Efficiency Gains for Rheumatology Consultation Using a Novel Electronic Referral System in a Safety-Net Health Setting

COVID-19: Effect on gastroenterology and hepatology service provision and training: Lessons learnt and planning for the future

In late 2019, reports arose of a new respiratory disease in China, identified as a novel coronavirus, severe acute respiratory syndrome coronavirus 2. The World Health Organisation named the disease caused by the virus 'coronavirus disease 2019 (COVID-19)'. It was declared a pandemic in early 2020, after the disease rapidly spread across the world. COVID-19 has not only resulted in substantial morbidity and mortality but also significantly impacted healthcare service provision and training across all medical specialties with gastroenterology and Hepatology services being no exception. Internationally, most, if not all 'non-urgent' services have been placed on hold during surges of infections. As a result there have been delayed diagnoses, procedures, and surgeries which will undoubtedly result in increased morbidity and mortality. Outpatient services have been converted to remote consultations where possible in many countries. Trainees have been redeployed to help care for COVID-19 patients in other settings, resulting in disruption to their training - particularly endoscopy and outpatient clinics. This has led to significant anxiety amongst trainees, and risks prolongation of training. It is of the utmost importance to develop strategies that continue to support COVID-19-related service provision, whilst also supporting existing and future gastroenterology and Hepatology services and training. Changes to healthcare provision during the pandemic have generated new and improved frameworks of service and training delivery, which can be adopted in the post-COVID-19 world, leading to enhanced patient care.

Identifying Content Themes in Primary Care Physician and Rheumatologist Communications Within Electronic Consultations: A Qualitative Study

Objective

Electronic consultation (eConsult) communications between primary care physicians (PCPs) and rheumatologists may reveal common knowledge gaps and educational opportunities. The aim of our study was to identify content themes in PCP questions and rheumatology recommendations through analysis of eConsult and the need for rheumatology appointments and facilitated urgent visits post‐eConsult.

Methods

A descriptive cross‐sectional study involving qualitative and quantitative analysis of rheumatology eConsults in a single center was performed from May 1, 2019, to January 9, 2020. Conventional content analysis was used to derive content themes in PCP questions and rheumatology recommendations. We evaluated the proportion of eConsults, which included a need for rheumatology appointments and expedited visits through frequency counts.

Results

Among 120 rheumatology eConsults, six PCP questions and five rheumatology recommendation content themes were identified. The most common PCP question themes were the following: 1) joint pain, 2) suspected rheumatic disease differential, and 3) abnormal laboratory tests. The most common rheumatology recommendation or teaching themes were the following: 1) education on differential diagnoses of rheumatic diseases, 2) education on the specific rheumatic disease, and 3) laboratory test interpretation. The majority of eConsults (82%) recommended a subsequent rheumatology appointment, and 27% facilitated an expedited appointment.

Conclusion

In this analysis of eConsults, we identified common knowledge gaps in PCPs and rheumatology educational topics, including differentiating inflammatory from noninflammatory arthritis, using caution in interpreting abnormal laboratory tests without clinical manifestations, managing chronic gout, evaluating elevated creatine phosphokinase levels, and differentiating C‐reactive protein (CRP) from high‐sensitivity CRP. Timely feedback through eConsult recommendations may allow for focused educational opportunities.

Leveraging Telemedicine as an Approach to Address Rheumatic Disease Health Disparities

Telerheumatology is the application of telehealth to rheumatic disease. Although generally acceptable to both providers and patients, little is known about the safety of telerheumatology or about when, how, and for whom it is best used. Telerheumatology's impact on the rheumatology workforce as well as access to care and health disparities in rheumatic disease is not known. These outcomes likely will depend on the specific telemedicine modalities employed.

Managing patients using telerheumatology: Lessons from a pandemic

The coronavirus disease 2019 (COVID-19) pandemic has presented unique challenges to rheumatology provision. Measures to control the pandemic have limited face-to-face contact with rheumatology healthcare professionals. One innovation has been the widespread adoption of telerheumatology to assist in the care of patients with rheumatic and musculoskeletal diseases, building on an existing evidence base in rheumatology. Widespread adoption has only occurred following the COVID-19 pandemic. We discuss the evidence supporting telerheumatology adoption prior to the pandemic, and outline several innovative approaches used to assist in the care of rheumatology patients that have been introduced. Alongside the advantages of these interventions, we discuss the limitations and regulatory challenges. Advances must be balanced, considering wider issues of equity of access, implementation, adoption, and sustainability of telerheumatology post-pandemic. We propose it is not ‘if’, but ‘how’ rheumatologists embrace newer telerheumatology technology, outlining practice points and future research agenda.

Electronic consultations (E-consults) and their outcomes: a systematic review

OBJECTIVE

Electronic consultations (e-consults) are clinician-to-clinician communications that may obviate face-to-face specialist visits. E-consult programs have spread within the US and internationally despite limited data on outcomes. We conducted a systematic review of the recent peer-reviewed literature on the effect of e-consults on access, cost, quality, and patient and clinician experience and identified the gaps in existing research on these outcomes.

