Written by: Center for Care Innovations

Vulnerable patients are more likely to have complex health conditions that require the attention of specialists. But their difficult lives make interfacing with the specialty care system challenging. After receiving complaints from specialists about patients missing or showing up late to appointments, the Community Health Center Network piloted electronic curbside consults with tech company RubiconMD to better triage their patients’ specialty needs.

The New Normal in Specialty Care

Health reform changed the landscape not only for payers and primary care providers, but for speciality care as well. The ACA saw Medicaid enrollment double in two years, giving access to speciality care to millions who had previously been left out of that system. Primary care providers are dealing with more complex patients, and as such are needing to send patients on to specialists with more frequency. With such an influx of patients, many patients are forced to wait weeks for an appointment with a specialist.

An Imperfect Handoff

For safety net organizations, interfacing with specialists can be a fraught proposition. Because of the difficult nature of their lives and their lack of experience with the health system, safety net patients are often less likely to show up for specialty appointments, or may show up late. Many community health centers are also hiring physicians and advanced practice providers right out of training, and some of these providers may not have a lot of experience writing good consult questions. This results in higher costs and frustrating experiences for specialty providers, as well as less effective care for patients.

Seeking a “Quadrafecta”

After hearing complaints from specialists, The Community Health Center Network (CHCN), sought a way to change the way they did specialty referrals that would be good for patients, good for primary providers, good for specalists, and would strengthen their relationship with Alameda Health System, their mission-aligned partner. They needed a “quadrafecta.” The solution they found was digital “curbside consults” through a platform by health tech company RubiconMD.

Curbside Consults

“Curbside consult” refers to when a physician asks the opinion of another provider without getting them officially involved in a patient’s case. With questions that go into specialty domains, providers may call up a specialist they are friendly with for advice on whether a patient’s case warrents a specialty visit or how to best frame a clinical question for a specialist. Such consults make specialty visits more effective and efficient, but unfortunately in most places they are not formalized. Instead they are born out of social relationships between doctors in their community—relationships that many new physicians hired by safety net clinics have not yet cultivated. RubiconMD offers curbside consults as a digital service, allowing providers to get advice on their cases from specialists across the country.

How It Works

  • A primary care provider using RubiconMD sees a patient who has a complex case. The provider is unsure if the case warrants an appointment with a specialist, or would like some help crafting a good clinical question with which to send the patient to a specialist. Or perhaps the provider needs suggestions on further testing to run before their patient is seen by a specialist.
  • The provider uploads the case into RubiconMD’s web-based platform. The platform may be connected directly to an EHR, or offers fields to input the case particulars that mirrors an EHR. Usually the provider can copy and past the information directly from their chart notes.
  • Using a RubiconMD phone app, the provider can upload pictures of the patient’s relevant body parts, skin lesions, etc. They may also take pictures of computer screens to more quickly enter information about lab reports or patient charts.
  • RubiconMD will prompt the provider to ask a specific question for their case, as well as their current plan of treatment, which helps both the RubiconMD specialists and the PCP better understand the case.
  • The patient information is anonymized to protect patient privacy and comply with HIPPA regulations. Then the case is assigned to specialist on RubiconMD’s network of specialists relevent to the primary provider’s question.
  • A specialist on that network can look at the case and submit an answer, which is sent back to the primary provider. If they do, the specialist gets paid by RubiconMD.
  • Much like an in-person curbside consult, the e-consult is not official and not legally binding.
  • The answers are sent back to the submitting primary provider, who uses the consult to inform decisions about whether and how to send a patient on to a specialist appointment.
  • The primary provider can rate the quality of the consult. RubiconMD assigns more consults to specialists that receive high ratings.

Lessons from Practice

  • EHR integration with a system like RubiconMD sounds easy, but can be a challenge to implement.
  • While useful, e-consults are not a golden bullet to create efficient provider workflow. This is a tech intervention, and as such not always easy for less tech-savvy providers.
  • It’s important to consider the ecosystem of your local specialists. Specialists in urban areas are more likely to be overburdened with demand, and appreciate a system that makes visits more efficient and takes off some of that strain. In rural areas with less demand, it is important to be careful about interventions that might alienate local specialists.

What’s Next?

CHCN piloted RubiconMD with 40 very motivated primary care providers. After ten months, they started to spread to the rest of their clinics with a staged expansion and RubiconMD trainings. Now they can have over 100 e-consults across the network in a week, with over 200 providers trained. They have also started supplementing the RubiconMD system with consults from some of their specialists at Alemada Health System.

Learn More

  • The Community Health Center Network is composed of health centers headquartered in Alameda County, California. Learn more: chcnetwork.org
  • Learn more about RubiconMD: rubiconmd.com



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