • Limitations to this study include lack of access to pre-implementation data or results for a control group without eConsult, inability to establish causality, lack of detailed clinical information on patients or individual eConsult requests beyond specialty, which limited ability to assess referral appropriateness, inability to compare overall eConsult utilization to similar electronic referral systems, and lack of generalizability
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