Los Angeles County Finds E-Success In Managing Specialist Care

An electronic program launched in 2012 by Los Angeles County’s health care system has reduced wait times for specialty care and eliminated the need for some safety-net patients to see specialists at all, according to a new study in the journal Health Affairs.

The program, eConsult, allows primary care doctors to get specialists’ advice for their patients and expedite referrals for those who need in-person appointments. About a quarter of the requests included in the study were resolved without patients needing to see an advanced-care doctor, though there was variation among the specialties.

“It completely changed how specialty care was delivered in a safety net system,” said Michael Barnett, an assistant professor of health policy and management at Harvard T.H. Chan School of Public Health and lead author of the study.

The Los Angeles County Department of Health Services provides care for about 670,000 patients each year in a system that includes four hospitals, 19 health centers and dozens of community providers. The system serves a low-income population — mostly uninsured or covered by Medi-Cal — who traditionally have had difficulty getting access to specialty care.

The eConsult system handles over 17,000 requests each month. About 4,500 providers from more than 400 clinics use the system, according to the county. In 2016, the program served about 130,000 patients.

One of the major benefits of the eConsult system is that it centralizes requests for care from specialists such as cardiologists, neurologists or gynecologists, Barnett said.

Primary care doctors using eConsult have access to a secure, web-based portal to make requests for assistance from specialists. A specialist “reviewer” responds and helps the primary care physician decide how best to manage the patient’s condition.

That may mean giving advice, suggesting a specific treatment or recommending the patient see a specialist. If a patient needs a visit right away, the system allows for an expedited appointment.

In many cases, primary care doctors can resolve clinical issues with their patients simply by having a conversation, Barnett said. “Many referrals are for issues that could be resolved pretty easily if a primary care doctor could get a specialist’s attention,” he said.

That means those patients wouldn’t need to take another day off work, figure out transportation across town and wait to see a specialist, said Paul Giboney, director of specialty care for the Los Angeles County Department of Health Services. Instead, the care could be delivered in the offices of their primary care doctors.

About 30 percent of patients who needed a face-to-face visit with a specialist in 2015 were able to get one within 30 days, up from 24 percent in 2014.

Difficulty getting appointments with specialists is a challenge for low-income patients across the United States. Without timely access, patients may get sicker and turn to the emergency room for care.

That was happening on a large scale in L.A. County before the implementation of the eConsult program. Some patients had to wait more than nine months for an appointment with a urologist or a gastroenterologist, for example, the study said.

The eConsult program started as an experiment to reduce the backlog, but Giboney said the county’s public health care system is now using it “day in and day out.”

Despite the size and complexity of the Los Angeles County health care system, the eConsult program works efficiently, suggesting that “specialty access is not an intractable problem,” the study said.

Giboney said the results show that electronic conversations between primary care doctors and specialists can improve the way business is done.

“Within a day, the specialist is already engaged and adding something to the patient’s care,” he said. “We are a public system that is delivering a speed of specialty care that is really unmatched.”

Since eConsult was rolled out in L.A. County, Giboney said he has talked to providers from Colorado, Illinois and Connecticut about starting similar programs.

Despite the efficiency of the system, Barnett said, there is still room for improvement on the wait times. The average amount of time it took for a patient to see a specialist in 2015 was still 52 days, though it had dropped about 17 percent from 63 days in 2014.

Patients who needed ear, nose and throat doctors and those who had kidney problems, cancer or blood diseases saw the most dramatic reductions in waiting time. The wait to see an ear, nose and throat specialist, for example, dropped from 72 to 44 days.

Wait times increased in only one of the dozen specialties examined: Patients had to wait on average 75 days in 2015 to see a podiatrist, up from 65 the previous year.

Barnett said the next step is to study the impact of the program on quality of care.

Giboney said he isn’t satisfied with the wait times either, despite the reduction, but he noted that sometimes doctors want patients to wait a few weeks to see if a treatment is working before going to see a specialist.

“It is not always about reducing the wait time,” Giboney said. “It’s about delivering the right specialty care at the right time.”

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

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