Implementing Project CORE (Coordinating Optimal Referral Experiences) in a Large Children's Hospital.

Background: Poor communication and coordination between primary care providers (PCPs) and subspecialty providers (SPs) results in fragmented care and patient dissatisfaction. Project CORE was initiated in 2011 to enhance communication and coordination between PCPs and adult SPs in 5 academic medical centers (AMCs) through enhanced referral (ER) processes and asynchronous electronic consultations (ECs). We sought to apply that model in a large childrens hospital as part of a global initiative to improve access to care and enhance collaboration between PCPs and pediatric SPs. Objective: 1) To integrate ERs and ECs for 20 pediatric subspecialties into the electronic health record (EHR) used by the hospital and 22 affiliated PCP practices. 2) To demonstrate the feasibility of using templated decision support to ask clinical questions that allow comanagement of pediatric patients without an in-person SP encounter. Design/Methods: Subspecialty specific templates for pediatric subspecialties were developed through a collaborative process including PCPs and SPs. These templates were embedded in the ER and EC processes of the EHR. After appropriate training, CORE launched in 4 PCP practices in 8/18. Additional subspecialty templates were developed and added through subsequent Plan-Do-Study-Act (PDSA) cycles over the next 15 months. After 4 PDSA cycles, the functionality was opened to all PCP practices. Utilization of ER and EC was measured throughout implementation; PCP and SP satisfaction was assessed in 10/19. All clinical questions were reviewed for appropriateness and clarity; appropriate feedback was provided to the PCP and/or SP when indicated. Results: From 8/18/19 through 4/1/20, 5976 ERs and 572 ECs were ordered by PCPs from 22 participating practices. 523 ECs were completed by SPs in 15 pediatric subspecialties. 49 (9 %) of ECs were converted to in-person encounters with the PSP. Endocrinology, dermatology, gastroenterology and orthopedics were most common ECs. 98% of ECs were completed in less than 20 minutes. For some subspecialties, ECs accounted for up to 30% of their contacts with participating PCPs. (see graph). Quality review identified no serious safety events. PCP and SP satisfaction with the ER and EC process remained high throughout implementation. Conclusion(s): The ER and EC developed for adult practitioners though Project CORE can be successfully implemented in a large childrens hospital, improving collaboration between PCPs and SPs. ECs may account for a substantial referral volume in some pediatric subspecialties.