The VCC: Remote Written Second Opinions and e-Communications

By Liz Switzer

As we close out our series on the Virtual Care Clinic (VCC), this week we focus on how a patient gets a second opinion while never leaving home.

Medicine physicians are partnering digitally with the PDC on a Remote Written Second Opinion, which launched in February and allows patients to request a remote review based on their medical records. About eighty-five percent of the second opinion requests have been assigned to Medicine faculty, according to Blake Cameron, MD, MBI, associate professor of medicine and medical director of Telehealth and Access Innovation, Private Diagnostic Clinic (PDC) and the Digital Strategy Office (DUHS).

As one of the top hospitals in the country, Duke specialists are nationally recognized for their expertise, and the Second Opinion service further advances Duke’s national reputation with its reach beyond the health system’s traditional Southeast market area.

A couple of dozen cases have so far come through, the majority of which are in orthopedics and oncology, some of which are requests to vet the care of patients that are not going to a nationally designated cancer center. Insurance, however, is not accepted and the upfront cost is $1,500, which covers the cost of gathering records and the physician’s time to generate a report.

e-Communications

The e-Communications program—provider-to-provider requests for a specialist to review a patient’s case and provide recommendations based on chart review—started with nephrology, expanded to endocrinology and rheumatology, and at the height of COVID-19, nearly every specialty began using it. The program goal is to break down barriers of communication between providers. It began in collaboration with primary care, but has since extended to include specialty-to-specialty communications as well.

The benefit for Afreen Shariff, MD, assistant professor and director of the new Duke Endo-Oncology Program, was dramatic. When she started the Endo-Oncology e-communication service during the peak of COVID in May 2020, her first priority was to address the bottleneck experienced by cancer patients to access timely endocrine care. The wait time for a cancer patient to see endocrinology was an average 87 days. Two years later, the average wait time for receiving recommendations is down to just two days which has not only dropped time to recommendation but also helped reduce preventable hospitalizations.

See New Endo-Oncology Program is Reducing Wait Times and Hospital Admissions

Since the initial launch of E-Communications in 2016, there have been over 23,000 uses. Results show substantial efficiency. Interactions between primary care and specialty medicine providers are estimated to have avoided 55% of proposed visits by simply answering a question or supporting primary care physicians with medical guidance. The program has cumulatively saved patients more than 500,000 miles driving to appointments.

“This is one of the most transformative things that that we've done at Duke to improve coordination between primary care and specialty medicine,” says Cameron, who started the program. “We have created the ability for providers to talk to each other about patient care in an efficient way that has, I think, taken the place of the informal ‘curbside consults’ that were commonplace in the past when general internists rounded in the hospital and rubbed shoulders with specialist colleagues.”

Moving forward, ultimately the topline goal of streamlining the patient experience calls for aligning all of the work digital health in the same direction around a single patient journey. As a practical matter, an array of digital tools—and there are dozens of others like MyChart—will support the end goal.

“We want patients to know what to expect at each step of the journey, and to easily access whatever services they need, without feeling like they have to navigate bureaucracy,” Cameron said. “No one wants to see the doctor, but we aspire to make each visit – and the experience surrounding it – the most pleasant medical appointment the patient has ever had.”

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