It was once commonplace for primary care physicians to seek informal guidance from specialists regarding a patient's care during a "curbside consultation." This phrase, still in use today, is said to have come about as doctors walked to a hospital parking lot and paused to talk about a case at the curbside.
Another well-known spot for curbside consultations were doctors-only hospital dining rooms, which, by the early 1990s, had all but been replaced by larger and more democratic cafeterias for families, patients, and medical staff.
In a 1996 article in the Canadian Medical Association Journal, simply titled, "The Demise of the Hospital Dining Room," Michael Kaye, M.D., wistfully described how informal collaboration between primary care physicians (PCPs) and specialists had become part of a bygone era.
"At lunch, advice about patient care, whether a formal consultation was indicated, ways to resolve differences of opinion, the names of the best person for a task - all of these issues could be resolved, often after only a few moments of discussion. Such goings-on now appear remote, dinosauric!" he wrote.
Can 21st century technology help to overcome the growing physical divide between PCPs and specialists?
Few opportunities for collaboration
Today's PCPs rarely rub shoulders with specialists in the course of a working day. "I've been struck by how primary care doctors and specialists are very separate," said C. Blake Cameron, M.D., a nephrologist and researcher at Duke University Medical Center in Durham, NC. "It used to be that the primary care doctor would get up early in the morning and do hospital rounds," and confer with other doctors along the way, said Cameron.
Now, of course, PCPs spend their days in their offices with patients, while hospitalists have taken ownership of some of the PCPs' former tasks. Informal collaboration between PCPs and specialists - over lunch, in a hallway, or at the curbside - is less common.
As a kidney specialist, Dr. Cameron has a special interest in collaboration with PCPs; kidney disease is often a consequence of other diseases - such as diabetes, heart disease, and high blood pressure - that are managed by PCPs.
"Collaboration is important in kidney disease, as it's a silent disease. It gets overlooked in day-to-day practice," said Cameron. Unfortunately, as many as half of people with kidney disease are unaware that they have it, added Cameron, as there are often no overt symptoms.
Creating a 'virtual medical neighborhood'
While a Fellow at Duke in both nephrology and clinical informatics, Cameron became interested in addressing the problem of undiagnosed chronic kidney disease (CKD) in primary care through the concept of a "virtual medical neighborhood."
He said he realized that deficiencies he saw within CKD care were symptoms of a lack of communication and collaboration within the healthcare system.
To remedy this all-too-common problem in United States healthcare, in 2006, the American College of Physicians released a policy document calling for fundamental changes in how healthcare is delivered and paid for in the U.S. The report advocated a "medical home" approach, in which primary care services are continuous, patient-centered, and coordinated, rather than episodic, disease-oriented, and fragmented.
The medical home concept gained traction in policymaking circles. By 2008, the National Committee for Quality Assurance, the Joint Commission, and others launched medical home accreditation programs in the U.S.
These accreditations require sweeping changes in the organization and delivery of care, and they include a stronger focus on patient-centered care, as well as more effective collaboration between the physician and other health professionals - both physically and virtually.
The term "medical neighborhood" describes the medical home's close and complex relationship to myriad other parts of the healthcare system, such as specialty physicians, hospitals, nursing homes, and physical therapists.
While the term "neighborhood" conjures up images of streets and sidewalks, the geographic footprint of primary care is vast. The nearest specialist "neighbor" could be miles away.
Cameron saw an opportunity to use electronic communication tools to overcome geography and to make collaboration within the medical neighborhood "virtual" rather than physical - therefore restoring the "curbside" to the modern era.
The medical home is still a relatively new concept and remains a work in progress. However, the electronic components of the framework are becoming a reality, as they are supported by existing web-based tools and the electronic health record (EHR).
A three-pronged approach
Cameron and his colleague Kevin Shah, M.D., medical director for Primary Care Improvement and Innovation at Duke University Medical Center, received seed money from the Duke Institute for Health Innovation (DIHI) to approach the virtual medical neighborhood for CKD from three angles. These are:
- CKD Help Desk: Standardized treatment maps for Duke PCPs that suggest initial steps for CKD evaluation and treatment are in development.
