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About 15 years ago, rheumatologists at the University of Colorado School of Medicine, Aurora, implemented a preappointment consult triage system as a way to identify rheumatology patients who require timely evaluation and treatment.
Over time, the endeavor caused some soul searching. They wondered how effective their consult triage system was in identifying all patients with inflammatory rheumatic diseases and in ensuring they were seen promptly. They also wondered about the revenue implications of routine outpatient care of autoimmune and inflammatory rheumatic disease (AIRD) patients, compared with that of non-AIRD patients.
“Hospital leadership is very interested in making sure that all patients have access to specialty care in a timely manner,” said Sterling G. West, MD, one of the study authors who is also professor of medicine at the university. “However, there are not enough rheumatologists to see all patients with rheumatic complaints, and this deficit is likely to get worse. Although all patients with a rheumatic complaint would likely benefit from a rheumatology consultation, it is clear that timely access to rheumatologic care is most beneficial for patients with inflammatory rheumatic diseases to prevent future morbidity and disability.”
Year-long follow-up finds high sensitivity, more revenue
What started out as a quality improvement project morphed into a robust study that was published online July 12, 2018, in Arthritis Care & Research. Using data recorded in the electronic medical record, Dr. West and his colleagues retrospectively reviewed 961 new outpatient rheumatology consults sent during a 9-month period for final diagnosis and revenue generation for routine outpatient care over 1 year following consult review or initial evaluation. The first step of the consult management involves an intake access coordinator, Ryan Goecker, obtaining information about the patient from the referring clinician. Next, one of three experienced rheumatologists at the university – Duane W. Pearson, MD, Christopher C. Striebich, MD, or Jason R. Kolfenbach, MD – reviews the information about the case. “We do request that labs and x-rays be done ahead of time, depending on what the consult question is, so that we have the data to be able to decide whether a patient likely has an inflammatory process that we need to see or not,” Dr. West explained. “It takes somewhere between 5 and 20 minutes per consult. In total, it takes our rheumatologists about 5 hours a week to do the consults. However, even after subtracting the physician time spent screening consults, the time saved by the consult triage system enabled over 200 more time slots per year to be available to see new AIRD patients than would have been possible without the triage system.”
Following review of the data supplied about the case, patients who may have acute inflammatory monoarticular arthritis or some other rheumatologic emergency are seen within 24-48 hours, while consults with a possible AIRD are approved and seen within 1-4 weeks. Priority is given to those with suspected vasculitis, systemic lupus erythematosus, myositis, and disabling inflammatory arthritis. Patients with probable noninflammatory conditions such as osteoarthritis, fibromyalgia, and mechanical low back pain are not scheduled for an in-person visit. “Instead of simply declining the consult, we try to give some direction, or we say, ‘Why don’t you try this, this, and this, sort of a miniconsult,” Dr. West noted. “One of the potential adverse reactions to doing consult triage would be that the referring provider would be upset if we decline their consult. We acknowledge that. But over time we’ve been able to convince them that this is best for all concerned, so that the inflammatory disease group gets in to see us in an appropriate amount of time.”
Of the 961 consults, 673 were scheduled for an in-person AIRD evaluation and 288 consults were not scheduled. Patients were seen an average of 13 days after consult review. Of the 673 approved consults, 597 (89%) came for evaluation. Of these, 357 were diagnosed as having an AIRD, while 240 were diagnosed as having a non-AIRD. Among the patients not scheduled for a rheumatology visit, 128 had 1-year follow-up data, with 6 patients eventually diagnosed as having an AIRD. This translated into a consult triage sensitivity of 98% and a positive predictive value of 60%. “There’s a fair number of people with noninflammatory disease who do get into see us,” Dr. West said. “That has to do with our desire to not be overly rigid. The sensitivity, specificity, and positive predictive value were not quite as high as some people would like to see, but we really weren’t missing people who really needed to be seen.”
In their conservative cost analysis, revenue data for outpatient care was available for 318 of the 357 AIRD patients and 192 of 240 non-AIRD patients. It demonstrated that care of AIRD patients generates 44 times more revenue, compared with non-AIRD patients ($5,877 vs. $134 per patient, respectively; P less than .001).
“Our consult triage protocol appears to be an effective method to assure that patients with inflammatory rheumatic diseases get expedited access to appropriate rheumatologic care,” Dr. West concluded. “Using conservative measures, caring for patients with inflammatory rheumatic diseases results in significantly more revenue generation.” Generalizability of such a protocol to other practice settings depends on the time rheumatologists are willing to commit to it. “That’s the big thing,” he said. “The question comes up, could a nurse or a nurse practitioner learn the skills over time to be able to do efficient consult triage, to free up the doc from that? Yes. I think that’s absolutely possible.”
