The number of patients referred by primary care providers to specialists has doubled in the last 10 years, underscoring the significant need to improve communication and care coordination in these exchanges.
The University of Colorado School of Medicine, led by senior associate dean for Clinical Affairs Anne Fuhlbrigge, MD, has implemented a program from the Association of American Medical Colleges, called Project CORE (Coordinating Optimal Referral Experiences). (Shown at right, Drs. Oberst-Walsh, Fuhlbrigge, and Matt Thompson, MBA, Project Manager)
The Project CORE model was initially developed and piloted at the University of California, San Francisco. It developed a strategy for ensuring that PCPs and specialists work from the same set of expectations before and after a referral. The outcomes of the project have now been replicated in a number of university settings, and include:
For patients, improved access to specialty care and fewer unnecessary tests and visits
For PCPs, the receipt of timely input and expertise from specialists, allowing for more comprehensive care
For specialists, the receipt of clear clinical questions and related documentation, providing more efficient referrals and patient visits
Implementing the AAMC program at CU required a team of primary care providers and specialists who could develop the appropriate Epic-based templates and pilot the program in their own departments.
Linda Oberst-Walsh, MD, serves as the primary care lead on the adult health side of the Project CORE team. She believes the changes in how we practice medicine were a big reason why referrals were leading to increased costs and poor care coordination.
“In the past, we on the primary care team used to run into our specialists all the time in the hospital, and we were able to ask questions on the fly,” she said. “But life is so much busier now, and so much is done online. It has led to a loss of relationship between PCPs and specialists over the years. PCPs miss out of learning opportunities, specialists waiting times are increasing, and patients are experiencing less continuity of care.”
The CORE model uses the electronic health record system to provide point-of-care decision support in two areas: Enhanced Referrals and e-consults. While the AAMC provided guidance on how to implement Project CORE, it required specialists and PCPs from CU to provide input to make the tool effective.
A pilot for enhanced referrals was recently completed, enhancing the referral process for PCPs referring patients to the Division of Endocrinology and Division of Rheumatology. Both specialties are data-driven in terms of making patient assessments, and frequently receive patients via referrals from PCPs.
“The template builds are really a fine-tuned collaboration between the needs of the specialists and the needs of the PCPs. We started with a basic template of what we think specialists are going to need, speaking with our specialists to look at their data, common referrals, and the patients they are seeing who really don’t need to be seen. PCPs and specialists work together to determine the pain points to develop customized templates,” said Dr. Oberst-Walsh.
E-consults are asynchronous exchanges a PCP can initiate using a template for straightforward, low-acuity issues. Should a specialist believe they needed to see the patient, they can convert the e-consult into a referral. Patients can also request an in-person visit.
“There are a lot of clinical scenarios that lend itself to a formal e-consult. For example, a primary care provider is seeing a patient with hypothyroidism. And despite taking a very high weight-based dose levothyroxine, the patient’s labs are too high. This patient doesn’t necessarily need to visit with a specialist, so using the e-consult system, the PCP can email me the most recent labs and all the patient’s basic information, and I can provide suggestions that allow the PCP to continue managing the patient’s care.”
During the first two months since go-live, 43 primary care providers have sent an e-consult through Epic, with 17 sending more than one request. A total of 72 e-consults have been sent, 49 to endocrinology and 23 to rheumatology. Roughly 12% of e-consults sent have been converted to an in-person visit at the request of the specialist.
When PCPs suspect that patients need specialty care, they can refer their patient to a specialist using an Enhanced Referral, which provides both a clear clinical question and the diagnostic, patient-specific data that the specialist will need to review before seeing the patient. The process of requesting an Enhanced Referral not only helps the PCP decide whether the referral is necessary, but it also ensures the first specialty visit is effective for patient and provider while reducing unnecessary follow up visits for reviewing diagnostic tests.
“Rheumatology was a good fit for the Enhanced Referrals project because it’s a complicated field that’s very data driven,” he said. “There’s a national shortage of rheumatologists which leads to prolonged wait times and in some instances inappropriate care. When we are provided data upfront, we are able to judge the clinical need and appropriateness, which allows us to functionally triage patients in terms of the level of care needed. It’s about moving data, not patients.”
During the first two months of implementation, 182 enhanced referrals have been sent, with 129 going to endocrinology and 53 to rheumatology.
Primary care response
Initial feedback provided to the Project CORE team from PCPs has been positive. Approximately 90% of survey respondents say that they were highly satisfied with the e-consult response they received from the specialist, and 80% agree that the e-consult response influenced their care plan. Additionally, 70% of PCPs, in the absence of an e-consult, would have ordered a standard referral to the specialist, with the other 30% indicating they would have called or email the specialist.
The Project CORE team will continue to analyze the data coming from the first wave of the pilot. In September, the next wave of e-consults and enhanced referrals will go live, with gastroenterology, infectious disease, pain management, clinical pharmacy, hematology, and renal taking part.
In addition, Child Health will go-live with project CORE on August 1, with gastroenterology and endocrinology being the first two pilot specialties. This effort is being led by Primary Care Lead, Dr. David Keller.
Dr. Fuhlbrigge believes the early results indicate that moving forward with Project CORE was the right thing to do for patients and providers.
“I’m encouraged by our early results,” she said. “The time and effort that’s gone into this project and thoughtfulness with which our providers have meaningfully engaged in enhancing how PCPs engage with specialists is encouraging. We believe that this will not only enhance relationships between PCPs and specialists, but also improve how we care for patients by reducing the burden of having ineffective and unnecessary appointments.”
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