Health Promotion

Strengthening Pediatric Primary Care with E-Consults

By: Karen Rubin, MD

Connecticut Children’s is embracing new technology to strengthen pediatric primary care by ensuring subspecialists in certain clinical areas are available to community-based pediatric primary care providers (PCPs) through electronic consultations, or e-consults.

How E-Consults Work

Now becoming more popular around the country, e-consults mark the latest advancement in our Co-Management program, which is a “shared care” model that expands the capability of community-based PCPs to treat common pediatric conditions that are often unnecessarily referred to subspecialists. Co-Management brings competent care closer to where patients and families live, which reduces their emotional and cost burden. Co-managed care also tackles the issue of limited access and poor communication around specialty referrals, which leads to ineffective use of specialists and delays in care, especially for the underserved.

E-consults make it easier for pediatric PCPs and subspecialists to communicate in order to provide patients with the most efficient and effective care. A PCP sends an e-consult request electronically to a subspecialist, including relevant protected health information from the patient’s electronic health record. The sub-specialist sends a formal consult note back to the provider within 24 to 48 hours, offering appropriate advice in an expedited, simplified, and more efficient manner than is possible with a traditional referral for a subspecialist appointment. Additionally, the recommendation about whether a referral to a subspecialist is needed, as well as management advice and education about the particular health issue improves access to specialty care for those who need it.

Partnering to Provide Pediatric E-Consults

Since 2015, Connecticut’s Community Health Center, Inc., under the leadership of Dr. Daren Anderson at its Weitzman Institute (WI), has provided over 20,000 e-consults to more than 1,000 providers in 13 states through a web-based platform. A remarkable 69 percent of e-consults between adult primary care providers and adult specialists were resolved without the need for a referral for a traditional specialist appointment. In addition, detailed analysis of claims data in cardiology revealed that e-consults saved money.

Such e-consults are a complementary approach to the Co-Management program I launched at Connecticut Children’s in 2012. The program promotes co-managed care between subspecialists and pediatric PCPs to improve access to evidence-based care for children. As part of the program, collaborative care tools provide guidance to PCPs so they can more independently and confidently manage high-volume, low acuity conditions that are often referred to subspecialists, which frees up subspecialists’ schedules for patients who most need that level of care. First, we identified common diagnoses and complaints for which pediatric specialty consultations are often sought, such as headaches, obesity, hypertension, and anxiety and depression. Then, subspecialty and PCPs co-created clinical protocols to clearly define the appropriate roles for each team member and the evidence-based screening, evaluation and treatment for each condition, including guidelines for when specialty referrals are needed. The protocols equip providers with extra knowledge to treat their patients quickly and effectively.

In May 2017, Dr. Anderson and I formed a partnership to explore the feasibility of combining our work. A group of seven e-consult providers from three Connecticut Children’s specialties – cardiology, pulmonary, and endocrinology – joined the WI network as e-consult providers. We ensured that the e-consult platform contained an easy way for subspecialists to attach relevant Co-Management protocols as part of their response, making the information sent to PCPS more evidence-based and shortening the provider response time per e-consult. The most common e-consult questions are now informing the development of new Co-Management protocols to make the system even more efficient and scalable.

Pediatric Referral Outcomes

From January 2018 through June 2019, 57 percent of the 265 pediatric e-consults were resolved without a need for a subspecialist referral, which is consistent with outcomes from the rest of the network.

Another Collaborative Intervention

Dr. Anderson and I, along with our respective care teams, are also partnering together on Project ECHO, a third complementary intervention that provides live case discussions and didactics to educate primary care teams in complex areas and improve their ability to manage cases effectively in primary care offices. Project ECHO is a scalable learning platform that uses video conference technology, best practice protocols, and case-based learning to train and support primary care teams. Connecticut Children’s master educators developed and delivered exciting new content for a year-long  ECHO module called “Complex Pediatrics”.  This module focuses on complex conditions best addressed by a multidisciplinary team of experts.

Next Steps

As healthcare policy struggles to address rising costs and access disparities to subspecialties, primary care is increasingly recognized as an efficient strategy for ensuring optimal health outcomes. Co-Management and the sharing of knowledge could not be more timely. Plans are underway to tightly integrate the e-consults, Co-Management clinical tools, and Project ECHO into a single virtual educational community for pediatric PCPs. Dr. Anderson and I plan to pitch this as a promising strategy for statewide and national level reform.

Karen Rubin, MD is Connecticut Children’s Chief Clinical Transformation Officer and leads the Office of Innovation in Clinical Care Delivery . She is also director of Connecticut Children’s Co-Management program, which is a part of Connecticut Children’s Office for Community Child Health.

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