1. eConsult: Utilizing Technology to Bridge the Integration Gap
Ricardo Mendoza, MD
Christopher Benitez, MD
Clayton Chau, MD, PhD
Paul Giboney, MD
Gary Tsai, MD

2. Objectives
Describe how eConsult can facilitate more effective management of patients with a broad range of comorbid mental health and substance use disorder conditions across large scale health, mental health, and substance use disorder systems of care.
Describe how eConsult can be adapted to effectively support the care of cross-cultural patients when utilized across large systems of care with a culturally diverse workforce.
Describe how eConsult is being utilized in LA County to achieve the Triple Aim of Healthcare Reform and how these initiatives will be monitored to assess efficacy.

3. Approach Policy Context
Quick history of LA County’s DHS’ specialty care improvement initiative
Psychiatry eConsult Web Portal
Facilitated panel discussion
Audience participation
Question and answer

4. Triple Aim of Healthcare Reform
A framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance.
New designs developed to simultaneously pursue 3 dimensions – “Triple Aim”
Improving the patient experience of care (including quality and satisfaction)
Improving the health of populations
Reducing the per capita cost of health care

5. Why Triple Aim
The US Health Care system is the most costly in the world, accounting for 17% of the GDP with estimates that percentage will grow to nearly 20% by 2020 (National Health Expenditure Projections, Centers for Medicare and Medicaid Services, Office of the Actuary)

6. Triple Aim is Producing
Accountable Care Organizations (ACOs)
Bundled payments, and other innovative financing approaches
New models of primary care, such as patient-centered medical homes
Integration of Information technology
Sanctions for avoidable events, such hospital readmissions or infections

7. Triple Aim Concept Design
Focus on individuals and families
Redesign of primary care services and structures
Population health management
Cost control platform
System integration and execution

8. eConsult Supported by the Hi-Tech Act of 2009
Part of Stimulus Act or ARRA post Great Recession
Promoting Health Information Technology
Electronic Medical Records
Meaningful Use
Interoperability
Just one tool used to support the Triple Aim

9. eConsult An Indirect Consultation Model of Care Integration
Other National efforts
Emerging within context of:
Tremendous rise in ranks of Insured
EMR and MU Technological Push
ACCESS to Care a high value target
Primary Care is being pushed to limits
Not enough psychiatrists and SUD specialists to meet the needs

10. The DHS Experience:
Paul Giboney, MD

11. 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

12. 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.
Referral

13. Practical “real world” improvement
Principles
Effective Practice
Practical “real world” improvement

14. Strategies Toward Integration
DHS’ 1st Steps
Patient Centered Medical Neighborhood (PCPs and Specialists).
eConsult
Specialty Primary Care Workgroups
Patient-Centered Specialty Scheduling
Reduction in process variation
Reduction in no-show rates
Improved patient experience

15. Specialty Primary Care (SPC) Workgroups:
Collaboration across facilities and disciplines
Triple Aim
Equity/Reduced variability
Expected Practices / DHS Clinical Care Library

16. SPC Workgroups 31 Workgroups = 180+ participants “Expected Practices”
Identifying opportunities to collaborate between facilities
Better use DHS resources
DHS-wide approaches to common issues, clinical interventions, and scope of care.
90+ in DHS Clinical Care Library.
Establishment of inter-facility “handoffs” eg Urology patients from lower level to higher level facilities.
Novel diabetic management strategies
Teleretinal Diabetic Retinopathy Screening Program
Clarifying scope of care in cataracts and diabetic foot screening to focus resources on patients most in need of intervention.

17. 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)
Provides ability to send consult notes (from specialty visit) back to PCP

18. The DHS eConsult Network
Submitting Sites
4 Medical Centers
2 Multi-specialty
Ambulatory Care Centers
17 DHS Health Centers
170 Community Partner
(My Health LA) sites
14 Department of Public
Health Clinics
14 Juvenile Courts Health
Services Clinics
9 Sheriff’s Department
(Medical Services
Bureau) clinics
Specialty Care
58 Specialty Services
>370 eConsult reviewers located at 10 different DHS facilities
3,600+ Providers have submitted at least one eConsult
eConsult
These locations can be envisioned together as a
“Patient Centered Medical Neighborhood”

19. How eConsult Works PCP submits eConsult request for assistance
Patient Scheduled for Specialist or PCP treats in Medical Home
Next steps determined
Dialogue between PCP and specialist
Specialist reviews & responds to PCP within 4 days
PCP submits eConsult request for assistance
How to achieve the goals

20. What does eConsult look like?

21. What does eConsult look like?

23. 2.7 Days ! Impact Responsiveness Via Paper and RPS
Responsiveness = Weeks/Months….and beyond!
Respond to over 13,000 eConsult requests each month.
To date – in over 280,000 eConsult submissions, the average time of response (in calendar days) by our specialists =
2.7 Days !