- Electronic consultations: For more complex concerns, kidney specialists provide advice and guidance to Duke PCPs through written communications in the EHR, without directly seeing or interacting with the patient. These "eConsults" address the need for further testing, treatment, or an in-person referral.
- Proactive surveillance: Working in conjunction with the Duke Population Health Management Office, Cameron and his colleagues use sophisticated EHR record searches and risk prediction tools to find patients who need a certain treatment or referral. In particular, they focus on finding patients with late stage CKD, who may otherwise soon experience a traumatic and costly transition to dialysis.
The CKD medical neighborhood project, which began in 2016 and is funded through 2017, has generated great interest across Duke. Specialists in endocrinology, geriatrics, and cardiology are looking to replicate the program so that they too can collaborate with PCPs in an effort to improve patient care, said Cameron.
Medical homes and neighborhoods still in early stages
Most U.S. hospital systems have not yet formalized the medical home or medical neighborhood concept, and patients routinely bear the brunt of a lack of collaboration. For example, patients are often unaware of who the "go-to" doctor to manage their illness is, and the PCP and specialist often do not know either.
In addition, many patients do not follow through with a written referral from the PCP, and those who do follow through are often deterred by long wait times to see the specialist.
"The current system is burdensome for patients," said Cameron. "It makes them the intermediary; they have to manage their own care."
Meanwhile, many referrals made to specialists are considered "over referrals," meaning that PCPs will make a referral when "what's needed are answers to simple questions," said Cameron.
PCPs on board
Although still a pilot project at Duke, the CKD virtual medical neighborhood has been wholeheartedly embraced by Duke PCPs. "They tell me it's the greatest thing since sliced bread," said Cameron. Indeed, Cameron's colleague, PCP Michele Casey, M.D., regional medical director for Duke Primary Care, echoes this.
"This program has had a significant positive impact on patient care. Providers often have what they consider 'easy' but important questions about a patient. Until now, they had no way to get help other than making a face-to-face referral."
Michele Casey, M.D.
If it all sounds too good to be true, it sort of is - at least right now. "I don't get paid for this," said Cameron. The grant from the DIHI covers the costs of the program, but it is still unknown how the program will be funded in the future. "Our goal is to figure out the business model," said Cameron.
Los Angeles 'eConsult' project demonstrates success
In the March 2017 issue of Health Affairs, researchers from Harvard Medical School, Harvard School of Public Health, and the Los Angeles County Department of Health Services (DHS) describe the results of a 4-year study of an "eConsult" system, launched by the Los Angeles County DHS.
The Los Angeles County DHS is the second-largest public health system in the U.S., serving 670,000 patients annually. The article's title aptly describes the study results: "Los Angeles Safety-Net Program eConsult System Was Rapidly Adopted and Decreased Wait Times to See Specialists."
In 2012, the Los Angeles County DHS implemented its web-based eConsult system, in which all requests from PCPs for specialty assistance were reviewed electronically by specialists.
When the system was first implemented, usage was low. By 2015, more than 3,000 PCPs were using it, and more than 12,000 consultations were taking place each month, compared with just 86 during the third quarter of 2012. The median time it took to receive an electronic response from a specialist was 1 day (which was reduced even further over time), and around a quarter of the eConsults were resolved without the need for the patient to see a specialist in person.
In addition, the median time to an appointment for those who did need to see a specialist decreased over the study period, "without any increase in specialist staffing, which implies that deployment of DHS's eConsult system decreased the backlog of patients waiting for appointments," the authors wrote.
The authors also note that while their study focused on a "safety net" public health system, the results are "likely relevant to any health system with significant constraints on specialty supply and access," and that it may be particularly promising in "large, integrated delivery systems where there are deep existing relationships between primary care providers and specialists."
What is clear is that these technological advances are being driven by a real need to provide alternatives to the traditional "curbside consultation."