Analysis of the implementation of an innovative IT solution to improve waiting times, communication with primary care and efficiency in Rheumatology

Rheumatic and musculoskeletal diseases (RMDs) are highly prevalent; up to 28.9% of the population would consult their doctor for one such condition in any given year [1]. RMDs pose a significant challenge in terms of health resources, workplace absenteeism, and socio-economic impact. RMDs affect the lives of workers, both personally and through family members they must take care of [2].

Despite their frequency, RMDs are often not properly addressed, unless seen by rheumatologists [3]. However, studies show a trend towards a decrease in the number of specialists available [4‐7]. This shortage of rheumatologists is counterintuitive, given the increase in demand for rheumatological care as population ages [8]. As a way to absorb the demand and to avoid overloading the health system, Primary Care Physicians (PCPs) provide rheumatological care and refer as few patients as possible to Rheumatology. Many times, this strategy results in delayed important diagnoses [9].

The 'traditional' model of referral from Primary Care (PC) to specialized care works on a first-come, first-served basis [10]. Referrals to rheumatologists range widely from routine referrals for soft-tissue conditions, where non-rheumatology care may be more appropriate, to urgent cases (e.g., systemic vasculitis or systemic lupus erythematosus flare). Inefficiencies in the scheduling and delivery of care through this referral model can result in a delayed access to first consultations. This may affect patients in need of priority assistance, either to palliate an acute disability, or to minimize chronic damage [7, 10‐12]. As a paradigm, accurate and rapid recognition of patients with rheumatoid arthritis and other types of inflammatory rheumatic diseases is essential, as early diagnosis and intervention improve long-term outcomes [13]. Given the current scenario in relation to the shortage of rheumatologists, innovative healthcare models are required [14].

In the Vigo Health Area (North West of Spain), we have implemented one such innovative pathway to improve the referral process of patients with RMDs by applying information technology (IT) tools and telemedicine to improve communication between the PCPs and the Rheumatology team. The main aims of this telehealth program are the prioritization of referrals in a sensible way, the optimization of time to Rheumatology consultation, and the improvement of clinical problem resolution. In this article, we describe the program in detail and present the results of the implementation study so that it can be replicated and adapted elsewhere.

The core elements to support the implementation of an innovative health program are the context or environment, the analysis of the situation, the implementation team, the definition of aims, users and scope, program phases, and evaluation [15, 16].

Figure 2 shows the clinical process circuit for rheumatology e-consultation. All processes and algorithms were agreed upon by PC medical directors.

In summary, any suspected RMD is recorded by the PCP onto the IT system (IANUS) and, following the pre-agreed criteria, priority of referral is established and the specific tests requested (Fig. 3).

The e-consultation request submitted by the PCP with a priority tag specifying the waiting time for an e-consultation (less or over 5 days) is received by Rheumatology. In the e-consultation, a rheumatologist analyzes the information provided together with the diagnostic tests and either advises the PCP on the way to proceed by means of an e-report, or sets a face-to-face appointment for the patient (sometimes, also requesting further tests electronically). Then, an assistant contacts patients to provide details about the date of appointment and possible further tests to be done before the face-to-face consultation. Some patients, i.e., those referred to bone densitometry are managed directly through the IT system via a specific circuit including a fracture risk score calculation inserted in the intranet. These patients are not seen face-to-face in Rheumatology unless the results of the densitometry are unfavorable, and osteoporosis is severe or secondary, in which case, an appointment is set by an assistant.

All PCPs of the area (100%) channeled referrals to Rheumatology through the proposed program (Electronic History and Electronic Request Manager).

Before the program, patients referred from PC to Rheumatology had to wait for a long time before their first face-to-face visit. In the case of minor clinical problems, these could have been solved immediately, without requiring a visit to the hospital. After the implementation of this e-consultation program, waiting times were significantly reduced, while assuring prioritization of inflammatory diseases, and improving communication between health care levels. Furthermore, the overall optimization of the waiting list had a positive effect on referrals from other specialties as well as reductions in waiting times due to wider availability of consultation slots.

In general, most studies of health services in Rheumatology show a significant consultation delay of patients with inflammatory diseases [23‐26]. Even though referral criteria and early management constitute a key aspect of the primary care and specialist interface [13], there are delays due to systemic inefficiencies in the referral process, scheduling, and care delivery, that may preclude access to specialist care, thereby increasing waiting times [10, 12, 14].

The situation in our area prior to the implementation of the integrated e-consultation program, was no outsider to such inefficient context. This could be defined by the following characteristics: 1) all referrals to Rheumatology were made for face-to-face visits; 2) absence of a prioritization scheme (i.e., a patient with a recent onset arthritis had to wait as much as a patient with suspected osteoporosis); and 3) many first visits to Rheumatology required additional consultation. Many of the patients referred to Rheumatology could have easily avoided the visit, many others requiring specialist attention had to wait too long for a visit.