Going forward, Dr. Pearson and Dr. Kolfenbach, who are authors on the paper, have launched a pilot project in which the rheumatologist is compensated for doing a record review and e-consult on patients not recommended to be seen in the rheumatology clinic. “For consults who do not have inflammatory disease, we can say [to the referring clinician], ‘If we did see them, this is what we would be doing,’ ” Dr. West said. “Sometimes if there are still questions, we’ll say something like, ‘Once you get the results back, let us know and we can look at it again.’ That way they are getting similar compensation as telemedicine and other forms of consultation.”
At the Zuckerberg San Francisco General Hospital (ZSFG), use of a novel electronic consultation and referral system that was implemented in 2007 by University of California, San Francisco, providers continues to thrive for rheumatology and other specialty services. With this electronic system, previously called e-referral, all provider communication is captured in real time and recorded within the electronic health record. In a 2015 article from Arthritis Care & Research, researchers led by Jinoos Yazdany, MD, MPH, reviewed 2,105 e-referrals made between 2008 and 2012 (Arthritis Care Res. 2015;67[8]:1158-63). The main outcome of interest was use of preconsultation exchange, defined as back-and-forth communication between referring and specialty care providers, facilitating triage of referrals, requests for more information, or resolution of questions without a visit. The researchers found that about 25% of e-consults were resolved without a clinic visit, and that the proportion of e-consults undergoing preconsultation exchange increased over time, from 55% in 2008 to 74% in 2011.
“We’ve had situations in which somebody within our hospital system has requested a rheumatology referral but did not realize the urgency of the patients’ clinical signs and symptoms,” Dr. Yazdany, a rheumatologist and health services researcher at UCSF, said in an interview. “E-referrals are often responded to within that day. When we see an e-consult for a young woman with a rash and protein in her urine, a rheumatologist will recognize that is very concerning for a serious diagnosis like lupus of the kidney or systemic vasculitis. In that situation, we would pick up the phone and sometimes even call the patient and have them come to the emergency room for an urgent evaluation. Over the years, there have been many situations in which we’ve been able to intervene much earlier than we otherwise would have. In some cases that early intervention was lifesaving, or at least organ-preserving for the patient.”
Two studies from the early 2000s examined the use of preappointment management in rheumatology (see Arthritis Care Res. 2001;45:295-300 and Arthritis Rheum. 2004;51:253-7), but this is among the first to incorporate use of an electronic medical record to provide real-time exchange between the specialist and the referring provider. Clinicians at UCSF are reimbursed for reviewing e-consults in one of two ways. Those at ZSFG have protected and compensated time for the task, “so it’s basically part of their job to spend a half day a week on e-consults,” Dr. Yazdany said. “The department of public health and our health care system fold that into operational costs. That’s absolutely critical for success. To be done well and thoughtfully, managing consults and referrals takes time. It takes a lot of expertise.” Meanwhile, clinicians at UCSF’s main university hospital receive a small payment for each e-consult they review. “If it’s a complex consult it’s a higher reimbursement,” she said. “If it’s a simple one, it’s slightly less reimbursement, so it’s a fee-for-service model. It’s something that the health system funds, because it creates efficiencies and access for patients.”
Gaining popularity across specialties
Delphine S. Tuot, MD, a nephrologist who directs the ZSFG e-consult system, said that the notion of preconsult triage is gaining popularity in all medical specialties. For example, the Blue Shield of California Foundation is funding implementation of e-consult systems across many of California’s safety net health care delivery systems. “We have many health care plans that are interested in this process as well, because it improves access to specialty care, particularly in rural areas or in areas where the specialist workforce is limited,” said Dr. Tuot, who is codirector of the UCSF Center for Innovation in Access and Quality at ZSFG. Such efforts are also being promoted by the Public Hospital Redesign and Incentives in Medi-Cal Program (PRIME), which is part of California’s Medicaid waiver. PRIME “is encouraging health systems to look at innovative ways to deliver specialty care,” Dr. Tuot said. “E-consults and other non–face-to-face ways to deliver specialty care, including telemedicine encounters, count toward that metric for the Medicaid waiver.”
