Gastroenterology and Primary Care Partner to Improve Access and Outcomes for Patients

How long should a patient have to wait for an appointment with a medical specialist? Three days? Three weeks? The answer may seem obvious, but in the U.S., many people wait weeks or months for even urgent appointments.

In 2020, the Department of Medicine’s divisions of primary care medicine and gastroenterology (GI) decided to further the progress it had already made in shortening wait times for general gastroenterology clinic appointments.

Primary care is the point of entry to the health care system for most patients. And among the medical subspecialties, GI is one of the most frequent referrals for specialist care.

From left: Thomas Zikos, MD; Philip Okafor, MD, MPH; Atul Shah, MD; and W. Ray Kim, MD

With patient volume increasing at Stanford Health Care, this referral pattern prompted the formation of the Primary Care/GI Partnership, an initiative designed to assure that patients are seen by a general gastroenterologist in a timely manner. The goal is to improve both access and quality of care.

Working as a team, the Department of Medicine’s GI division and Stanford Health Care primary care physicians at the Hoover Pavilion (one of Stanford’s largest primary care clinics) created a prototype for achieving these goals.

“If our model works, we could scale it across all primary care locations and possibly to other subspecialities,” says Philip Okafor, MD, MPH, clinical assistant professor in the division of gastroenterology and hepatology.

The framework for the Primary Care/GI Partnership is based on close collaboration to assure prompt access to high-quality specialty care. The expectation is that this partnership will result in improved value and patient satisfaction, which is likely to lead to better patient outcomes.

Four Critical Components

The Primary Care/GI Partnership has four components:

1

The Community GI Group

Three Department of Medicine gastroenterologists (Philip Okafor, MD, MPH; Atul Shah, MD, clinical assistant professor; and Thomas Zikos, MD, clinical assistant professor) form the Community GI Group of academic gastroenterologists. These three physicians are dedicated to accepting referrals from the primary care physicians at the Hoover Pavilion. The group works under the direction of the chief of gastroenterology and hepatology, W. Ray Kim, MD.

The mission of the Community GI Group is to speed access and improve communications for both primary care physicians and patients. The group maintains a dedicated inbox on Epic, Stanford Health Care’s electronic medical record system, to support direct communication between gastroenterologists and primary care physicians.

When a primary care physician enters a gastroenterology referral in Epic, he or she can then reach out directly to the Community GI team via the dedicated Epic inbox, if needed. The primary care physician can discuss details about the patient directly with the Community GI team—for instance, if he or she wants tests done before the clinic visit.

In addition to prompt feedback for the primary care physician, the Community GI Group has reserved slots in their clinic schedules to enable them to see urgent referrals.

The system is working to reduce access time and to provide quality care, according to Okafor.

“For example,” he says, “I received a message in our Epic inbox about a primary care physician’s patient who was anemic. I was able to schedule a visit with that patient within days, using one of our reserved scheduling slots. And at the same time, I proactively reserved time for an endoscopy procedure to follow the clinic visit. Within a week, that patient was seen in clinic, underwent their procedure, and had a diagnosis.”

2

Electronic Consults (eConsults)

In addition to reserving schedule slots for urgent appointments, the Community GI Group covers eConsult referrals to gastroenterology. This platform had been established prior to the start of the Primary Care/GI Partnership and is ideal for managing less urgent clinical issues for lower-acuity patients, freeing up clinic time for patients who need immediate care.

A primary care physician can access one of the community GI physicians to ask a question or get information about a patient’s condition. The specialist can then advise the primary care physician about appropriate medications or tests without the need for a GI visit.

Data collected in 2020 indicate the following:

Most of the GI eConsults take less than 20 minutes.

Sixty-five percent of GI eConsult calls were resolved without the need for additional follow-up.

The expectation is that the issue will be resolved within three days, but nearly 90% of the issues were resolved in less than two days and about 75% on the same day. And for patients who did require a clinic visit, 90% were seen within two days.

3

MD2MD Phone Contact System

The Community GI Group also covers the MD2MD phone system for gastroenterology. When primary care physicians have a case that requires immediate attention, they can contact a gastroenterologist by paging the Community GI team via the Epic system, which connects the two physicians via telephone.

For example, Okafor remembers an MD2MD phone call he received from a primary care physician whose patient was being admitted to the hospital for a kidney procedure. The primary care physician wanted to know if one of the Community GI team members could help facilitate an endoscopy on the patient while the patient was in the hospital so that she could avoid having to return for the procedure later. “We took care of that patient and saved her the inconvenience of coming back,” says Okafor. “She was discharged the very next day.”

4

Clinical Management Pathways

The Primary Care/GI Partnership is creating evidence-based clinical management pathways, which describe the essential steps needed to care for a patient with a clinical problem (in this case, common GI conditions). Designed for use by primary care physicians, the first one is an acid reflux management pathway that guides the physician in the decision-making process, including when a referral to gastroenterology is appropriate.

The pathways are developed in close collaboration with the primary care physicians. They are available through the Epic system for easy access. If this proves useful, the group will develop clinical pathways for other GI conditions, such as irritable bowel syndrome and colorectal cancer screening.

Improving outcomes for patients

The overriding impetus for the Primary Care/GI Partnership is improving quality of care for patients. It is likely that doing so will also decrease the cost of that care, but for now the focus is on access and getting patients into care faster.

“Patients notice how quickly they are able to get an appointment,” Okafor comments. “One patient was amazed that he called for an appointment on a Friday and was able to see me the following Monday!”

“Patients notice how quickly they are able to get

an appointment. One patient was amazed that

he called for an appointment on a Friday and

was able to see me the following Monday”

“Patients notice how quickly they are able to get

an appointment. One patient was amazed that

he called for an appointment on a Friday and

was able to see me the following Monday”

Over the next few years, the team will evaluate the prototype to quantify its impact. If it demonstrates improvements, the program may be scaled into other Stanford Health Care primary care locations.

“A personal outcome of our program has been my getting closer to the primary care physicians,” adds Okafor. “They’re not just names on a form now. I know who they are and what they need, which I believe improves communications for the patient’s benefit.”