Editor’s note: The federal government’s Beacon Program provides funding to 17 communities that have already made inroads in the development of secure, private, and accurate systems of electronic health record (EHR) adoption and health information exchange. This is the fourth in a series of Health Affairs Blog posts in which leaders of several Beacon communities discuss their experiences over the first year of the program. Earlier posts in the series were authored by leaders of the Central Indiana, Colorado, SE Minnesota, and Inland NW Beacon community. The Beacon program’s first year was also the topic of a May 17 Washington D.C. event sponsored by the Office of the National Coordinator for Health Information Technology (ONC) and the Engelberg Center for Health Care Reform at the Brookings Institution, and a Twitter chat on Wednesday May 18 hosted by ONC’s Aaron McKethan.
Social networking came to medicine twelve years ago, long before Facebook, Twitter, LinkedIn, and MySpace (remember that one?). In April of 1999, we completed the first version of Doc2Doc, a secure, web-based tool for managing patient referrals, consultations and other care transitions. This launched a decade-long effort to evaluate the care transition process and structure workflows and tools to optimize this complex activity. Along the way, hundreds of thousands of patient care transitions have been managed by Doc2Doc across multiple populations, and tens of thousands of shared care plans have been developed by doctors working collaboratively in this online environment.
With the launch of MyHealth Access Network, the Tulsa Beacon program, the Doc2Doc system is now hitting its full stride as it is used to coordinate care across an entire region. Altogether, the Tulsa Doc2Doc implementation has managed nearly 70,000 care transitions for patients from 44 counties in four states. Doc2Doc connects over 1,100 endpoints in the Tulsa region, including many clinics and providers who are competitors in any other setting.
Tulsa’s Beacon Strategy
The Tulsa Beacon community program is built on three major activities which work together to create a virtuous cycle of health improvement, as shown in the graphic below.
The aggregation of community-wide health data into our health information exchange provides the comprehensive clinical information required to assess current health status and support the next activity. In the second activity, clinical decision support provided by advanced tools like the Archimedes Model help to identify patients with opportunities for care improvement or risk reduction. These identified care gaps and risks are brought to the attention of the providers via the MyHealth health information exchange portal and secure messages delivered directly to the providers. Finally, in the third activity, care coordination tools like Doc2Doc enable doctors and other healthcare providers to take the most important next steps for each patient immediately.
The Care Transition Challenge
Care transitions are a relatively recent focus of healthcare economists and policymakers. This makes good sense, financially and clinically, since failed care transitions result in readmissions, missed appointments, and failed care plans—all of which drive up costs and reduce quality of life.
Typically, the term “care transition” has been used to describe the transition of patients from the inpatient setting to home or long-term care. We have adopted a much broader definition of the term—care transitions in the Tulsa Beacon community include any movement of a patient from one care provider or level of care to another. Thus, our focus on care transitions means that patient referrals from primary care providers (PCPs) to specialists, from emergency departments to PCPs, from doctors to home health, and from inpatient settings to long-term care are all included in the scope of our project. The Doc2Doc platform is used to initiate and manage patient care transitions through to completion, and can do so securely from any “point A” to any “point B”.
The initial development of the Doc2Doc system over a decade ago was driven by the recognition of significant problems in care coordination and especially with care transitions. Contributing factors seemed to be:
- Relationships between PCPs and specialists have eroded as they practice in different physical settings, experience increasingly divergent specialization (as well as compensation), and generally have very little occasion to interact with one another professionally.
- Volume drives workflows on both sides of a care transition, making the once common practice of the “curbside consult” a very rare event.
- Efforts by payers to control costs and utilization have resulted in increasingly complex algorithms and pathways for obtaining referral authorizations. As the complexity of and time required for this uncompensated activity has grown, the work of managing referrals has typically shifted to non-clinical administrative personnel.
- A multi-clinic evaluation of referral processes revealed very little standardization, and even those clinics with an electronic health record were converting referrals to paper which had to be faxed, stacked, tracked and managed by hand.
- Specialists all want to practice “at the top of their license”—and most specialists will admit frustration with being referred patients which could have been managed by the PCP with minimal guidance.
- Similarly, most specialists can recall patients that they wished had been referred sooner, or with a specific workup already completed.
- On the other hand, referring physicians have complained that they do not hear back from the specialist about the end result of the visit, and occasionally are surprised when the specialist manages a different problem or issue than was intended—sometimes taking over the care of the patient altogether.
- Overall, there has been no effective way to monitor quality surrounding care transitions or to provide feedback if the performance and quality had been measurable.
Many of these observations, made over a decade ago, were validated by a recent Milbank Quarterly report called “Dropping the Baton” which reviewed the literature on care transitions from primary care to specialty care.