At the national level, the Association of American Medical Colleges has collaborated with more than 20 academic medical centers in 14 states, including Dartmouth-Hitchcock and Yale University, to implement tools built into the electronic medical record system through a program known as Project CORE (Coordinating Optimal Referral Experiences). According to Scott Shipman, MD, MPH, director of clinical innovations for the AAMC, nearly all of the current CORE sites have either gone live with the model in rheumatology or are planning to do so. “Better communication and coordination between primary care providers and specialists is important for all specialties, but because of the complexity of evaluation and management of problems in rheumatology, there is a tremendous opportunity for the CORE model to help get providers on the same page,” Dr. Shipman said in an interview. “We do this through simple decision support that we build into the referral order in the EMR, available at the point of care. Additionally, given the workforce challenges facing rheumatology in most regions of the country and consequent access barriers, offloading some of the demand via e-consults holds great promise.” Current focus areas for Project CORE, he said, include continued support of current CORE sites in their implementation and scaling efforts to maximize impact, advocacy to promote payer engagement in support of e-consult reimbursements, and working to extend the model to additional academic medical centers.
Dr. Tuot emphasized that performing e-consults “takes time and effort on behalf of specialists, so if you’re by yourself in solo practice it probably does not make sense to implement,” she said. “You need to spend your time seeing patients as much as possible. For primary care providers who are asking for curbside consults, it’s probably best to have things in writing from the specialist, such as in an e-consult, to make sure there’s no misunderstanding.”
As demand for rheumatology services increases, clinicians “have to figure out a way to see patients in most urgent need of our services,” Dr. Yazdany said. “That requires that we use technology like the e-consult system to prioritize the patients that we’re seeing. As we look at the rheumatology workforce shortage, especially in some geographic regions, it’s going to be absolutely critical. There are some diseases that no other specialists have experience caring for. In those situations, those patients need to get in to see rheumatologists in a timely fashion.”
Paper-based preconsult triage system
At Essentia Health, an integrated health care system with facilities in Minnesota, Wisconsin, and North Dakota, Meghan Scheibe, MD, a rheumatologist, is currently working with a rheumatologist colleague and a registered nurse to implement a paper-based preconsult triage system, “because our wait times have unfortunately skyrocketed,” she said. “We receive a lot of outside referrals from other health care groups and large health care systems that don’t have access to rheumatology.” Currently, the triage system is comprised of a referral note which includes the reason for consultation. Dr. Scheibe and her colleague rank the referral as expedited, intermediate concern, or low priority based on information provided by the referring clinician. “We mark those for our nurse to help schedule, and we let the referring provider know what the wait time is,” Dr. Scheibe said. “Then they have an opportunity to communicate back to us or say, ‘Yes, that’s fine,’ or, ‘I’m really worried about this patient. Could you get her in sooner?’ ”
It’s early in the process, but so far, implementation of the preconsult triage protocol “is allowing us to focus on the consultations on which we can be most impactful and not overwhelm the rheumatology workforce that we have,” she said.
Research reported in the UCSF study was supported by the American College of Rheumatology’s Ephraim P. Engleman Endowed Resident Research Preceptorship and the National Institute of Arthritis and Musculoskeletal and Skin Diseases. None of the sources interviewed for this story reported having relevant financial disclosures.
About 15 years ago, rheumatologists at the University of Colorado School of Medicine, Aurora, implemented a preappointment consult triage system as a way to identify rheumatology patients who require timely evaluation and treatment.
Over time, the endeavor caused some soul searching. They wondered how effective their consult triage system was in identifying all patients with inflammatory rheumatic diseases and in ensuring they were seen promptly. They also wondered about the revenue implications of routine outpatient care of autoimmune and inflammatory rheumatic disease (AIRD) patients, compared with that of non-AIRD patients.
“Hospital leadership is very interested in making sure that all patients have access to specialty care in a timely manner,” said Sterling G. West, MD, one of the study authors who is also professor of medicine at the university. “However, there are not enough rheumatologists to see all patients with rheumatic complaints, and this deficit is likely to get worse. Although all patients with a rheumatic complaint would likely benefit from a rheumatology consultation, it is clear that timely access to rheumatologic care is most beneficial for patients with inflammatory rheumatic diseases to prevent future morbidity and disability.”
