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With Specialists In Short Supply, L.A. County Turns To e-Consulting

Doctors called it the black hole.

If their low-income or uninsured patients needed specialty care, they put in a referral to the massive Los Angeles County health care bureaucracy and then waited — for weeks or even months. It could take eight months to see a neurologist, more than three to see a cardiologist.

e consult 570To speed things up, doctors at county and community clinics urged their patients to go straight to the emergency room, the unofficial back door for specialist appointments. That way, patients could bypass the long waits and get the recommended colonoscopy or CT scan. But that route was expensive and burdensome to ERs.

It’s a problem across the nation: Specialists are hard to find for many patients, and even harder to afford. Sick people may grow sicker as they wait for appointments, causing them unnecessary discomfort and making treatment more costly in the long run. Diabetics may suffer with untreated foot ulcers, raising the risk of amputation; patients with abnormal chest X-rays may turn out to have cancer.

With a million patients a year depending on Los Angeles County for health care, local officials decided they had to act. Hiring scores of costly specialists wasn’t an option. So in 2012 they created a program called eConsult, modeled after a system at San Francisco General Hospital, to streamline the referral process.

In L.A. County, a program run by L.A. Care Health Plan, allows for a Web-based conversation between primary care doctors and specialists that can include the exchange of medical records and photographs. The specialist typically responds to inquiries within three days and a decision on a referral soon follows.

Much as a triage nurse clears the way for accident victims in a crowded ER, clinics would use guidelines for each specialty — created by specialists and primary care doctors working together — to determine who needs an appointment and how quickly. The primary care physicians can continue to care for the remaining patients, consulting with specialists electronically.

Three years later, it’s clear the program hasn’t been a panacea. Most patients in Los Angeles County still need face-to-face appointments with specialists, and there still aren’t enough of them to go around. But both primary care doctors and specialists say things have gotten better.

The county quickly realized its hypothesis was right — about 30 percent of patients referred by providers at county and community clinics didn’t actually need to see a specialist in person. Primary care doctors said they now have a clear way to communicate with specialists about their patients. And when patients do get to the specialist’s office, more have the necessary lab work or tests so the appointments are more efficient.

Overall, doctors agree that the electronic referral system has improved both communication and collaboration among doctors on both sides. And primary care doctors say the new system is far better than the old days, when they would have to “beg, borrow and plead” to get appointments for their patients.

Wait times for specialists in general also have dropped, although a small number of patients with nonurgent health issues still may have to wait up to six months for appointments, according to the county’s specialty care director, Dr. Paul Giboney.


In L.A. County, about 10,000 eConsult requests come in each month across more than 40 specialties. The program has the potential to become a national model: Giboney said health leaders in Illinois, Alaska, Connecticut and elsewhere have contacted him to ask about how the county’s program works.

But some primary care doctors have argued that they don’t have the skills, time or resources to manage patients who need more advanced care. In addition, the system isn’t set up to pay community physicians for the added work, tests or procedures that specialists request before seeing patients.

“Without any extra reimbursement, those costs are hitting the primary care providers,” said Dr. Richard Seidman, chief medical officer at Northeast Valley Health Corp., which runs several community clinics.

EConsult works better for some specialties than others. For example, an endocrinologist may be able to advise a doctor on how to manage the complications of diabetes or a cardiologist can suggest ways to manage a heart murmur but an ophthalmologist can’t treat cataracts through an electronic conversation. Nearly 90 percent of patients referred to ophthalmology end up with an in-person appointment.

Nevertheless, Dr. Lauren Daskivich, an ophthalmologist with L.A. County, said she no longer has to try to interpret one-line referrals and can more easily figure out what type of eye doctor a patient needs to see and how soon. “For the first time, we have actually been able to triage how urgently they need to get in,” she said.

Nationwide, the problem of access to specialists has eased somewhat due to the Affordable Care Act, which enabled more than 16 million people to get insurance. But the health law didn’t cover everyone, most notably people living here illegally, and specialists may not take the insurance that patients have.

Electronic consultation by itself can’t resolve the access problem for poor patients, said Dr. Nwando Olayiwola, associate director of UC San Francisco’s Center for Excellence in Primary Care, who studies these efforts nationally. “It solves a huge part of the problem but it doesn’t solve all of it,” she said.

For now, the Los Angeles County health care system is still overburdened. One doctor put it simply: Technology doesn’t solve the problems that were there before technology.

At the UMMA Community Clinic in South Los Angeles, more than 40 percent of patients remain uninsured and some have been in the queue for a specialist appointment for months. The clinic’s Dr. Cesar Barba says he’s grateful there is a way to talk to specialists and identify those who need to be seen more quickly.

The eConsult system helps, but it “is not the ideal,” Barba said. “The best solution is if we had more specialists. That would be ideal.”

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