Background/Purpose: Specialty care is traditionally delivered as face to face consults.  These encounters range from consult not needed to consult needed quickly.  Our care systems are not designed to distinguish these different needs, creating excess visits that delay access. This delay results in overutilization and unnecessary expense (consult not needed), underutilization of needed care and worsening disease (consult needed quickly), and potential harm and patient anxiety (both). To provide specialty care just when it is needed, we developed Ask-a-Doc, a web-based tool accessed from within the electronic health record (EPIC).

Methods:   Ask-a-Doc was developed using process redesign methodology.  Ask-a-Doc allows the Primary Care Physician (PCP) to ask a question and the specialist to answer it through electronic chart review, phone call, or video call.  Ask-a-Doc consists of 3 steps: Step 1 – ask a question (PCP).  Step 2 – connect to the specialist (Scheduler).  Step 3 – answer the question and complete the documentation (Specialist).  23 PCPs, 7 schedulers, and 11 specialists (6 rheumatologists, 5 pulmonologists) were trained to use Ask-a-Doc.  Redesign measures included service excellence, work effort, process reliability, and clinical outcome.

Results:    Step 1 – The PCP selected a specialty or specialist, turnaround time (now, today, within 3 days), preferred mode of communication (electronic messaging, phone call, instant video), and asked a question.  The question could be patient-specific or not patient-specific.  The request was submitted electronically to the Ask-a-Doc scheduler.  Step 2 – The scheduler identified the correct specialist and sent the form to that specialist’s Ask-a-Doc inbasket folder.  If the request was to communicate by phone or video, the scheduler connected the specialist back to the PCP.  Step 3 – the specialist reviewed the EPIC record, answered the question, and provided structured electronic documentation.  Analysis of the first 74 Ask-a-Doc questions showed the following (Table 1):  Service excellence – Primary care satisfaction of 4.5 (range 0-5), mean turnaround time of 3 hours, met or exceeded requested timeframe 100%.  Work effort – 12 minutes average per message.  Process – 100% response rate.  Outcome – 57 consults saved (77%).

Conclusion:   Using process redesign methodology, we developed Ask-a-Doc to improve care delivery between PCPs and specialists.  The results demonstrate excellence in service, a highly reliable process, and significant reduction in waste.  Ask-a-Doc provides specialty care “just-in-time”, so patients that don’t need to be seen are not, and those that do can be seen promptly – by design, not by accident.  As reimbursement for care delivery moves towards bundled payments, Ask-a-Doc is a value-added service that rheumatologists can provide.