Year-long follow-up finds high sensitivity, more revenue
What started out as a quality improvement project morphed into a robust study that was published online July 12, 2018, in Arthritis Care & Research. Using data recorded in the electronic medical record, Dr. West and his colleagues retrospectively reviewed 961 new outpatient rheumatology consults sent during a 9-month period for final diagnosis and revenue generation for routine outpatient care over 1 year following consult review or initial evaluation. The first step of the consult management involves an intake access coordinator, Ryan Goecker, obtaining information about the patient from the referring clinician. Next, one of three experienced rheumatologists at the university – Duane W. Pearson, MD, Christopher C. Striebich, MD, or Jason R. Kolfenbach, MD – reviews the information about the case. “We do request that labs and x-rays be done ahead of time, depending on what the consult question is, so that we have the data to be able to decide whether a patient likely has an inflammatory process that we need to see or not,” Dr. West explained. “It takes somewhere between 5 and 20 minutes per consult. In total, it takes our rheumatologists about 5 hours a week to do the consults. However, even after subtracting the physician time spent screening consults, the time saved by the consult triage system enabled over 200 more time slots per year to be available to see new AIRD patients than would have been possible without the triage system.”
Following review of the data supplied about the case, patients who may have acute inflammatory monoarticular arthritis or some other rheumatologic emergency are seen within 24-48 hours, while consults with a possible AIRD are approved and seen within 1-4 weeks. Priority is given to those with suspected vasculitis, systemic lupus erythematosus, myositis, and disabling inflammatory arthritis. Patients with probable noninflammatory conditions such as osteoarthritis, fibromyalgia, and mechanical low back pain are not scheduled for an in-person visit. “Instead of simply declining the consult, we try to give some direction, or we say, ‘Why don’t you try this, this, and this, sort of a miniconsult,” Dr. West noted. “One of the potential adverse reactions to doing consult triage would be that the referring provider would be upset if we decline their consult. We acknowledge that. But over time we’ve been able to convince them that this is best for all concerned, so that the inflammatory disease group gets in to see us in an appropriate amount of time.”
Of the 961 consults, 673 were scheduled for an in-person AIRD evaluation and 288 consults were not scheduled. Patients were seen an average of 13 days after consult review. Of the 673 approved consults, 597 (89%) came for evaluation. Of these, 357 were diagnosed as having an AIRD, while 240 were diagnosed as having a non-AIRD. Among the patients not scheduled for a rheumatology visit, 128 had 1-year follow-up data, with 6 patients eventually diagnosed as having an AIRD. This translated into a consult triage sensitivity of 98% and a positive predictive value of 60%. “There’s a fair number of people with noninflammatory disease who do get into see us,” Dr. West said. “That has to do with our desire to not be overly rigid. The sensitivity, specificity, and positive predictive value were not quite as high as some people would like to see, but we really weren’t missing people who really needed to be seen.”
In their conservative cost analysis, revenue data for outpatient care was available for 318 of the 357 AIRD patients and 192 of 240 non-AIRD patients. It demonstrated that care of AIRD patients generates 44 times more revenue, compared with non-AIRD patients ($5,877 vs. $134 per patient, respectively; P less than .001).
“Our consult triage protocol appears to be an effective method to assure that patients with inflammatory rheumatic diseases get expedited access to appropriate rheumatologic care,” Dr. West concluded. “Using conservative measures, caring for patients with inflammatory rheumatic diseases results in significantly more revenue generation.” Generalizability of such a protocol to other practice settings depends on the time rheumatologists are willing to commit to it. “That’s the big thing,” he said. “The question comes up, could a nurse or a nurse practitioner learn the skills over time to be able to do efficient consult triage, to free up the doc from that? Yes. I think that’s absolutely possible.”
Going forward, Dr. Pearson and Dr. Kolfenbach, who are authors on the paper, have launched a pilot project in which the rheumatologist is compensated for doing a record review and e-consult on patients not recommended to be seen in the rheumatology clinic. “For consults who do not have inflammatory disease, we can say [to the referring clinician], ‘If we did see them, this is what we would be doing,’ ” Dr. West said. “Sometimes if there are still questions, we’ll say something like, ‘Once you get the results back, let us know and we can look at it again.’ That way they are getting similar compensation as telemedicine and other forms of consultation.”
At the Zuckerberg San Francisco General Hospital (ZSFG), use of a novel electronic consultation and referral system that was implemented in 2007 by University of California, San Francisco, providers continues to thrive for rheumatology and other specialty services. With this electronic system, previously called e-referral, all provider communication is captured in real time and recorded within the electronic health record. In a 2015 article from Arthritis Care & Research, researchers led by Jinoos Yazdany, MD, MPH, reviewed 2,105 e-referrals made between 2008 and 2012 (Arthritis Care Res. 2015;67[8]:1158-63). The main outcome of interest was use of preconsultation exchange, defined as back-and-forth communication between referring and specialty care providers, facilitating triage of referrals, requests for more information, or resolution of questions without a visit. The researchers found that about 25% of e-consults were resolved without a clinic visit, and that the proportion of e-consults undergoing preconsultation exchange increased over time, from 55% in 2008 to 74% in 2011.
