Future-Proofing Primary Care
Primary care is the linchpin for the transformation of health care services for aging populations of patients with high incidence/prevalence of chronic conditions eg, obesity, diabetes, heart failure, and anxiety/depression. Services that were previously physician centric are now pivoting toward primary care team (PCT)-based care for patients in the least restrictive settings. PCPs are adept at individualizing care in the most appropriate setting. But, ever more complex treatment options, and informed patients expecting equal participation in care decisions, have increased the number and complexity of primary care referrals to specialty physicians. In order for primary care to meet patient expectations of accessing the right care, in the right place at the right time, health systems must establish more robust primary-specialty care connections.
Extending the PCMH Model with Technology
PCMH is an evidence-based, patient-centered care model that supports patients with complex needs in non-institutional settings. It fosters patient engagement, self-management and care coordination by interdisciplinary teams when holistically addressing biopsychosocial issues that would otherwise result in avoidable emergency room visits and hospital admissions. Specialist physician input often needs feeding into primary care team (PCT) deliberations so diagnosis, treatment, and prognosis can be fully factored into the broader care management process. For PCTs to assure access to high quality, comprehensive, patient-centric and coordinated care, they have to be able to communicate across the care continuum and “in-reach” into specialty care. New health information and communication technology projects make this is possible. But can they routinely deliver “at scale”, and to underserved populations?
Technology-Assisted Team Work Across the Care Continuum
Electronic health records (EHRs) support team communication and care coordination activities within individual hospitals by making patient-centered records securely available “real-time” to authorized users. Interoperability and cyber security issues reduce these functional capabilities between hospitals and across the care continuum, where an information-rich exchange between primary care teams in multiple localities, and the specialist care services that support them, extends the reach and effectiveness of the PCMH.
Telehealth offers a video solution, but cannot consistently provide the just-in-time information flow PCTs need when managing complex care patients who would benefit from a specialist opinion.
The Challenges of Specialist Referral
PCP referrals for specialist consultations have risen 100% since 1999, compounding the shortage of specialist physicians, especially in rural areas, lengthening consultation wait times by 30% from 2014 to an average of 24 days in 2017. Critical links across the continuum of care are therefore weakening, although not for want of clinician commitment or effort, but due to the ongoing reliance on “in-person” consultations. Workups for in-person specialist referrals are often incomplete, sent to the wrong specialist and inappropriate. Delays in receiving specialist consultation further impact patient care.
eConsultations: A Case Study in HIT Support for the PCMH
Electronic consultations (eConsults) resolve the issues of just-in-time PCP referral, providing a specialist consult feedback loop to PCPs, lessening variations in referral practice, increasing access to specialist care consultation, reducing wait times for specialist visits, and increasing clinician satisfaction. eConsultation support for care management in primary care reduces specialist referrals, building market traction for eConsult adoption. The National Committee for Quality Assurance (NCQA) PCMCH cites eConsults as an effective referral tool for PCMH pilots that financially reward referral tracking and compliance with referral best practices5. Premier eConsult programs incorporate referral guidelines as a decision-support tool for PCPs to help make appropriate referrals.
In the future eConsults may feed into PCT’s patient and family-centered care planning processes and could include specialty care input into a virtual “huddle”. Current bi-directional exchange between specialist and PCP may become tripartite, if patients want information on eConsult exchanges and recommendations.
Adam Darkins is CSO of AristaMD.