Dr. Paul Giboney shares his experiences implementing eConsult LA, a program that has transformed healthcare delivery for patients in Los Angeles.
Los Angeles County is home to over 10 million residents and 3.2 million households. In 2012, the Los Angeles County Department of Health Services (LACDHS), in partnership with LA Care Health Plan, Health Care LA IPA, MedPoint Management, the Community Clinic Association of Los Angeles County and SafetyNetConnect, Inc. introduced the eConsult program to transform the manner in which patients obtain specialty care services. eConsult allows providers at LACDHS operated clinics and community-based clinics to communicate with clinical specialists via an online platform, avoiding the need for unnecessary specialty visits and improving coordination between primary and specialty care. As the department’s Director of Specialty Care, Dr. Paul Giboney has helped develop the eConsult program into a county-wide endeavor to drastically improve care delivery. He shares the inspiration for the innovative program as well as the challenges and successes experienced as part of its implementation.
Can you tell us about your role at the Los Angeles County Department of Health Services (LACDHS)?
My formal title is the Director of Specialty Care. In that role I have the responsibility for improving the way we deliver specialty care across our very large network. LACDHS is the second largest public health system in the United States. We see over 600,000 unique patients every year and operate 4 hospitals and about 20 outpatient clinics of various sizes. I’ve been tasked to develop any number of tools in order to improve the quality, effectiveness and timeliness of the specialty care we deliver.
What inspired the LACDHS to partner with LA Care to create the “eConsult” program?
The Department of Health Services, like other large agencies, has historically struggled with a few things. One challenge was that we were a fragmented system, a siloed system typical of large governmental agencies. We had hospitals and clinics and none of them coordinated together. You would have huge variations in wait times and variations in how they delivered specialty care. You would have services that were available in one geography in the county but not available in other geographies. You had different processes in place for accessing those services. Sometimes it was mail or fax, or an electronic one-way submission platform. Sometimes it was even a piece of paper traveling down a hallway and sitting in an inbox somewhere. We also had 6 different electronic health records in our system, all of which were deployed differently and had different medical record numbers. Basically we had a horribly dysfunctional specialty care process that was impossible to monitor. We had very long wait times, as much as 6 to 9 months in some of our specialties. Some issues never got addressed at all. And so in that context, we implemented eConsult. The idea originated with our Chief Medical Officer, Dr. Hal Yee, who in 2005 was the originator of the concept. He had implemented it successfully in San Francisco and when he joined LACDHS in 2011 he wanted to see it done here. At my previous role at Community Health Center, back in 2009, I had done a very small project with LACDHS on eConsult work and when I joined the department in late 2011, Hal Yee and I decided that this was something that we needed to do and we leapt right in.
What was the implementation journey like?
It was actually an amazing project and a great opportunity for our system to learn how to collaborate more and to become a truly integrated delivery network - breaking down those silos and walls. Initially the project was a collaboration with our local Medicaid health plan called LA Care. They provided some seed funding and we partnered with them for the first year and a half of the project before their involvement in the LACDHS side of the project ended. We then took on the project on our own. We took a step-wise approach. We very methodically added specialties and sites to the system. Our first eConsult was submitted July 18th, 2012, and at that time we only had 2 submitting sites and only 2 specialties, Dermatology and Neurology. Over the next 2 years, we continued to roll out eConsult to all of the pieces of our very large network. Not only do we have submitters in our 4 medical centers and all of our outpatient facilities but we also brought on the physicians in our correctional facilities, public health clinics, juvenile court health clinics and a large network of community clinics that are private non-profit federally-qualified health centers. All in all, it adds up to over 400 unique submitting locations across the county and over 4,500 providers submitting eConsults. As far as we know this is the largest implementation of its kind in the United States.
Did you face challenges along the way?