“We’ve had situations in which somebody within our hospital system has requested a rheumatology referral but did not realize the urgency of the patients’ clinical signs and symptoms,” Dr. Yazdany, a rheumatologist and health services researcher at UCSF, said in an interview. “E-referrals are often responded to within that day. When we see an e-consult for a young woman with a rash and protein in her urine, a rheumatologist will recognize that is very concerning for a serious diagnosis like lupus of the kidney or systemic vasculitis. In that situation, we would pick up the phone and sometimes even call the patient and have them come to the emergency room for an urgent evaluation. Over the years, there have been many situations in which we’ve been able to intervene much earlier than we otherwise would have. In some cases that early intervention was lifesaving, or at least organ-preserving for the patient.”
Two studies from the early 2000s examined the use of preappointment management in rheumatology (see Arthritis Care Res. 2001;45:295-300 and Arthritis Rheum. 2004;51:253-7), but this is among the first to incorporate use of an electronic medical record to provide real-time exchange between the specialist and the referring provider. Clinicians at UCSF are reimbursed for reviewing e-consults in one of two ways. Those at ZSFG have protected and compensated time for the task, “so it’s basically part of their job to spend a half day a week on e-consults,” Dr. Yazdany said. “The department of public health and our health care system fold that into operational costs. That’s absolutely critical for success. To be done well and thoughtfully, managing consults and referrals takes time. It takes a lot of expertise.” Meanwhile, clinicians at UCSF’s main university hospital receive a small payment for each e-consult they review. “If it’s a complex consult it’s a higher reimbursement,” she said. “If it’s a simple one, it’s slightly less reimbursement, so it’s a fee-for-service model. It’s something that the health system funds, because it creates efficiencies and access for patients.”
Gaining popularity across specialties
Delphine S. Tuot, MD, a nephrologist who directs the ZSFG e-consult system, said that the notion of preconsult triage is gaining popularity in all medical specialties. For example, the Blue Shield of California Foundation is funding implementation of e-consult systems across many of California’s safety net health care delivery systems. “We have many health care plans that are interested in this process as well, because it improves access to specialty care, particularly in rural areas or in areas where the specialist workforce is limited,” said Dr. Tuot, who is codirector of the UCSF Center for Innovation in Access and Quality at ZSFG. Such efforts are also being promoted by the Public Hospital Redesign and Incentives in Medi-Cal Program (PRIME), which is part of California’s Medicaid waiver. PRIME “is encouraging health systems to look at innovative ways to deliver specialty care,” Dr. Tuot said. “E-consults and other non–face-to-face ways to deliver specialty care, including telemedicine encounters, count toward that metric for the Medicaid waiver.”
At the national level, the Association of American Medical Colleges has collaborated with more than 20 academic medical centers in 14 states, including Dartmouth-Hitchcock and Yale University, to implement tools built into the electronic medical record system through a program known as Project CORE (Coordinating Optimal Referral Experiences). According to Scott Shipman, MD, MPH, director of clinical innovations for the AAMC, nearly all of the current CORE sites have either gone live with the model in rheumatology or are planning to do so. “Better communication and coordination between primary care providers and specialists is important for all specialties, but because of the complexity of evaluation and management of problems in rheumatology, there is a tremendous opportunity for the CORE model to help get providers on the same page,” Dr. Shipman said in an interview. “We do this through simple decision support that we build into the referral order in the EMR, available at the point of care. Additionally, given the workforce challenges facing rheumatology in most regions of the country and consequent access barriers, offloading some of the demand via e-consults holds great promise.” Current focus areas for Project CORE, he said, include continued support of current CORE sites in their implementation and scaling efforts to maximize impact, advocacy to promote payer engagement in support of e-consult reimbursements, and working to extend the model to additional academic medical centers.
Dr. Tuot emphasized that performing e-consults “takes time and effort on behalf of specialists, so if you’re by yourself in solo practice it probably does not make sense to implement,” she said. “You need to spend your time seeing patients as much as possible. For primary care providers who are asking for curbside consults, it’s probably best to have things in writing from the specialist, such as in an e-consult, to make sure there’s no misunderstanding.”
As demand for rheumatology services increases, clinicians “have to figure out a way to see patients in most urgent need of our services,” Dr. Yazdany said. “That requires that we use technology like the e-consult system to prioritize the patients that we’re seeing. As we look at the rheumatology workforce shortage, especially in some geographic regions, it’s going to be absolutely critical. There are some diseases that no other specialists have experience caring for. In those situations, those patients need to get in to see rheumatologists in a timely fashion.”