The success of the implementation of the program was based on two fundamental aspects: the involvement and consensus of all stakeholders and the establishment of the electronic referral as the only way to access Rheumatology. All the information on the e-forms, including referral criteria and tests to be performed, as well as the circuits to be followed, had been agreed upon by the rheumatologists and PCPs in the area. The program was presented at each PC center by a representative of both the board of directors and Rheumatology. Also, the involvement of the IT Department since the beginning of the project made its implementation in the intranet accessible to all [27]. Patients could only be referred to Rheumatology through e-consultation, and the IT system included tools to help prioritize and diagnose in advance, which eased the way to both the PCPs and the rheumatologists. In summary, such a thorough process led to a successful implementation as previously suggested by other authors [28]. It is important to highlight at this point that there was an agreement not to apply this referral system to rheumatologic emergencies, such as suspected septic arthritis, or giant cell arteritis. In these cases, patients have to be referred by the PCP directly to the Emergency Department, which has to contact Rheumatology by telephone, or arrange an e-consultation within 24 hours.

A significant proportion of the attention to chronic diseases (among them, RMDs), would not require patients’ attendance by medical specialties and could be managed by PC if there was a channel of agile and immediate communication between this and the specialists. Even before the COVID-19 pandemic, it was obvious that many situations could be managed by Rheumatology without a face-to-face visit [29]. This has been made even clearer during the pandemic [30‐34]. Nevertheless, we tend to think of telemedicine as a virtual visit, but there are other ways to solve a case referred by a PCP such as a chat, an e-mail or report, that do not involve the patient.

This type of consultation has a positive impact on both levels of care since mutual interaction, trust and learning between PCPs and rheumatologists are greatly enhanced.

It is necessary to prioritize patients’ attention based on adequate and reliable clinical information provided by the PCP to offer individualized care according to the particular situation and demand of each patient. This prioritization can be established by rheumatologists in a triage stage, through protocols previously agreed upon with the PCPs [10, 14, 24, 35, 36]. Better results can be obtained, saving the time used by the rheumatologist in consultations, by doing this triage with IT systems in place, as in our program.

Such a strategy should always be implemented in close coordination with the PCPs, this being the reason why they have been involved in every stage of the process.

One of the most outstanding aspects of our study is the reduction in waiting times for a first face-to-face visit. Before the implementation of our strategy, the average waiting time was 83.1 days, with virtually all patients within 2-3 months. Only very occasional cases had waiting times longer than one year (exceptional patients who were referred for review in 1.5-2 years and who were registered as first visits). Once our project was launched, the average waiting time for a first face-to-face visit was reduced by approximately 85%. A key aspect of any waiting time management strategy is the coordination between administration and triage of referrals. Much work has been done to define the best referral system. Single-entry models have been used successfully in some service industries, where users 'gather' at a single-entry point to access the first service available. These could represent a useful approach to reducing waiting times for health services when, for example, waiting times between consultants are variable, as patients who wait longer can be scheduled for the next available slot [37, 38]. Although there are benefits reported for centralized referral systems, these apply to homogenous patient populations requiring a specific procedure. However, their positive impact on the population of RMD patients, characterized by a high variability in diagnosis and urgency of referrals, is not clear [14]. This is where our work offers a real innovation. By evaluating all the reasons for consultation, on the one hand we give greater autonomy to PCPs (who can now order directly a bone densitometry, for example) and, on the other hand, we give priority to patients with more serious conditions. All this takes place in a collaborative environment between PCPs and specialists for the resolution of cases with bidirectional e-consultations. Rheumatology and PC professionals, despite the fact that they had to learn how to use a new IT tool, soon discovered that it was also useful for rapid patient assessment. For the PCP, screening tools are always helpful and become true learning experiences. At the organizational level, the institution had already a common integrated electronic medical record between PC and Rheumatology, but there was clear room for improvement, especially at referral level.

Other aspects of the evaluation of implementation are still missing. Although our perception was that both provider and patient satisfaction were really high, we have not assessed the experience of patients and providers with this process, or safety outcomes. Unfortunately, as we had no prior indicators for these aspects before the program implementation, a comparison was not possible. On the other hand, we did not have excessive problems from the PCPs when implementing our project, likely due to the previous explanation of its characteristics and the degree of consensus reached. The greatest reluctance came from the rheumatologists, in relation to the change in working procedures. This initial resistance was overcome when they began to perceive the advantages that the strategy entailed both for the patient and for the services involved in it.

From a cost-effectiveness point of view, and after the 12-month part-time period allocated by a rheumatologist to its development and implementation, the program has not involved any additional financial costs to the Public Health System. Even when we did not perform a formal economic evaluation, using the technical resources already existing in the system, not requiring the hiring of personnel and avoiding the displacement of the patient, is inescapably associated with saving money.

Despite its encouraging results, our work may have some limitations. The fact that it has focused only on the Vigo Health Area may limit the extrapolation of the results. In turn, our program could be considered for implementation by other health areas. Another possible limitation is the certain degree of digitalization required, which in some places can be a problem.

In summary, innovative circuits and e-consultation tools widely agreed upon by users achieved a more efficient referral from PC to Rheumatology in the Vigo Health Area. Patients requiring priority consultation are now assessed in the shortest time possible. All other patients wait only a little longer in favor of the first. In addition, the communication between PCPs and rheumatologists was strengthened and facilitated, providing the former with greater resolution capacity.