The challenges that you face in any eConsult implementation are multi-faceted so we really used a lot of different approaches to target those obstacles. One challenge is getting people to think about specialty care differently. For many, specialty care is not delivered until a patient gets some sort of request approved, which gets scheduled. The patient then takes off time from work, takes 2 buses across town, sits inside a waiting room and then finally meets inside an exam room with the specialist and gets their “specialty care.” We blew up that concept of delivery of specialty care because it’s our belief that when the primary care doctor and the specialist begin that conversation on eConsult, specialty care has already started. The specialist is bringing value into the care of that patient the moment they respond to an eConsult. Many times we’ve found that this delivery of specialty care is all the patient needs. They don’t need to go to the hospital to see a specialist face-to-face, they’ve already got that value-added specialty expertise in their primary medical home context. Helping people to think about care delivery differently is for both parties - the primary care provider and the specialist. Another major challenge was breaking down the fragmentation and high degree of variability in our system. Before any specialty could go live on eConsult, we convened a workgroup of individuals representing the totality of our system. For example, if we were getting ready to launch in Cardiology, we would create a workgroup that would include Cardiology representatives from each of the areas of our large network that provide cardiology services as well as some primary care doctors and we build what we call a primary-specialty care workgroup. It was only when that workgroup together agreed on their common approach to launching an eConsult portal in Cardiology, that we would turn it on. So when we turned on Cardiology, it was immediately available to all the submitters who had been onboarded to eConsult up to that point. It was not rolled out in one cluster or one facility or one service line. That was a big challenge as a lot of people wanted to try it out or they wanted to pilot it. But we said “No pilots, we threw our shoes over the creek” on this. It was almost algorithmic growth. Over that two-year period of implementation, we built work groups, added specialties, added submitters and our volume grew greatly. We are now currently doing about 18,000 eConsults every month. We just hit the 500,000 eConsult mark since we started the program. That was one of the challenges we had to face: how do we break down silos and reduce variability across the system? Another challenge was getting buy-in. We have seen a lot of eConsult implementations around the United States where eConsult is one of several different ways to access specialty care. Deciding that eConsult represented such high value but recognizing that it was such a disruptive innovation, we made it mandatory. There is now no other way to get non-urgent, non-emergent outpatient specialty care services in our system except through eConsult.
You have conducted extensive research on “variation in clinical practice.” Do you think eConsults have the potential to reduce this variability?
At the heart of it, eConsult has absolutely nothing to do with technology. The technology is the easy part - it’s just getting people to talk. A successful eConsult implementation is about the process of getting people to collaborate and own it. The secret sauce to our implementation is not the platform, it is our primary - specialty care workgroups. When we convened primary - specialty care workgroups, they would have to hash out all the details pertinent to their specialty. They would have to decide what kind of information they would have up on eConsult to review and how they were going to maintain all of their principles in a successful implementation. By the time the specialty goes live, the group owns it and they’re invested in it. It’s not a top-down process. Certainly Hal and I laid out some ground rules. We laid out some principles that were not to be violated. But in general, each primary - specialty care workgroup launched an eConsult portal that was their own. In the process of doing this, we asked our workgroups to also design “Expected Practices.” For many clinical presentations, they asked “What is our usual approach to that problem and how does that usual approach impact our delivery of care?” For example, “Here’s our usual approach towards dizziness.” Or “here’s our usual approach to heart murmur evaluation.” Because these are the types of conversations that you’re constantly having on eConsult. The Expected Practices are housed in our Clinical Care Library. Our Clinical Care Library is available to our entire network of users. Right now we have about 160 expected practices within the library and we’re seeing about 2,000 downloads a month. It is being heavily used. I do think eConsults have a great capacity to reduce this variation in practice, however, only if done in a larger context. Just because two people are talking does not mean that variation has been reduced. It’s because two people are talking in the context of an implementation that was driven by a workgroup that has ownership of that process and in some ways, governance over it to hold each other accountable. Every month when that primary - specialty care workgroup meets, they have the ability to look at their eConsult dashboards. They look at response times and percentages of face-to-face visits versus those being managed entirely by eConsult and talk about those variations. They discuss about what’s going on in various populations or certain settings, making sure that the services that we’re offering are offered across our system. Another thing that I think is really important about our implementation is that we are convinced that one of the high-value aspects of eConsult is the collaborative relationship between the person who needs specialty expertise and the person who is delivering the specialty expertise. Even though we have such a large system, we have actually reduced the eConsult interaction to a continuity relationship. For example, I am a primary care physician at our Hudson Clinic. Whenever I go on to eConsult for a Cardiology consult, I get Dr. Garg. There are 14 other cardiologists in our system who respond to eConsults within our system, but every time that I use the system, I get Dr. Garg. And he is also most likely to be at the facility that my patients will go to, should they need a face to face visit. Our continuity develops this relationship where Dr. Garg becomes my friend, my insider at the medical center. He is the one who has helped me in the past with patients and now he will help me in the future with patients. The relationship holds me accountable as a primary care doctor to do a good job in my submission, but the accountability goes both ways. Dr. Garg is incentivized to do a good job of coaching and educating me as a primary care doctor because the more he does that, the more he helps improve my capacity as a primary care doctor. The more he invests in me, the more value he’s going to see from eConsult as well. And maybe there will be fewer, but better eConsults from me in the future. When he does get an eConsult from me, I’m coming to him as a more informed partner in our ultimate goal of providing better care to the population. The relationship is a powerful aspect of our eConsult implementation. We have not seen that investment in relationship in other implementations that we’re aware of and we think that it’s been a major part of our success.