Paper-based preconsult triage system
At Essentia Health, an integrated health care system with facilities in Minnesota, Wisconsin, and North Dakota, Meghan Scheibe, MD, a rheumatologist, is currently working with a rheumatologist colleague and a registered nurse to implement a paper-based preconsult triage system, “because our wait times have unfortunately skyrocketed,” she said. “We receive a lot of outside referrals from other health care groups and large health care systems that don’t have access to rheumatology.” Currently, the triage system is comprised of a referral note which includes the reason for consultation. Dr. Scheibe and her colleague rank the referral as expedited, intermediate concern, or low priority based on information provided by the referring clinician. “We mark those for our nurse to help schedule, and we let the referring provider know what the wait time is,” Dr. Scheibe said. “Then they have an opportunity to communicate back to us or say, ‘Yes, that’s fine,’ or, ‘I’m really worried about this patient. Could you get her in sooner?’ ”
It’s early in the process, but so far, implementation of the preconsult triage protocol “is allowing us to focus on the consultations on which we can be most impactful and not overwhelm the rheumatology workforce that we have,” she said.
Research reported in the UCSF study was supported by the American College of Rheumatology’s Ephraim P. Engleman Endowed Resident Research Preceptorship and the National Institute of Arthritis and Musculoskeletal and Skin Diseases. None of the sources interviewed for this story reported having relevant financial disclosures.
About 15 years ago, rheumatologists at the University of Colorado School of Medicine, Aurora, implemented a preappointment consult triage system as a way to identify rheumatology patients who require timely evaluation and treatment.
Over time, the endeavor caused some soul searching. They wondered how effective their consult triage system was in identifying all patients with inflammatory rheumatic diseases and in ensuring they were seen promptly. They also wondered about the revenue implications of routine outpatient care of autoimmune and inflammatory rheumatic disease (AIRD) patients, compared with that of non-AIRD patients.
“Hospital leadership is very interested in making sure that all patients have access to specialty care in a timely manner,” said Sterling G. West, MD, one of the study authors who is also professor of medicine at the university. “However, there are not enough rheumatologists to see all patients with rheumatic complaints, and this deficit is likely to get worse. Although all patients with a rheumatic complaint would likely benefit from a rheumatology consultation, it is clear that timely access to rheumatologic care is most beneficial for patients with inflammatory rheumatic diseases to prevent future morbidity and disability.”
Year-long follow-up finds high sensitivity, more revenue
What started out as a quality improvement project morphed into a robust study that was published online July 12, 2018, in Arthritis Care & Research. Using data recorded in the electronic medical record, Dr. West and his colleagues retrospectively reviewed 961 new outpatient rheumatology consults sent during a 9-month period for final diagnosis and revenue generation for routine outpatient care over 1 year following consult review or initial evaluation. The first step of the consult management involves an intake access coordinator, Ryan Goecker, obtaining information about the patient from the referring clinician. Next, one of three experienced rheumatologists at the university – Duane W. Pearson, MD, Christopher C. Striebich, MD, or Jason R. Kolfenbach, MD – reviews the information about the case. “We do request that labs and x-rays be done ahead of time, depending on what the consult question is, so that we have the data to be able to decide whether a patient likely has an inflammatory process that we need to see or not,” Dr. West explained. “It takes somewhere between 5 and 20 minutes per consult. In total, it takes our rheumatologists about 5 hours a week to do the consults. However, even after subtracting the physician time spent screening consults, the time saved by the consult triage system enabled over 200 more time slots per year to be available to see new AIRD patients than would have been possible without the triage system.”
Following review of the data supplied about the case, patients who may have acute inflammatory monoarticular arthritis or some other rheumatologic emergency are seen within 24-48 hours, while consults with a possible AIRD are approved and seen within 1-4 weeks. Priority is given to those with suspected vasculitis, systemic lupus erythematosus, myositis, and disabling inflammatory arthritis. Patients with probable noninflammatory conditions such as osteoarthritis, fibromyalgia, and mechanical low back pain are not scheduled for an in-person visit. “Instead of simply declining the consult, we try to give some direction, or we say, ‘Why don’t you try this, this, and this, sort of a miniconsult,” Dr. West noted. “One of the potential adverse reactions to doing consult triage would be that the referring provider would be upset if we decline their consult. We acknowledge that. But over time we’ve been able to convince them that this is best for all concerned, so that the inflammatory disease group gets in to see us in an appropriate amount of time.”
