Taking on the specialist shortage

UVA believes it has the answer
By Bernie Monegain
09:05 AM
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The University of Virginia Health System is putting its EpicCare electronic medical record to work on a pilot designed to speed patients' access to specialists.

UVA Health System, which includes a 612-bed hospital, the UVA School of Medicine, a level I trauma center, cancer and heart centers and specialty clinics, is one of five academic medical centers in the U.S. testing the eConsults/eReferrals model. 

The other academic medical centers with similar projects, all of them employing EpicCare EMRs, are Dartmouth-Hitchcock Medical Center, UC San Diego Health System, University of Iowa Hospitals and Clinics and University of Wisconsin Health.

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The five centers are supported by a $7 million grant from the federal Center for Medicare and Medicaid Innovation. UVA is launching its project this month with four specialties: endocrinology, cardiology, digestive health and neurology. Plans are to eventually expand the model to 14 specialties.

[See also: E-consults hold promise for efficient PCP and specialist interaction.]

The program addresses a common challenge faced by primary care doctors across the country: There simply are not enough specialists to meet the need.

The goal is to make available additional appointments with specialists for patients with more complex medical conditions. Using the EpicCare EMR, eConsults or eReferrals will make it possible for specialists to answer many questions – in some cases without requiring an appointment.

"What we're planning to do is use the EMR to access specialists more quickly without face-to-face visits," Mohan Nadkarni, MD, a primary care physician at University Medical Associates in Charlottesville, Va., told Healthcare IT News.

A request for a consult would go through the medical record to a specialist with a specific question about a patient. If the specialist can give an adequate answer without seeing a patient face-to-face, he or she responds through the medical record.

"It's all documented very well for the PCP in the record," said Nadkarni. "It replaces what doctors often call 'curbside consults,' where they walk in the hall, you see a specialist, and say, 'wait a minute, I have this patient. I just have a quick question,' he adds. "That's really not very satisfactory because you don't have all the patient chart information to have a specialist make a decision, and it's not documented in the chart. It's not good medicine to do it that way."

"If you can answer the least complex questions using this model and reduce appointments by 10 percent, you can open up more appointments for patients who will truly benefit from face-to-face interactions with specialty physicians," said Chris Ghaemmaghami, MD, UVA's chief medical officer, in a Jan. 22 news release announcing the UVA pilot.

[See also: 3 benefits of eReferral systems.]

Here is how it works:
eConsults: Primary care physicians can ask specialists a quick question about a patient – for instance, consulting an endocrinologist on whether to adjust the insulin level for a diabetes patient. The primary care physician will send a message through EpicCare to a specialist, who can review the patient’s medical history before making a recommendation. "This will ensure a specialist has all the information he or she needs and that the consult is documented in the patient’s medical record," said Nadkarni.

eReferrals: For cases requiring a more detailed review – such as a patient experiencing occasional chest pain – the primary care physician will fill out a template and answer a series of questions about the patient’s condition and medical history that is sent to the specialist. After a review of the eReferral, the specialist can determine if a patient needs an appointment.

"This should greatly improve collaboration between primary care physicians and specialists," Nadkarni said.

Patients benefit

Patients who don’t need to be seen in person by a specialist can get the information they need to improve their health sooner, said Daniel McCarter, MD, a primary care physician at Stoney Creek Family Medicine in Nellysford, Va., in a statement. For McCarter's patients – who often travel long distances to see him – not having to make a second appointment with a specialist can mean not having to take a day off from work.

For patients with more serious conditions who need to make an appointment, the new model could mean getting an appointment sooner. As Nadkarni sees it, that would be one of the best outcomes.

As for the consults, the e-consult replaces the "curbside" consultation with something that's more formal and helps reduce the need for some patients to have a face-to-face visit with a specialist while enhancing access for patients who do need to see a specialist face-to-face, said Nadkarni. As for the technology, it's pretty simple, said Nadkarni. There are a few adjustments made to the EHR, he said, but for the PCPs and the specialists, "it's seamless."

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