Pediatric specialist workforce shortages and increasing demands for referrals from primary care providers (PCPs) have led to access challenges for many children's hospitals. Children's Hospital at Dartmouth-Hitchcock is one of eight children's hospitals implementing CORE for Kids, the pediatric arm of Project CORE (Coordinating Optimal Referral Experiences).
This program aims to improve quality and efficiency of care between primary care and specialty care providers in the ambulatory setting. The participating hospitals use tools such as eConsults and enhanced referrals, which are based in the EMR, to improve communication and coordination between PCPs and specialists.
Scott Shipman, M.D., M.P.H., director of clinical innovations at Children's Hospital at Dartmouth-Hitchcock, says Project CORE's goals are to improve specialty care access, improve quality and convenience for patients, enhance primary care and control the costs of care.
Key to these goals, he says, is the eConsult—a tool that allows a PCP to ask a question of a specialty colleague without making a traditional referral. "While the EMR-based tools are essential, they are one component of a successful model," Shipman says. "There must also be a culture of collaboration and trust between PCPs and specialists that is essential for delivering effective care."
The eConsults are housed entirely in the EMR. Here's how it works:
- The PCP fills out the referral template and submits it to a specialist. It displays in the EMR as an eConsult and as a referral.
- A specialist reviews and sends a response
- The PCP connects with the patient's family
- Family members receive expert information about their child's health care from the PCP they trust
When a PCP submits an eConsult, specialists typically turn around the request in three days or less, and both the PCP and specialist receive credit for every eConsult completed. So far, 90 percent of Project CORE's eConsults didn't require follow up with a specialist.
Erik Shessler, M.D., vice chair of community pediatrics at Children's Hospital of Dartmouth-Hitchcock, says eConsults help the hospital leverage limited specialty resources and use those resources effectively. "We've done more than 1,000 eConsults over the last two years," he says. "It's popular with PCPs—once they get a chance to experience it (or experience the process), they tend to use the tool a lot."
Shessler says the educational value of the tool for PCPs has been a nice benefit, too. "We have a hematology provider who so frequently eConsults, providers save her responses, so they don't end up asking her again."
A handful of state Medicaid programs have moved to pay for or are in the process of paying for eConsults. Shipman says a growing number of commercial payers are covering them, too. In some instances where payment may be a challenge, he says there are business benefits for health care organizations.
"Hospitals are getting more new patients through the door with fewer no-shows, increased completion rates and improved efficiency," he says. "They are culling the least value-added referrals and allowing more sick patients through the door; what you're building is a foundation for efficient care."
