Prescription for Change

How Sharp Rees-Stealy deployed digital consults to boost specialty care access

by Gillian Hughes and Eliza Campbell

Despite their investments in access expansion, most physician organizations continue to struggle to improve access to specialty care.

According to a recent survey by Merritt Hawkins, the average appointment wait time for specialty care in 15 major markets was 24.1 days in 2017, a 30.3% increase from 2014. And in some specialties, such as dermatology, wait times are climbing to more than one month.

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While many providers may now find themselves with more availability than usual as a result of Covid-19, specialty care volumes will likely take longer to rebound than primary care as referrals lag. To capture volumes as quickly as possible, organizations must prioritize timely access now more than ever—such as by exploring new ways to apply telehealth technologies in specialty care. Sharp Rees-Stealy, a medical group based in San Diego, deploys EHR-based digital consults (also called "e-Consults") to give patients and primary care providers (PCPs) faster access to specialists.

Sharp Rees-Stealy's EHR-based e-Consults connect PCPs and specialists

A few years ago, Sharp Rees-Stealy built a "Curbside Consult" program in its EHR after realizing that specialists often spent time on appointments that didn't require in-person care or could be adequately handled by a PCP. Under the group's program, the referring physician sends a message, and oftentimes a photo, via EHR to the on-call physician for that specialty.

After receiving the request, the specialist reviews it and decides whether a referral is necessary. Frequently, the specialist determines that an in-person visit isn't needed, and that the patient can be effectively managed in primary care, with virtual input by the specialist ad hoc. But even if it's determined that an in-person visit is needed, the specialist often recommends a treatment regimen that the PCP can start the patient on in the interim. Not only does this approach expedite patient care, but it also helps bypass the initial consult, saving an in-person visit. Sharp Rees-Stealy aims for a two-day turnaround time for these requests and has scaled the program across 15 specialties.

The implications for specialty access

  1. Decreases wait times for in-person visits. By triaging and resolving some cases virtually, Sharp Rees-Stealy frees up specialist capacity so that its physicians are only spending valuable office time seeing the patients who need it the most. For example, the group found that fewer than 50% of e-Consults in dermatology actually resulted in an office visit.

  2. Upskills PCPs to manage low-acuity specialty cases. In addition to decreasing wait times, these virtual touchpoints also help educate referring providers and improve their referral patterns in the long term. These e-Consults serve as opportunities to educate PCPs on appropriate referrals and equip them with specialist knowledge to manage less complex cases in primary care. According to Brent Steineckert, Patient Access Director at Sharp Rees-Stealy, "[Our] referring providers are becoming better at diagnosing and treating specialty conditions."

How to implement e-Consults at your organization

  1. Start in specialties with longer than average wait times. Sharp Rees-Stealy has a large percentage of revenue tied to risk-based contracts so e-Consults help keep utilization down. For organizations with less revenue at risk, start rollout in specialties with long wait times. While physicians may lose out on some fee-for-service dollars in the short-term, a program like this can be a valuable growth strategy to get patients in sooner, keep them loyal to your group, and generate more downstream revenue. Organizations might also want to consider counting e-Consults toward performance metrics, such as access or citizenship, in physician compensation.

  2. Reserve time on physician schedules. While Sharp Rees-Stealy reports that it can take a while to build volumes on this platform, dedicating time on physician calendars to respond to these requests ensures timely responses. The medical group opted to make e-Consults part of specialty on-call coverage.

  3. Scale up based on EHR integration. Sharp Rees-Stealy is on a single, integrated EHR across its entire ambulatory network, which facilitates direct PCP-to-specialist connection. For groups with less advanced technology capabilities, consider starting with phone-based triage in the interim.

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