Duke Health’s electronic consulting (eConsult) initiative, launched in 2018 as a pilot project with a single nephrologist reviewing EHRs, has played a key role during the COVID-19 pandemic by enabling safe, timely telehealth options. The program’s coronavirus response was made possible by a recent expansion offering digital consulting to multiple specialties across all of Duke’s primary care clinics.
“Duke Health has temporarily broadened the use of eConsults to help expand support to primary care providers and patients across a wider array of specialties,” says Kevin P. Shah, MD, MBA, associate chief medical officer, Duke Primary Care, and an early advocate of eConsult. “As North Carolina gradually opens, eConsults have the potential to help Duke meet a likely pent up demand for specialty care.”
During the promising pilot project, eConsult reduced referral delays and improved collaboration between nephrologists and PCPs. The pilot was considered a successful test of feasibility, but concerns lingered about system-wide access, scalability, and PCP involvement.
The PCP participation question has been answered by the continuing growth of eConsult within the divisions of Endocrinology and Metabolism and Rheumatology and Immunology. The partnerships between specialists and PCPs have reduced referral times by 25%, improved patient care, and created more efficient care delivery, participants say.
“We now have a system that allows us to intelligently triage every referral with a professional review,” says C. Blake Cameron, MD, MBI, co-director for access for the Duke Department of Medicine and medical director for kidney care at Duke Connected Care, a physician-led, clinically-integrated network that helps improve the quality of health care while addressing rising costs. “Patients who need urgent consults get to the specialists much more quickly with eConsult. We are also avoiding those visits when they are not necessary by working closely with PCPs.”
In addition to reducing referral delays, participants say one of the most important successes has been improved partnerships between specialists and PCPs. Referral processes vary dramatically, Cameron says. “Many of our PCPs do not have a great way to interact with specialists,” he says. “It’s usually a binary approach—either they refer, or they don’t. The optimal spot is somewhere in the middle.”
Brian A. Shaner, MD, a Duke family medicine physician who has had experience as a practice medical director, says specialist interactions have been productive. “Physicians participating in eConsults are now managing more complex cases because of the involvement with the specialist,” Shaner says. “But when a referral is necessary, we go directly to the nephrologist with a more packaged, worked-up case. Patients do not have to wait for a specialist visit to get evaluations that I can perform in my clinic."
The future of scalability is harder to assess, Shah says. “Scaling raises a whole new set of questions around operations, financing, and growth far from Durham that require new solutions and planning,” Shah says. “It won’t be as simple as ‘flipping a switch.’”
But he acknowledges that eConsult demonstrates progress as physicians move away from an old way of executing a transaction—the traditional referral—to the new eConsult approach. “Primary care physicians are now improving care for their patients by building partnerships,” Shah says. “We clearly see that PCPs learn with each eConsult. The next time, they improve the process. Our hope is that in a scaled model we could measure this effectively.”
