Published in the July 2019 issue of Today’s Hospitalist
IN 2016, Geisinger—the powerhouse regional integrated health system in Pennsylvania and New Jersey—found itself facing the same dilemma as other health systems with multiple sites: Many of its community hospitals had too sparse specialty coverage. Hospitalists who had questions for (or consults requested from) specialists could wait hours or even days for those to be turned around.
Sometimes the lag led to patients being transferred to Geisinger’s main campus in Danville, Pa. Or “some patients were discharged by the time the specialist actually did the consult or answered the question,” says rheumatologist Eric Newman, MD, Geisinger’s director of quality and innovation for the Geisinger Medicine Institute, the health system institute that encompasses all of primary care and most medicine specialties.
Fortunately, Geisinger already had implemented an outpatient innovation “outpatient innovation” it could adapt to inpatient care. Its outpatient Ask-A-Doc program is a Web-based platform that streamlines communication between primary and specialty care. The tool had slashed turnaround time on outpatient consults and cut costs by reducing unnecessary ED and office visits.
“We set it up so specialists actually make a bit more RVUs per minute with Ask-A-Doc than they would if they saw a patient.”
~ Eric Newman, MD
Creating an inpatient version of Ask-A-Doc took the hospital’s Epic team and innovations IT team about six months of customized programming, Dr. Newman explains. “Our inpatient version is designed to be completely self-contained within the electronic health record.” Three years and more than 1,800 inpatient Ask-A-Doc consults later, use of the tool has cut the average turnaround time for specialty consults and queries at offsite hospitals from more than 10 hours to just over two.
“But that’s the average turnaround time,” Dr. Newman points out. “Among consults, 88% are being completed in 75 minutes or less.”
Saving specialists’ time
When Geisinger’s hospitalists used to request specialty consults at offsite hospitals, specialists might have an hour’s drive each way to see a patient. Or they would have to arrange a telemedicine visit during the day, “which can have its own issues in terms of how easy those are to set up,” Dr. Newman says.
With Ask-A-Doc, specialists can often save that time by answering hospitalists’ questions and avoiding a consult altogether. If they do need to visit, they can tee up a more successful consult by using the platform to ask hospitalists to have certain test results available beforehand. When Ask-A-Doc was first tested at one hospital, “the hospitalists fell in love with it, and specialists found it saved them a significant amount of work,” Dr. Newman says. It’s since grown organically across the system according to what hospitalists need and how willing various specialties are to use it as a tool.
Currently, 10 specialties—addiction medicine, cardiology, endocrinology, hematology/oncology, infectious diseases, laboratory medicine, nephrology, neurology, pulmonary medicine and rheumatology—are using the platform, although not every specialty is available in every Geisinger community hospital.
Here’s how it works: When hospitalists have a question, they order an Ask-a-Doc consult, which is sent to the in-basket of the on-call Ask-A-Doc clinician in that specialty.
“It’s a dynamic in-basket, so it shows up only if there is a message there,” Dr. Newman says. “You want to separate these messages from all the other noise.” The on-call specialists are also paged to let them know they’ve received a message and are supposed to respond within three hours.
Hospitalists’ pagers are automatically notified when they get a reply. “That saves them the time they used to spend checking the chart to see if the specialist has gotten back,” Dr. Newman explains.
An RVU calculation
Because most Ask-A-Doc requests end up being answered without an actual consult taking place, specialists wondered whether they might lose substantial income. To solve that problem, Geisinger adapted part of the compensation formula it used with the outpatient program: calculating an RVU value for each successful Ask-A-Doc interaction.
“On the inpatient side, we set it up so that specialists actually make a bit more RVUs per minute with Ask-A-Doc than they would if they saw a patient,” Dr. Newman says. When the inpatient platform was first introduced, Geisinger decided to split those RVUs between the requesting hospitalist and the specialist.
“It was a new program, and we really wanted to engage our physicians in it,” he says. After they used the tool for a year and integrated it into their workflow, hospitalists stopped receiving that portion of RVUs. “We applied them solely to the specialist doing the consultative work.”
Given the platform’s success in Geisinger’s community-based hospitals, interest in the tool began percolating at its larger specialty-based hospital campuses: Geisinger Medical Center and Geisinger Wyoming Valley. That initially was seen as a problem.
“In the medical center, the specialist should be close enough to address the patient in a relatively timely fashion,” says Dr. Newman. Then there were potentially negative financial implications of using the platform in the main campus: The system could lose the dollars it was billing insurers for consults if Ask-ADoc became too popular at the academic center.
But it became clear that the tool could help deliver more efficient care, even at the main campus, particularly if specialty departments could assign NPs/PAs to handle onsite messages. Endocrinology, for instance, noted that it gets “a large number of consults for patients with diabetes” that its specialty-trained NP/PA could handle. Geisinger is now piloting the program at the two larger hospitals for a limited number of specialties.
Fewer unnecessary transfers
In terms of outcomes, Dr. Newman says it would be “incredibly difficult” to tie any decrease in hospital length of stay or costs to the initiative without setting up an expensive and lengthy research paradigm.
But “we did look at length of stay when we first piloted the program, not to see if we were shrinking it but to make sure it didn’t rise,” he points out. The concern: If specialists could now much more easily ask hospitalists to run tests on patients before a consult, would that lead to unnecessary testing and more complicated care?
The health system found, however, “that we didn’t make things worse in terms of length of stay, and we reduced unnecessary transfers. So we were able to say, ‘OK, we know it’s got other benefits, so we can now operationalize it in different locations.’ ”
And from the point of view of quality of care, workflow and efficiency, “Physicians are using it and it’s growing,” Dr. Newman says. “We all know that if you give docs something to do or use and it’s not helping, they won’t use it.”
Edward Doyle is Editor of Today’s Hospitalist.