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Improving the bottom line and patient access through eConsults [PODCAST]

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The Hospital Finance Podcast

In this episode, we are joined by Elizabeth Jaggers, Administrative Director for the University of Iowa Physicians, to discuss the process of implementing eConsults across 16 specialties.

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Highlights of this episode include:

  • An overview of eConsults and why the University of Iowa Health Care decided to implement eConsults.
  • What has contributed to the success of eConsults for University of Iowa Health Care.
  • Details on how providers are reimbursed for eConsults.
  • Some best practices to follow when implementing an eConsults program.
  • How providers measure ROI with eConsults.
  • And more… 

Mike Passanante: Hi, this is Mike Passanante and welcome back to the award-winning Hospital Finance Podcast®. eConsults are becoming an increasingly popular option for offering specialty consults without the need for an in-person visit. The University of Iowa Physicians and the University of Iowa Health have adopted eConsults across 16 specialties. To talk to us about their journey towards implementing eConsults, I’m joined by Beth Jaggers, Administrative Director for the University of Iowa Physicians in the Carver College of Medicine. Prior to her current role, Beth worked as administrator in the departments of urology, cardiothoracic surgery and radiology and held various roles in finance. Beth holds an active CPA and CPC license and earned her MBA from the Tippie School of Management at the University of Iowa. Beth, welcome to the show.

Beth Jaggers: Thank you so much for having me.

Mike: So Beth, for those in our audience who may not be familiar with eConsults, can you give us a short overview of what they are?

Beth: So eConsults is an asynchronous provider-to-provider exchange in our digital health platforms. And what asynchronous means is that it doesn’t have to be real-time. So this really enables referring providers to consult with a specialist around a specific condition over minutes, days, weeks to be able to get care to a patient in their patient home.

Mike: Beth, why did the University of Iowa decide to implement eConsults?

Beth: Yeah. so the University of Iowa was part of the AAMC eConsult grants. So we were one of the first academic medical centers to really test out this new way of delivering healthcare. And the reason why we were really interested in it is — the state of Iowa has a population of about 3 million people, and we’re pretty rural. So this is really a great opportunity to provide patient care and specialist care to people across the states without having to come to Iowa City, Iowa to see a specialist. So we were really excited to be able to partner with other primary care stakeholders to be able to give our community and the population of the state of Iowa the care that they need.

Mike: And you’ve been successful in making eConsults work. So let’s get some practical advice from you. On the ground, how does an eConsult work?

Beth: Yeah. So there’s a lot of different ways to set this up. Physicians do consults all the time. But the way the University of Iowa did it is we really wanted to make this have the least amount of manual intervention as possible. So the old way of faxing in consults wasn’t very appealing to us. So we asked ourselves, “How can we leverage our electronic medical records system to really help us launch eConsults?” So we have two different pathways for providers to access our specialists for eConsults. One is just through our EMR. We have the ability to have other hospitals and then we also have our own primary care network through UI Health Care. And so they can simply place an order in our EMR and it’s just like a normal consult. They place the order; it goes into the specialist provider’s inbox. That order has various questions to help the ordering provider map out a care pathway plan for their patient. And then typically within one to two days, our specialist reads that order and maps out a care plan. Or one alternative is that they need to be seen face-to-face. But we’re really trying to encourage that collaboration between the ordering provider and the specialist. Again with the goal to keep the patient in their medical home. If a provider isn’t affiliated with UI Health Care or is an external on a different EMR, we have the ability to partner with outside institutions and give them access to our order set through CareLink, which is also an Epic option. So those are the two ways that we have eConsult to work in UI Health Care. But again, it can be very informal, just a paper order or a fax or anything that qualifies for an order, in order to get that information to the referring provider.

Mike: Beth, how do providers get reimbursed for eConsults?

Beth: Yeah. So we are really thankful that through the work of the AAMC that Medicare has added two CPT codes to their fee schedule in order to reimburse providers for this work. And what’s really great is that they reimburse the ordering provider, which is typically a primary care provider, and the specialist the same amount. So all you have to do to actually get reimbursed is that you have to put in an order, and the requesting provider, which again is typically that primary care provider, needs to document 30 minutes of work for creating and treating and managing that patient’s eConsults. And for the specialists, they actually only have to spend 5 minutes of medical consultation time to bill that as well. So typically that primary care provider bills a 99452 CPT code, and that specialist gets to bill a 99451. And you can be in the same organization and bill both of those codes, or have one be external and one in your organization, and still bill those as well. So it’s really a great service.