How do eConsults address the specific needs of underserved patients in the safety net?
Patients without insurance often get treated differently. In many places in our country, they get pushed to the end of the line. They get a level of service that perhaps is different from an insured patient, but not so with our eConsult implementation. In fact, the reviewer of the eConsult is blind to the payer source of the patient. When a primary care doctor submits an eConsult to a specialist, the specialist treats every request with the same clinical diligence and the same set of clinical recommendations regardless of insurance status. When it comes time to see them in clinic, we treat them exactly the way we treat everybody else. That’s created much more equity with regards to payer type in our system and we’re very devoted and dedicated as part of our mission to treat people well regardless of their payer type. eConsult has in some ways created that mechanism for us to do that. We went from a system with long wait times and very unresponsive access to specialty care and here we are, doing 18,000 eConsults a month and the average response time to that first request for specialty care is 3 calendar days, including weekends and holidays. Many of our specialty reviewers are providing a response in a mere number of hours. For an underserved population, eConsult has driven care to a level that I would actually put up against any system in America. I’d encourage anyone to go to their primary care provider, ask for a specialty referral, and then ask them if they’re getting an individualized response from the specialist in 3 calendar days. I would say that in most systems in America that I’m aware of, that is not happening. What we have seen is because of all of the advantages of eConsult, when the patient goes to a specialist, the specialist has all of the pre-evaluatory testing that is needed. The patient has a much higher likelihood of having a definitive first visit with the specialist instead of going to the specialist,getting more tests and coming back in a couple of weeks for the results and plan. We’re seeing a very patient-centered approach here and we have found that we now have the ability to schedule the patient with the specialist far more precisely. The 6 to 9 month wait times are gone and we now are able to not only see patients quickly, but because of the eConsult conversation, we are able to determine the best timelines to see that patient. That’s been very cool.
As a physician yourself, what do you find most exciting about eConsults?
As someone who has worked in LA with the safety net population since 1999, especially when I was working out in the community, I felt like I was working on a little island. I was just out there all by myself and I was trying to just push and jump up and down to try and get my patients the specialty care that they needed. I felt like I was very much alone in that pursuit. eConsult creates a community. So now I’ve got Dr. Garg in the hospital, he’s my friend, he’s my insider, he’s my partner, and I’m no longer alone in that system. I am part of a community of care that is working together. I am part of the solution, I am part of the care. I feel like I have a system that’s responsive to my patient’s needs. I also find that it’s a rich professional interaction to collaborate with someone - to share thoughts, to share approaches and learn together. And as a family doctor, it makes me look great to my patient. In the old days it was “Well you need to go see the dermatologist. I’m going to submit that request to the dermatologist.” And three months later the patient comes back to me and says “What happened to my dermatology referral?” and I say “Oh, I don’t know. I haven’t heard anything back. Let’s send it in again.” It doesn’t help me care for the patient in a patient-centric way and it makes me look less competent. Now I can tell that patient “I’m going to take a picture of your rash and send it off to the dermatologist. In three calendar days, I’ll have a response from them and I’ll let you know what they said and if we need to change your treatment, we will. If you need to go in and see the dermatologist, you can go in and see them.” It’s also so much more rewarding from a patient standpoint and that’s really what I believe is at the heart of eConsult. It is a win for patients. If you’re a patient, what system do you want? What is the most patient-centered way? This level of coordination and connectedness is what patients are expecting from their providers. These are patients who are able to make all of their travel arrangements from their phone. They’re able to deposit checks with their phone. And we’re making them take 3 or 4 days off of work to make them go get something when their health system could actually deliver that to them in such a better and more efficient, timely way. This is where I get most excited about eConsults. This is the way medicine is heading, and that is what patients in 2017 should expect from their physicians.
Dr. Paul Giboney is the Director of Specialty Care at the Los Angeles County Department of Health Services (LACDHS).