By Matt Phillion
Statistically, the longer a patient waits to see a specialist, the more likely they are to fall off their care plan or experience additional complications. And wait times continue to increase; by some metrics, wait times to see a specialist have doubled in the past year.
“There are three main reasons for excessive wait times for specialists,” says Rebecca Chi, chief client experience officer with AristaMD, which offers a peer-to-peer collaboration platform for physicians to provide specialist-guided care to patients.
The first of these three reasons is long-standing shortages among specialists. But second is the types of patients who most need these kinds of services.
“These patient populations, often over 65 with an increase in comorbidities and a need for specialty care, often have trouble reaching out,” says Chi. “A lot of times people at that age create a connection with their primary care doctor, but are reticent to step outside that relationship they’ve worked so hard to establish and build trust to go see someone else.”
Picking up the phone or contacting that specialist isn’t easy for many, says Chi. “They don’t want to tell their story again,” she explains. “They don’t want to go back through their history; it’s almost laborious for them, and it’s intimidating.”
And the third factor for protracted delays should come as no surprise: COVID-19’s impact on the industry. “It’s just exacerbating something that was already an issue,” says Chi.
Three factors, one end result
The issues of access and available trained personnel are more complex in a world that has gone through a pandemic. “We’re seeing practitioners who are truly burned out,” says Chi. “COVID really drove everyone to the mat. It caused a large transition in specialty and PCP levels—people who were thinking about retiring are saying, ‘I’m done.’ ”
Others chose their moment to pick up and move during the pandemic, causing further turnover. With so many turning to telehealth and new digital platforms, the practice environment has changed more radically than ever before.
While the burnout is real, Chi says that pre-pandemic follow-through on specialist referrals was already imperfect. “We have 105 million referrals a year, but only about half of those are actually followed through on. That says a lot. A small fraction of those patients will complete those visits, and so patient outcomes start to decline. Chronic conditions like diabetes, hypertension, and more go undetected or untreated, or are treated insufficiently.”
This, of course, increases both the severity of the conditions as well as the cost of care, and the worst cases can result in death or long-term disability, Chi notes. “Undiagnosed conditions are exacerbated, and delays in diagnoses or treatments then lead to more complex and invasive options for treatments,” she says. “Many patients endure significant pain, with conditions like eczema, psoriasis, or IBS.”
This is where remote peer-to-peer collaboration can come into play, says Chi. “While patients are waiting to see the specialist, the primary care physician can deliver care,” she says. “In a way, we can get you to see a specialist and get [you] on a pathway at least for relief.”
Value-based care’s role
The shift to value-based care changes how referrals come into play, realigning the volume of patients and where they are directed to. Providers don’t want patients to end up in the emergency department (ED), both for health reasons and because of the high cost for non-emergent ED visits.
It used to be standard to write a referral to get the patient in to a cardiologist, Chi says, but if there’s a delay, the provider must send the patient to urgent or emergency care.
The “silver lining” to COVID-19—healthcare’s quick adoption of new best practices and technologies—also becomes apparent under value-based care. “Physicians had already equipped themselves with new technology, new services, and we’re now even more concerned about patients ending up in the emergency department. During COVID people would avoid the ED until the ambulance was called,” says Chi.
Meanwhile, for most patients, a remote peer-to-peer consult is often seamless. AristaMD has seen roughly 74% of electronic peer-to-peer visits replace in-person specialist visits.
Better access from afar
Remote peer-to-peer consults also address another national healthcare challenge: underserved communities and “specialist deserts” where communities do not have the funds to support a specialist and patients don’t have the means to travel to see one. “This is one way to empower the PCP to solve the problem,” says Chi. “It’s a physician-to-physician consult, which has been going on since the beginning of time.”
As discussed, patients often avoid the process of “onboarding” a new physician to their history and health story. For many, Chi says, working with a remote consult via their trusted primary care doctor is a relief. “They don’t have to go to another visit, there’s no additional copay,” she says. “And this kind of access democratizes healthcare in the best sense of the word. It’s bringing the right care at the right time to the right place; it might be while they’re at home, or with the PCP. [The specialist] might be able to solve the problem through patient education or through something the PCP is empowered to take on, and together they can resolve the patient’s needs. It makes for a very level playing field.”
Patients in rural and urban locations, and with any type of health insurance, can benefit from such access to care. “That’s really the essence of peer-to-peer remote consulting. It’s educating the PCP to help that patient right there,” says Chi.
The consulting physician responds within a few hours, and the primary care doctor is able to then reach the patient, often eliminating the need for a follow-up face-to-face visit with a specialist. That frees up specialist time for visits that truly need in-person attention.
AristaMD recently began tracking how often the online consults resulted in new diagnoses and found they occurred 40% of the time. “We’re actually able to see all of this come to fruition—these consults can treat and newly diagnose, and thereby alleviate or eliminate a specialty visit,” says Chi.
On the back end, additional benefits keep the patient moving in the right direction. If the peer consultant knows they are not the right physician for a specific patient, they are able to redirect the patient to the right person. The consultant can also complete the loop by reviewing the results of tests ordered from the calls.
AristaMD is also leveraging online consults to handle challenges surrounding medication reconciliation. “We just added a series of PharmDs to do medication consultations,” says Chi. “They review interactions between medications the individual is on and suggest options for medications that work more harmoniously together.”
The overall reaction to the peer-to-peer consulting concept has been wonderful, says Chi. “A lot of them can’t imagine practicing without this option,” she says. “We hear from some of them that it’s easier to use than their EHR. They love that we’re able to treat the member right where they are.” It’s not unlike writing a referral, and it can help PCPs stay on top of the latest information in an era where doing so alone is nearly impossible.
“One thing we forget is that in medicine we’re on a continual learning curve—PCPs especially, because they can’t know everything about every specialty area,” says Chi. “There are new meds coming out monthly or even faster, and we’re here to simplify their world.”
Remote peer-to-peer consults place answers and expertise at the doctor’s fingertips, she says. “It’s educational not just for the physician but for the patient, so they can be aware of their own condition,” says Chi. “You get this test, the reading comes back, and you put in for another e-consult so you can keep treating this person out of your own office.”
Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at firstname.lastname@example.org.