Mike: And Beth, in your experience, what are some of the best practices when implementing an eConsult program?

Beth: Yeah. So my number one answer to this is you have to engage the providers to figure out what works best for them and what they feel is an appropriate eConsult because not everything is going to qualify for this level of care. So engaging your referring providers to figure out, what things are they struggling with in their practice that they feel like if they could just pick up the phone and talk to a urologist or talk to a dermatologist and help them map out that care plan– those are things that you want to help build and create relationships to an eConsult provider. So engaging your providers, listening to your referring providers, working with a specialist to really connect them on those care pathways is very important. I also think it’s important to map out how you want this process to work before doing any implementation. So thinking about do you want to start this internally first. Like let’s just say you have multi-specialty clinic, how can we test out these workflows internally? Which is what UI Health Care did before doing an external pivot. And then looking at your areas of biggest need– and we focus on access. And I think dermatology is a great example where it may take a patient three, six months to establish a new relationship with a dermatologist. And what tools can we give that primary care provider to treat that patient in their medical home with the dermatologist’s knowledge, and get them the cure they need faster. And so I really encourage people to take a look at what their struggling with access to care, and figure out how you can prioritize those specialties with an eConsult model.

Mike: And a few a minutes ago you told us about how your model operates. But what resources are actually needed to implement an eConsult program in your experience?

Beth: Obviously it depends on how big you want it and how many specialties you want to cover. But in UI Health Care’s experience I think it’s really important to identify your IT resources as we really embedded this in our EMR. So making sure that this is prioritized within your IT resource is important. And we really leverage a lot of that work on our orders team. Like I mentioned before, we really built our specific orders by specialty to help queue the referring provider, the primary care provider with the questions that the specialists need to deliver care. And what’s great is the AAMC has a lot of good resources that are available publicly to help have you think about how to build those order sets. So I think IT plays a big role in that. And then I do think that it takes a lot of time to start a new program. So what was really successful for us is that we had a project manager that this was their entire role. And so they were able to spend a lot of time establishing those relationships between the referring provider and the specialist. And listening to the needs and really making sure that this was top of mind for everyone to move forward. Because there’s a lot of moving parts with establishing a program like this.

Mike: And of course ROI is pit and parcel of everything we do in healthcare these days. Can you describe how providers can achieve ROI or measure it with eConsults?

Beth: Yeah so I think the biggest low hanging fruit is when you talk to providers they’re doing this stuff right now, informally. So a lot of times you have a primary care provider or a general internal medicine provider calling a urologist and saying, “Hey, I’m seeing this patient and I’m struggling with XYZ, how would you see this in your clinic?” And this curbside consults happens all the time. Yet it’s not documented in the EMR and it’s not a billable service. And so really the low hanging fruit for the ROI is providing provider education and referring provider education to say, “Hey, if you just place this order and answer these questions, not only do I get reimbursed for this work as the specialist, but you get reimbursed for this work as well by asking these questions and treating your patient.” So that’s a win-win right there. But I think the big ROI comes in when you create relationships between primary care and medical homes and specialists to take out those lower acuity specialty visits. Primary care providers are trained in a variety of different specialties. And it would be great if we could just hand over care plans for how to treat dermatitis instead of going to a dermatologist for something that may be lower acuity for a dermatologist but higher acuity for a primary care doctor. Let’s treat them in their medical home so those specialists are seeing really a higher level of ENM and higher acuity of those patients. And so when we get into the nitty-gritty’s of reimbursement, we really tried to aim to take out those level one and two ENMs from specialty visits and make those into e-consults. And back fill those with higher acuity visits, like a level four and a level five. And that’s where you get those higher reimbursements, especially on that commercial side of things.

The other thing that we did at UI Health Care when we really looked at ROI is we did time studies of providers, especially on the specialist side of things. And what we found out is that a clinician spent anywhere between five to seven minutes on the specialist side making decisions for an e-consult. But when that patient was in their clinic, they were spending about 20 to 30 minutes. So we’re actually able to do more eConsults in the same amount of time as seeing a face to face visit. And so you can also argue an ROI with time as well.

Mike: Beth Jaggers, thank you so much for coming by the program today and sharing your experiences around eConsults.

Beth: Thank you.

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