As a primary care physician of more than 25 years, Marie Sandoval, MD, has seen many routine patient visits unearth a serious health concern requiring follow-up care and specialist expertise. Such was the case in late November 2023, when Jack Galt, a long-time patient walked in for his annual visit.

I mentioned, as an aside, that sometimes I have chest pain while I’m riding my bike. I didn’t think much of it at the time to be honest, but Dr. Sandoval thought it was something we should investigate to be safe.

Jack Galt, Charlotte, Vermont

Dr. Sandoval ordered an electrocardiogram and stress test of Galt’s heart. His results were concerning, and Dr. Sandoval needed the insight of a cardiologist.

In the past, Dr. Sandoval, a physician at Adult Primary Care in South Burlington, would have needed to refer Galt for an in-person cardiology appointment. He would have had to schedule that appointment and wait until it arrived to find out what, if anything, was wrong. But instead, Dr. Sandoval simply submitted an eConsult – a digital consultation between primary care and specialist physicians – and in less than 24 hours got detailed guidance from cardiologist Kevin Carey, MD.

With shared access to Galt’s electronic health record, Dr. Carey was able to review clinical notes, assess the EKG and stress test and guide Dr. Sandoval in referring Galt for a cardiac catheterization procedure that would provide answers about his health condition.

Not long ago, the process may have taken several weeks, or more. Instead, Galt and his family received the clarity they needed in less than a week.

The eConsult bypassed a lot of back and forth and got me a wealth of information really quickly. Ultimately, because of that quick catheter procedure, I found out that I had blockages in the arteries around my heart, which was causing the pain. I’ve been going to cardiac rehabilitation since then, which has been a fantastic experience – I’ve been feeling so much better by just making some adjustments to my daily health regimen.

Jack Galt

Going from zero to 4,000

Dr. Sandoval is one of a growing number of providers at University of Vermont Health Network who are using new technologies that help them collaborate better on behalf of their patients, including eConsults.

Three years ago, eConsults were not yet an option. What began in 2021 as a pilot program where one primary care clinic had access to a handful of specialties in Chittenden County has spread across UVM Health Network to include more than 20 specialties, including endocrinology, cardiology, pulmonology, and rheumatology, with others continuing to join.

In the first few months, providers ordered about 300 eConsults. In 2023, the first full fiscal year of the program, providers ordered 1,770 eConsults. In fiscal year 2024, providers are on track to order more than 3,600 eConsults. The team has set a goal of 4,000. May saw the single highest usage of eConsults since the program kicked off, with 381 eConsults ordered by clinicians across the health system.

“eConsults are about non-urgent medical collaboration at speed: a secure digital consultation that primary care physicians like me can request from a specialist for certain medical concerns,” says Dr. Sandoval, who also serves as the medical director of digital health for UVM Health Network. “They’re one of many bright spots we’re seeing as we adopt more tools and technologies to transform how we work together to care for our patients, and they are truly helping us to elevate the care we can provide from primary care.”

Rapid growth in digital tool use helps improve access to care

New digital tools like eConsults are quickly becoming a clinical essential for many primary care and specialist providers across UVM Health Network, opening new pathways for people in Vermont and northern New York to receive expert care, no matter where they enter the system.

“This is helping us to make the most of our capacity and treat more of our patients in the primary care setting, which is more comfortable and convenient for most people,” says Teresa Fama, MD, a driver of the Network’s eConsult strategy and a rheumatologist at UVM Health Network – Central Vermont Medical Center. “From the beginning, we saw eConsults as a way to improve the quality of in-person referrals and cut back on the number of referrals that, with the right guidance, could otherwise be addressed by a person’s primary care provider.”

In addition to the benefit to patients of getting answers about their health more quickly than in the past, the technology is easing backlogs at specialty clinics at a time when high demand for care, coupled with a persistent and severe workforce shortage, leads to longer-than-expected wait times for certain specialties.

Typically completed within a week, eConsults often negate the need for a separate, specialist appointment altogether – saving patients both time and expense. Early data show that more than three quarters of eConsults have provided enough information to primary care providers and patients that the health care concern can be managed without an in-person visit to the specialist. Only 13% of cases result in a separate specialist visit in the nine months following the eConsult.

Collectively, this is opening up much-needed capacity for those patients who do require in-person appointments. As one example, rheumatology at UVM Medical Center and Central Vermont Medical Center, one of the health system’s busiest specialties, eConsults have decreased average monthly referral volumes by 11%.

Getting the most of a specialist referral when it’s needed

When a specialist and primary care provider determine that a patient needs to be seen in person quickly, UVM Health Network has developed what are called ‘enhanced referrals’ for many specialties to ensure that appropriate patients are given earlier appointments.

Accessed through the Network’s electronic health record system, enhanced referrals direct providers to order eConsults when appropriate, while also offering further guidance on which tests, lab work, imaging or other information should be collected prior to a person’s visit to a specialist, thereby strengthening the quality of the specialist visit and the patient’s experience.

This means that when people arrive at our clinic, they have everything in hand to make our visit with them as productive as possible. We have so much more information at our disposal that helps us to diagnose and treat that person then and there, rather than having to wait for initial tests to be ordered.

Teresa Fama, MD

And once a patient has been treated by a specialist and their condition is well-managed, providers are participating in another initiative to transition them back to primary care for ongoing maintenance.

This ‘refer back’ initiative aims to address the fact that historically, many people continue to routinely see specialists even when they no longer require specialty care, which in turn impacts access for new and existing patients. Since the initiative launched in October 2023, 500 patients receiving care from specialists have been ’referred back’ to their primary care providers by 17 specialists for ongoing care.

Growing eHealth technologies

eConsults and enhanced referrals are two pieces of a growing collection of initiatives being implemented to improve access to care, and the care experience itself, across UVM Health Network. Also on the way is technology that will allow patients to schedule their own appointments online through MyChart, as well as a system that will allow patients to sign up through text and MyChart messages for appointments that have opened up due to patient cancellations. As part of the health system’s focus on care equity, future efforts will include expanding access to eHealth technologies to primary care practices outside of the health system, including those that may not use the same electronic health record.