Oklahoma School of Community Medicine: Developing and Implementing an Electronic Consultation Platform
Dr. David Kendrick is a practicing physician who has launched several technology platforms to improve the quality and efficiency of patient care. He has most recently established an electronic consultation system, which has evolved and grown to serve patients across three states. Dr. Kendrick is an associate professor of internal medicine and pediatrics and a Kaiser Chair of Community Medicine at the University of Oklahoma School of Community Medicine. He serves as the medical director for community medical informatics.
 
ConnectivityDr. Kendrick wanted to develop an e-consultation system to simulate the doctor’s lounge culture where providers gathered, developed relationships and discussed patient cases together. He also wanted to provide a technological fix that would reduce the number of unnecessary referrals. From experience he knew that the time crunch faced by many PCPs led to providers initiating a “quick” referral rather than taking the time to research and consult with colleagues about the case. Ultimately, Dr. Kendrick deduced that there were too many patients being referred for specialist visits that could be handled competently within primary care.
 
When Dr. Kendrick first built his e-consultation prototype, dubbed “Doc2Doc,” almost 120 PCPs who predominately practiced in rural settings signed up quickly. Specialists from the University of Oklahoma also agreed to review and respond to the incoming queue of consultation requests. The Web-based system’s work flow is as follows:
  1. A sending provider decides that the patient needs specialist input.
  2. Staff (who is usually a clerical referral coordinator) at the PCP’s office initiates the e-consultation.
  3. The sending provider adds the clinical information and question.
  4. The consulting provider responds to the e-consultation.
  5. There may be back-and-forth communication between providers.
  6. Useful clinical dialogue that is general in nature may be added to the system’s “knowledge base” for other providers to review.
  7. If needed, the e-consultation is routed to the clerical staff for referral scheduling.
It’s important to note that the system does not link with the EMRs and thus, the clinical exchange is not captured in the patient’s chart. This inconvenience, however, did not preclude implementing the system, but Dr. Kendrick learned that a lack of incentives for specialists caused problems in the quality of information and timeliness of their replies. A new approach was deemed necessary.
 
The Oklahoma Department of Corrections (DOC) used the University of Oklahoma’s Medical School faculty for its specialty referrals. The DOC system bears the costs of these referrals and thus wanted to eliminate unnecessary referrals. Dr. Kendrick approached the DOC and, having learned about the necessity of reimbursing specialist time, told the prison system upfront that they would need to pay $50 to the specialist for every completed consultation. The prison e-consultation system was implemented and, ultimately, led to an approximate 50 percent reduction in utilization of specialty care. Electronic consultations were a cost savings to the system. To date, almost 100,000 e-consultations have taken place and the system has spread to Louisiana and Kentucky.
 
In 2004, Dr. Kendrick was awarded an economic development grant to implement a randomized control trial (http://www.doc2docstudy.org/) of his e-consultation technology. This trial was implemented outside of the prison system. Its results are currently being prepared. Although this trial is no longer operating, many of the primary care practices continue to use the e-consultation platform. The roll-out of Medicaid’s reimbursement to both medical homes and specialists for care coordination activities have helped sustain the platform’s use. Dr. Kendrick is also currently working on a Health IT Beacon Community award and one of their major interventions is the spread of the Doc2Doc platform.