Of the 961 consults, 673 were scheduled for an in-person AIRD evaluation and 288 consults were not scheduled. Patients were seen an average of 13 days after consult review. Of the 673 approved consults, 597 (89%) came for evaluation. Of these, 357 were diagnosed as having an AIRD, while 240 were diagnosed as having a non-AIRD. Among the patients not scheduled for a rheumatology visit, 128 had 1-year follow-up data, with 6 patients eventually diagnosed as having an AIRD. This translated into a consult triage sensitivity of 98% and a positive predictive value of 60%. “There’s a fair number of people with noninflammatory disease who do get into see us,” Dr. West said. “That has to do with our desire to not be overly rigid. The sensitivity, specificity, and positive predictive value were not quite as high as some people would like to see, but we really weren’t missing people who really needed to be seen.”
In their conservative cost analysis, revenue data for outpatient care was available for 318 of the 357 AIRD patients and 192 of 240 non-AIRD patients. It demonstrated that care of AIRD patients generates 44 times more revenue, compared with non-AIRD patients ($5,877 vs. $134 per patient, respectively; P less than .001).
“Our consult triage protocol appears to be an effective method to assure that patients with inflammatory rheumatic diseases get expedited access to appropriate rheumatologic care,” Dr. West concluded. “Using conservative measures, caring for patients with inflammatory rheumatic diseases results in significantly more revenue generation.” Generalizability of such a protocol to other practice settings depends on the time rheumatologists are willing to commit to it. “That’s the big thing,” he said. “The question comes up, could a nurse or a nurse practitioner learn the skills over time to be able to do efficient consult triage, to free up the doc from that? Yes. I think that’s absolutely possible.”
Going forward, Dr. Pearson and Dr. Kolfenbach, who are authors on the paper, have launched a pilot project in which the rheumatologist is compensated for doing a record review and e-consult on patients not recommended to be seen in the rheumatology clinic. “For consults who do not have inflammatory disease, we can say [to the referring clinician], ‘If we did see them, this is what we would be doing,’ ” Dr. West said. “Sometimes if there are still questions, we’ll say something like, ‘Once you get the results back, let us know and we can look at it again.’ That way they are getting similar compensation as telemedicine and other forms of consultation.”
At the Zuckerberg San Francisco General Hospital (ZSFG), use of a novel electronic consultation and referral system that was implemented in 2007 by University of California, San Francisco, providers continues to thrive for rheumatology and other specialty services. With this electronic system, previously called e-referral, all provider communication is captured in real time and recorded within the electronic health record. In a 2015 article from Arthritis Care & Research, researchers led by Jinoos Yazdany, MD, MPH, reviewed 2,105 e-referrals made between 2008 and 2012 (Arthritis Care Res. 2015;67[8]:1158-63). The main outcome of interest was use of preconsultation exchange, defined as back-and-forth communication between referring and specialty care providers, facilitating triage of referrals, requests for more information, or resolution of questions without a visit. The researchers found that about 25% of e-consults were resolved without a clinic visit, and that the proportion of e-consults undergoing preconsultation exchange increased over time, from 55% in 2008 to 74% in 2011.
“We’ve had situations in which somebody within our hospital system has requested a rheumatology referral but did not realize the urgency of the patients’ clinical signs and symptoms,” Dr. Yazdany, a rheumatologist and health services researcher at UCSF, said in an interview. “E-referrals are often responded to within that day. When we see an e-consult for a young woman with a rash and protein in her urine, a rheumatologist will recognize that is very concerning for a serious diagnosis like lupus of the kidney or systemic vasculitis. In that situation, we would pick up the phone and sometimes even call the patient and have them come to the emergency room for an urgent evaluation. Over the years, there have been many situations in which we’ve been able to intervene much earlier than we otherwise would have. In some cases that early intervention was lifesaving, or at least organ-preserving for the patient.”
Two studies from the early 2000s examined the use of preappointment management in rheumatology (see Arthritis Care Res. 2001;45:295-300 and Arthritis Rheum. 2004;51:253-7), but this is among the first to incorporate use of an electronic medical record to provide real-time exchange between the specialist and the referring provider. Clinicians at UCSF are reimbursed for reviewing e-consults in one of two ways. Those at ZSFG have protected and compensated time for the task, “so it’s basically part of their job to spend a half day a week on e-consults,” Dr. Yazdany said. “The department of public health and our health care system fold that into operational costs. That’s absolutely critical for success. To be done well and thoughtfully, managing consults and referrals takes time. It takes a lot of expertise.” Meanwhile, clinicians at UCSF’s main university hospital receive a small payment for each e-consult they review. “If it’s a complex consult it’s a higher reimbursement,” she said. “If it’s a simple one, it’s slightly less reimbursement, so it’s a fee-for-service model. It’s something that the health system funds, because it creates efficiencies and access for patients.”
