1. Real-Time Referral Program Overview

2. 2 Primary Care – Specialty Care Primary Care Specialty Care An ideal system will provide timely specialty input, when needed. No more and no less

3. 3 Stakeholders: Purchasers / Payers Our care is too expensive for population- based and value-based payments Credible threats to exclude AMCs from network coverage The referral rate doubled between 1999 and 2009 1 in 3 patients is referred to a specialist each year (1 in 2 for the elderly)

4. 4 Stakeholders: The Patient “I have a problem today.” Care burden: Time from work Copayment Transportation Parking Child care

5. 5 Stakeholders: The PCP Timely access to specialty guidance Some questions have: A narrow scope Available data in the shared EHR Without the need for an exam Relational continuity with the patient

6. 6 Stakeholders: The Specialist Address lower-complexity questions efficiently High complexity cases improve teaching Reimbursement for non face-to-face work Improve access

7. 7 RTR Program eReferral + eConsult = RTR Program eReferral: Improves quality and clinical content of referrals, optimizing utilization eConsult: timely input from specialists for lower complexity, data-driven questions

8. 8 Impact at 1-Year- UCSF Experience

9. 9 RTR Program 72 hour eConsult response expectation Specialist can convert to a scheduled visit for case complexity 0.5 wRVU payment to Specialist 0.5 wRVU credit for PCP (toward productivity)

10. 10 I am referring @name@, a @age@ y/o @sex@, to Gastroenterology for direct scheduling for colonoscopy Indication: (choose one) My assessment that this patient is safe for an endoscopic procedure with sedation. This patient, (please select any that apply) ____ has had a recent MI or STROKE ____ requires HOME OXYGEN ____ is on ANTICOAGULATION therapy ____ has a clinically significant CARDIAC ARRHYTHMIA ____ has a history of CHRONIC OPIATE or SUBSTANCE ABUSE ____ has a history of a PSYCHIATRIC disorder to consider when planning sedation. ____ has severe OSA ____ Other co-morbidity that should be considered in consultation prior to sedation If the patient has one of the above risks, @he@ will be scheduled in the GI clinic for an evaluation prior to the procedure. eReferral

11. 11 eConsult

12. 12 Clarify Expectations for Follow-Up Pending specialist evaluation, I anticipate: -CONSULTATION ONLY: Recommendations and Return to Primary Care -CO-MANAGEMENT—PCP IS FIRST CALL: PCP maintains responsibility for day-to-day management -CO-MANAGEMENT—SPECIALIST IS FIRST CALL: Specialist assumes responsibility for management of thIs problem. -E-CONSULT

13. 13 Improved Access for Primary Care Population Referrals and eConsults per 100 Primary Care Visits

14. 14 Improved Access for Primary Care Population Referrals and eConsults per 100 Primary Care Visits

15. 15 Increased External Referrals

16. 16 UC- Wide Expansion RTR Implementation at UCSD, UCLA, UCD and UCI –Synergistic efforts to improve access to specialty care –Improve the total value of care for their PC populations –Share EPIC platform –Buy-in 14 specialties will be introduced over 12 months

17. ROI 17 Primary Population of 50,000 Improved access to specialty care has important implications not reflected in the model. Strengthening referral relationships Greater access to higher complexity, external referrals to our specialty practices The reduction in ED use and hospitalization within 120 days of referral (seen at UCSF) Year 1 (ramp up) Year 2 Averted visits2751378 eConsults186931 Gross Savings$70,695$353,476 eConsult Fee (Medical Center / Medical Plan) $19,893$99,468 Net Saving $50,802 $254,008 ROI 3.55:1

18. 18 Conclusion Significant impact on: Referral rates Specialty care utilization Costs eConsult does not appear to induce demand High acceptability among PCPs and specialists Referral templates fundamentally improved referral communication High quality, patient centered care – This is not merely reducing cost > quality Timely access to specialists PCP relationship continuity Decreased complexity of care management Save patient out-of-pocket costs Train tomorrow’s physicians to deliver more flexible care

19. 19 RTR