24. eConsult Dispositions
Cancelled / 6months no activity – 5%
Specialty Change – 6%
280,000+ eConsults

25. Access to Specialty Care
Rapid access to specialty expertise – 2.7 days on average
Ability to expedite cases needing more rapid specialty attention
Ability to designate specific face to face visit instructions based on clinical need
Allows PCPs to deliver “specialty” care in the Medical Home
Reduction in wait times for “routine” specialty care visits
(because we are using specialist time more efficiently)

26. Patient Centered Specialty Scheduling
DHS Appointment Service Center (DHS-ASC)
Through eConsult – 9,000/month
Anywhere in the system
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

27. Program Impact Patient wait times for specialty care travel
Fewer days off work
Culturally attuned care
Empowered PCP
Better coordinated care
Better informed specialist at visit
Fewer specialty visits required to devise treatment plan
- transitions of care better managed, process more transparent

28. Program Impact Primary Care Specialty Care Quick access to expertise
Extend expertise over a larger population of care.
Connected to larger system of care (reduced isolation)
Ability to triage
Enhance clinical capability (eConsult “CME”)
Reduced wait times
Reduced “no shows”
Improved scheduling process
More productive visits
Ability to track the status of referral
Better information
Improved care coordination
Pre-Visit Testing Completed
Time investment in submitting eConsult
Avoid inappropriate referrals
More conditions managed in Medical Home – more “balls” in PCP’s court.
Opportunity to teach/educate
PCP
Challenge in ordering specialty labs or diagnostics.
Residents/Fellows
Increased complexity of clinic patients
Co-Management of complex patients
Time investment in reviewing eConsult
Improved ability to meet patient’s needs

29. DHS Clinical Care Library

30. Development of DHS Psychiatric Web Portal
Christopher Benitez, MD

31. Polling Question
The Psychiatry Web Portal Welcome Page asks the PCP for the following information:
Brief Medical History
Brief Psychiatric and Substance Use History (include prior/known trials and results, suicide or violence, or psychiatric hospitalizations if any)
Current Medication(s) and Dosage(s)
Current Symptoms and Impairments (please include the results of any screening tests)
Clinical Question

32. Polling Question The Psychiatry Web Portal Welcome Page asks the PCP for the following information:
Brief Medical History
Brief Psychiatric and Substance Use History (include prior/known trials and results, suicide or violence, or psychiatric hospitalizations if any)
Current Medication(s) and Dosage(s)
Current Symptoms and Impairments (please include the results of any screening tests)
Clinical Question

33. Polling Question
Please rate your assessment of the amount of information being sought:
1 = Too Much; Represents an Obstacle for the PCP to seek Consultation
2 = Too Little Information for the SR to adquately answer the consultation request
3 = Just right
4 = Unsure

34. Polling Question Please rate your assessment of the amount of information being sought:
Too Much; Represents an Obstacle for the PCP to seek Consultation
Too Little Information for the SR to adquately answer the consultation request
Just right
Unsure

35. Polling Questions
Now that you have learned how eConsult works how concerned would you be about medico-legal liability if you were the Psychiatric Specialty Reviewer?
1 = Not Concerned
2 = Slightly Concerned
3 = Very Concerned
4 = Unsure

36. Polling Question
Now that you have learned how eConsult works how concerned would you be about medico-legal liability if you were the Psychiatric Specialty Reviewer?
Not Concerned
Slightly Concerned
Very Concerned
Unsure

37. Polling Question
Do you think that informed consent is necessary when transmitting PHI between a DHS primary care provider and a DMH psychiatrist?
1 = Yes
2 = No
3 = Unsure

38. Polling Question
Do you think that informed consent is necessary when transmitting PHI between a DHS primary care provider and a DMH psychiatrist?
Yes No
Unsure