In response to these observations, the Doc2Doc system was created to reconnect providers on both ends of care transitions to ensure effective coordination and exchange of knowledge. Later, as the administrative complexity of the care transition process became clear, a structured method for referral management was implemented to ensure clean handoffs from one organization to another and to create a detailed log of the actions taken. These action logs are used to monitor quality and support quality improvement activities.
Below are two cases taken from the Doc2Doc system which are illustrative of the importance of provider to provider communications.
Case 1: Improved access for routine transitions. A PCP saw a child with strange fingernail pigmentation and decided to get the pediatric dermatologist involved. Using a smart phone, several photos of the concerning rash were taken and the pediatrician entered the following request, complete with photos:
AA PATIENT, OF WHICH MOM HAS NOTED HER FINGERNAILS TO BE BLACK COLOR, WITH SOME STREAKING AND PEELING
HER TOE NAILS ALSO ARE STARTING TO TURN BLACK IN COLOR ON HER BIG TOE
MOM WAS CONCERNED SHE HAD A FUNGUS, HOWEVER IT DOES NOT LOOK TO BE FUNGUS IN ORIGIN
PMH: HEALTHY PT , NO PROBLEMS
The pediatric dermatologist (we only have one in our community) was notified immediately and reviewed the case within 10 hours, replying:
Post inflammatory hyperpigmentation. Reevaluate in 6 months. Use petrolatum to nail folds. If worsens, please refer
The PCP accepted this plan and contacted the mom directly to convey the plan and reassure her that everything was under control.
By itself, this case is not remarkable. However, a consideration of the implications of NOT having this interaction reveals:
- Medicaid patients in our community generally wait 9-12 months for a pediatric dermatology visit.
- Dermatologists are only able to schedule 60 days out—meaning that this patient will wait at least 7 months just to get a scheduled date.
- Moms (and dads) worry about their kids, and in the long interim between the promise of a dermatology visit and the actual visit, they may try different remedies with varying degrees of success or harm.
- Frustrated with the long wait, the patient may present to an urgent care, emergency room, or worst of all, change PCPs, driving unnecessary costs and inconvenience on everyone’s part.
Instead, this simple interaction enabled the PCP to remain an active participant in the specialty consultation as well as maintain the communication pathway to the patient. This results in a tighter connection between the patient and the patient-centered medical home, and enables the specialist to intervene with advice and procedures at the top of their license as needed.
Case 2: Differing perceptions of urgency. A PCP saw a child with a slightly divergent gaze and decided to refer to ophthalmology for a routine eye exam, with a requested timeframe of 6-9 weeks.
subtle esotropia of right eye on exam today. acute complaint was unrelated to vision. per mom pt’s older sibling has a history of “lazy eye”
Again, within hours the ophthalmologist received and reviewed the case, responded thusly:
Definitely needs exam soon. Sibling history of lazy eye greatly increases this 3 year old’s risk of strabismus. Subtle esotropia at age 3 certainly warrants exam. Thanks.
Further the ophthalmologist adjusted the timeframe for the visit down to “next day” and checked the box indicating to his appointment scheduler that he was willing to overbook the patient in order to get him seen.
This case demonstrates the importance of providing PCPs with better access to specialty care providers. In addition, this case exemplifies the effect that a direct feedback loop can have on helping PCP’s to elevate their level of practice and incorporate new knowledge into their management of patients. It’s highly unlikely that this PCP will miss the urgency of this situation ever again.
On the point of using this tool to create a learning healthcare system, Dr. David Adelson, a Dermatologist and frequent user of the Doc2Doc system offered the following:
It seems that the clinicians who are using Doc2Doc most regularly have improved their clinical skills. Now most of the patients are put on appropriate first line and even second line therapy and only when these fail am I consulted.
These cases are taken from a single day in May of 2008. Since then thousands of other similar cases in adults and children have received a shared care plan negotiated by physicians working together as a team. The effects on the relationships between providers, the timeliness of visits, and the overall utilization of care have been remarkable.
Issues remain, however. In order to perpetuate this model as a sustainable activity (beyond a research or study period), a reimbursement model must be identified that rewards providers for taking this extra step to ensure that the care utilization is necessary and appropriate. This is a current focus of our Beacon community effort and good progress is being made.
So, we are now in the process of expanding the use of the Doc2Doc platform for managing care transitions. Other receiving entities, such as physical therapy, home health, diagnostic imaging centers, and patient education have all been incorporated. We are expanding into emergency rooms and urgent care centers so patients can be referred directly back to their existing PCPs (or a new PCP if they lack one), altering the PCP immediately of the ER visit and also providing the ER with a connection to the patient and PCP that will enable them to monitor to be sure the patient completed the recommended follow-up.
This approach to managing care transitions appears to work well, across a variety of communities, care settings, and clinical conditions. Over the last decade, we have gathered significant data and rigorously evaluated this approach. Now we will leverage this capability to more broadly to improve care in the Tulsa region and meet our Beacon objectives for health and access improvement.