Application of Behavioral Economics to Improve eConsult

Application of Behavioral Economics to Improve the Quality and Value of eConsult Specialty Reviews

Using behavioral economics, the study objective is to increase the efficiency, quality, and timeliness of care for Los Angeles County (LAC) Department of Health Services (DHS) patients by nudging specialists toward more effective use of eConsult, a web-based consultation and communication portal for Primary Care Providers (PCPs) and specialists, improving access for patients in greatest need of specialty care.

Study Overview

• Status: Completed
• Conditions: Quality of Health Care
• Intervention / Treatment: Behavioral: Rating tool; Behavioral: Feedback

Detailed Description

Historically, the Los Angeles County (LAC) Department of Health Services (DHS) Safety Net system has faced challenges in delivering specialty services that are timely, geographically equitable, and coordinated in a patient centered manner. Recently, LACDHS improved infrastructure through implementation of eConsult, a web-based consultation and communication portal for Primary Care Providers (PCPs) and specialists, improving access for patients in greatest need of specialty care. The study investigators will conduct a pragmatic randomized trial with the goal of increasing the efficiency, quality, and timeliness of care for LACDHS patients by nudging specialists toward more effective use of eConsult. If successful, these nudges may reduce the number and increase the value of face-to-face consults.

• Study Type: Interventional
• Enrollment (Actual): 220
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • California
    • Los Angeles, California, United States, 90012
      • Los Angeles County Department of Health Services

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• LACDHS providers who are eConsult system users

Exclusion Criteria:

• None

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Health Services Research
• Allocation: Randomized
• Interventional Model: Sequential Assignment
• Masking: None (Open Label)

Number of Arms

3

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Rating tool only; Rating eConsults from peer specialists in first phase	Behavioral: Rating tool; eConsult Specialty Reviewers are asked to rate the quality of other specialists' recently completed eConsult exchanges on the following four dimensions: 1) efforts to elicit additional information from PCPs, when needed; 2) medical decision making; 3) inclusion of educational content for PCPs, when appropriate; 4) perceived effect on the PCP-specialist relationship (i.e., overall tone of the eConsult exchange)
Experimental: Feedback only; Receiving feedback from peer specialists in first phase	Behavioral: Feedback; eConsult Specialty Reviewers receive confidential feedback via email on their performance (top performer vs not a top performer) as compared to colleagues in their specialty. Feedback is based on other reviewers ratings of their eConsult exchanges on the following four dimensions: 1) efforts to elicit additional information from PCPs, when needed; 2) medical decision making; 3) inclusion of educational content for PCPs, when appropriate; 4) perceived effect on the PCP-specialist relationship (i.e., overall tone of the eConsult exchange)
Experimental: Rating Tool plus Feedback; Both rating and feedback in second phase.	Behavioral: Rating tool; eConsult Specialty Reviewers are asked to rate the quality of other specialists' recently completed eConsult exchanges on the following four dimensions: 1) efforts to elicit additional information from PCPs, when needed; 2) medical decision making; 3) inclusion of educational content for PCPs, when appropriate; 4) perceived effect on the PCP-specialist relationship (i.e., overall tone of the eConsult exchange); Behavioral: Feedback; eConsult Specialty Reviewers receive confidential feedback via email on their performance (top performer vs not a top performer) as compared to colleagues in their specialty. Feedback is based on other reviewers ratings of their eConsult exchanges on the following four dimensions: 1) efforts to elicit additional information from PCPs, when needed; 2) medical decision making; 3) inclusion of educational content for PCPs, when appropriate; 4) perceived effect on the PCP-specialist relationship (i.e., overall tone of the eConsult exchange)

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Rating - Medical Decision Making	Peers' ratings of Medical Decision Making in Specialists' responses to PCPs	Baseline to Post-Intervention, up to 12 months
Rating - Application of Expected Practices	Peers' ratings of Expected Practices in Specialists' responses to PCPs	Baseline to Post-Intervention, up to 12 months
Rating - Relationship Building	Peers' ratings Relationship Building in Specialists' responses to PCPs	Baseline to Post-Intervention, up to 12 months
Rating - Expert Elicitation	Peers' ratings of Specialists' skill in elicitation of information from PCPs	Baseline to Post-Intervention, up to 12 months
Rating - Educational Value	Peers' ratings of Educational Value of eConsults	Baseline to Post-Intervention, up to 12 months

Collaborators and Investigators

• Sponsor: University of Southern California
• Collaborators: Los Angeles County Department of Public Health

Publications and helpful links

General Publications

• Lee MS, Ray KN, Mehrotra A, Giboney P, Yee HF Jr, Barnett ML. Primary Care Practitioners' Perceptions of Electronic Consult Systems: A Qualitative Analysis. JAMA Intern Med. 2018 Jun 1;178(6):782-789. doi: 10.1001/jamainternmed.2018.0738.
• Barnett ML, Yee HF Jr, Mehrotra A, Giboney P. Los Angeles Safety-Net Program eConsult System Was Rapidly Adopted And Decreased Wait Times To See Specialists. Health Aff (Millwood). 2017 Mar 1;36(3):492-499. doi: 10.1377/hlthaff.2016.1283.
• Behavioral Economics and eConsult Steering Committee; Meeker D, Friedberg MW, Knight TK, Doctor JN, Zein D, Cayasso-McIntosh N, Goldstein NJ, Fox CR, Linder JA, Persell SD, Dea S, Giboney P, Yee HF. Effect of Peer Benchmarking on Specialist Electronic Consult Performance in a Los Angeles Safety-Net: a Cluster Randomized Trial. J Gen Intern Med. 2022 May;37(6):1400-1407. doi: 10.1007/s11606-021-07002-1. Epub 2021 Sep 9.

Study record dates

Study Major Dates

• Study Start (Actual): March 1, 2017
• Primary Completion (Actual): August 31, 2018
• Study Completion (Actual): August 31, 2018

Study Registration Dates

• First Submitted: December 5, 2018
• First Submitted That Met QC Criteria: December 20, 2018
• First Posted (Actual): December 24, 2018

Study Record Updates

• Last Update Posted (Actual): December 24, 2018
• Last Update Submitted That Met QC Criteria: December 20, 2018
• Last Verified: December 1, 2018

More Information

Terms related to this study

• Other Study ID Numbers: HS-17-00077

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No