Gaining popularity across specialties
Delphine S. Tuot, MD, a nephrologist who directs the ZSFG e-consult system, said that the notion of preconsult triage is gaining popularity in all medical specialties. For example, the Blue Shield of California Foundation is funding implementation of e-consult systems across many of California’s safety net health care delivery systems. “We have many health care plans that are interested in this process as well, because it improves access to specialty care, particularly in rural areas or in areas where the specialist workforce is limited,” said Dr. Tuot, who is codirector of the UCSF Center for Innovation in Access and Quality at ZSFG. Such efforts are also being promoted by the Public Hospital Redesign and Incentives in Medi-Cal Program (PRIME), which is part of California’s Medicaid waiver. PRIME “is encouraging health systems to look at innovative ways to deliver specialty care,” Dr. Tuot said. “E-consults and other non–face-to-face ways to deliver specialty care, including telemedicine encounters, count toward that metric for the Medicaid waiver.”
At the national level, the Association of American Medical Colleges has collaborated with more than 20 academic medical centers in 14 states, including Dartmouth-Hitchcock and Yale University, to implement tools built into the electronic medical record system through a program known as Project CORE (Coordinating Optimal Referral Experiences). According to Scott Shipman, MD, MPH, director of clinical innovations for the AAMC, nearly all of the current CORE sites have either gone live with the model in rheumatology or are planning to do so. “Better communication and coordination between primary care providers and specialists is important for all specialties, but because of the complexity of evaluation and management of problems in rheumatology, there is a tremendous opportunity for the CORE model to help get providers on the same page,” Dr. Shipman said in an interview. “We do this through simple decision support that we build into the referral order in the EMR, available at the point of care. Additionally, given the workforce challenges facing rheumatology in most regions of the country and consequent access barriers, offloading some of the demand via e-consults holds great promise.” Current focus areas for Project CORE, he said, include continued support of current CORE sites in their implementation and scaling efforts to maximize impact, advocacy to promote payer engagement in support of e-consult reimbursements, and working to extend the model to additional academic medical centers.
Dr. Tuot emphasized that performing e-consults “takes time and effort on behalf of specialists, so if you’re by yourself in solo practice it probably does not make sense to implement,” she said. “You need to spend your time seeing patients as much as possible. For primary care providers who are asking for curbside consults, it’s probably best to have things in writing from the specialist, such as in an e-consult, to make sure there’s no misunderstanding.”
As demand for rheumatology services increases, clinicians “have to figure out a way to see patients in most urgent need of our services,” Dr. Yazdany said. “That requires that we use technology like the e-consult system to prioritize the patients that we’re seeing. As we look at the rheumatology workforce shortage, especially in some geographic regions, it’s going to be absolutely critical. There are some diseases that no other specialists have experience caring for. In those situations, those patients need to get in to see rheumatologists in a timely fashion.”
Paper-based preconsult triage system
At Essentia Health, an integrated health care system with facilities in Minnesota, Wisconsin, and North Dakota, Meghan Scheibe, MD, a rheumatologist, is currently working with a rheumatologist colleague and a registered nurse to implement a paper-based preconsult triage system, “because our wait times have unfortunately skyrocketed,” she said. “We receive a lot of outside referrals from other health care groups and large health care systems that don’t have access to rheumatology.” Currently, the triage system is comprised of a referral note which includes the reason for consultation. Dr. Scheibe and her colleague rank the referral as expedited, intermediate concern, or low priority based on information provided by the referring clinician. “We mark those for our nurse to help schedule, and we let the referring provider know what the wait time is,” Dr. Scheibe said. “Then they have an opportunity to communicate back to us or say, ‘Yes, that’s fine,’ or, ‘I’m really worried about this patient. Could you get her in sooner?’ ”
It’s early in the process, but so far, implementation of the preconsult triage protocol “is allowing us to focus on the consultations on which we can be most impactful and not overwhelm the rheumatology workforce that we have,” she said.
Research reported in the UCSF study was supported by the American College of Rheumatology’s Ephraim P. Engleman Endowed Resident Research Preceptorship and the National Institute of Arthritis and Musculoskeletal and Skin Diseases. None of the sources interviewed for this story reported having relevant financial disclosures.
