A pilot electronic consulting project between two primary care practices and the Duke Division of Rheumatology and Immunology accelerated scheduling for patients with acute conditions and streamlined communications between the practices and specialists.

Using electronic health records (EHRs), primary care physicians referred patients who were considered candidates for rheumatology assessment. On-call rheumatologists reviewed the records within 48 hours to determine whether a face-to-face consultation with a rheumatologist was needed. If so, the patient was scheduled using the rheumatology division’s internal process.

Patients with acute conditions, such as rheumatoid arthritis presenting with vasculitis, often received appointments within two weeks. A typical appointment without EHR review required more time to schedule. Patients with non-urgent conditions often wait longer for an appointment with a Duke rheumatologist.  

To help address this challenge, a 12-week pilot, known as the “eCommunication” or electronic communication project, was organized as part of the gradual expansion of electronic consulting partnerships to additional primary care practices. The rheumatology division has embraced the model for further expansion.

Kevin P. Shah, MD, MBA, an internist and medical director for Duke Primary Care Improvement and Innovation, says the rheumatology project is one of several being tested within Duke Health. A successful trial within nephrology has prompted Duke cardiologists, endocrinologists, and geriatricians to explore the electronic consulting system.  

Duke rheumatologist Robert T. Keenan, MD, MPH, MBA, vice chief for clinical affairs for the Rheumatology Division, worked with Shah to plan and execute the consulting project. “This definitely improved access in getting the right patients the right kind of care in an appropriate timeframe,” Keenan says. “Because we were able to identify patients who had evidence of disease, it improved the efficiency of the referral process.”

Traditional referrals often fail to generate follow-up visits, practice experts acknowledge. “Particularly within rheumatology, the referral process can be a waste of time and money for patients when a referral to a specialist is neither necessary nor appropriate,” Keenan says. 

A key design feature of the pilot, Keenan says, was a requirement that the primary care practices use the eCommunication process for all rheumatology referrals. Primary care physicians were not permitted to follow the traditional referral practices.

“Both the primary care providers and the rheumatologists saw this as win-win,” Keenan says. “As everyone becomes more experienced, the efficiency will improve.”