MATERIALS AND METHODS

We searched 4 databases for empirical studies published between 1/1/2015 and 2/28/2019 that reported on one or more outcomes of interest. Two investigators reviewed titles and abstracts. One investigator abstracted information from each relevant article, and another confirmed the abstraction. We applied the GRADE criteria for the strength of evidence for each outcome.

RESULTS

We found only modest empirical evidence for effectiveness of e-consults on important outcomes. Most studies are observational and within a single health care system, and comprehensive assessments are lacking. For those outcomes that have been reported, findings are generally positive, with mixed results for clinician experience. These findings reassure but also raise concern for publication bias.

CONCLUSION

Despite stakeholder enthusiasm and encouraging results in the literature to date, more rigorous study designs applied across all outcomes are needed. Policy makers need to know what benefits may be expected in what contexts, so they can define appropriate measures of success and determine how to achieve them.

Factors affecting the successful implementation of the referral system: A scoping review

An effective referral system ensures that there is a close relationship among all levels of health care, and individuals can receive the best possible care. The main purpose of the present study was to summarize studies that have addressed factors affecting the successful implementation of the referral system. A scoping review was performed to identify English and Farsi papers that were indexed in PubMed, Scopus, Science Direct, Trip Database, Cochrane Library, Embase, Google Scholar, SID, and Magiran until November 2020. Data was collected from the included studies by a reviewer and was checked by a second reviewer the collected data was analyzed using narrative methods. About 1245 relevant studies were identified in the first stage. After checking titles and abstracts, 63 studies were included. The factors that affected the referral system were classified in 4 themes and fourteen subthemes including technology (electronic referral, coordination, response and feedback), processes (effectiveness, efficiency), organizational (management, policy and planning, rules and regulations), patient centered individual (insurance coverage, social capital, transportation, awareness, attitude, satisfaction, and social influence). Therefore, a wide range of factors are affecting the performance of referral systems. For implementing an effective referral system, it is necessary to consider these factors.

A comparison of faxed referrals and eConsult questions for rheumatology referrals: a descriptive study

BACKGROUND

In Canada, wait times for access to specialized rheumatology services have increased, leading to new strategies to improve timely care; electronic consultations (eConsults) enable providers to ask specialists a clinical question using a secure platform, often reducing the need for a face-to-face visit. In this study, we sought to compare the types of referrals received through fax versus eConsult and to determine whether faxed referrals could be addressed using eConsult.

METHODS

We conducted a descriptive study of consecutive faxed referrals sent to a tertiary care centre between Feb. 1 and Mar. 6, 2017, and a convenience sample of eConsults directed to rheumatology between Feb. 1, 2015, and Sept. 30, 2016, through the Champlain BASE eConsult Service, an Ontario-based service. We reviewed all referrals and categorized them by clinical content and question type. A rheumatologist with experience completing eConsult referrals assessed faxed referrals for their suitability to be answered through eConsults. Descriptive statistics were generated.

RESULTS

We analyzed 300 consecutive faxed referrals and 300 (of 470) eConsult referrals. Faxed questions more often pertained to rheumatoid arthritis (32/300 [10.7%] v. 17/300 [5.7%]), systemic lupus erythematosus (24/300 [8.0%] v. 10/300 [3.3%]), and polyarthritis (30/300 [10.0%] v. 18/300 [6.0%]). eConsults more often addressed abnormal serology without joint symptoms (27/300 [9.0%] v. 8/300 [2.7%]) and gout (15/300 [5.0%] v. 4/300 [1.3%]). Faxed referrals were more likely to have no specific question (116/300 [38.7%]), and eConsults were more likely to have more than 1 question posed (99/300 [33.0%]) and a drug-related question (67/300 [22.3%]). The rheumatologist identified potential benefit from eConsult in 216/300 (72.0%) faxed referrals and 55/59 (93.2%) declined faxed referrals.

INTERPRETATION

Despite differences in diagnosis between eConsults and faxed referrals, most faxed referrals showed the potential to be addressed through eConsult. Using eConsult may allow primary care providers to obtain answers to questions without requesting a face-to-face specialist referral, or provide support for patients awaiting face-to-face consultation.

Using Process Improvement and Systems Redesign to Improve Rheumatology Care Quality in a Safety Net Clinic

OBJECTIVE

To develop and evaluate interventions to improve quality of care in 4 priority areas in an urban safety net adult rheumatology clinic serving a racially/ethnically and socioeconomically diverse patient population.

METHODS

The Institute for Healthcare Improvement's Model for Improvement was used to redesign clinical processes to achieve prespecified benchmarks in the following areas from 2015 to 2017: 13-valent pneumococcal conjugate vaccine (PCV13) administration among immunocompromised patients; disease activity monitoring with the Clinical Disease Activity Index (CDAI) for patients with rheumatoid arthritis; latent tuberculosis infection (LTBI) screening for new biologic users with RA; and reproductive health counseling among women receiving potentially teratogenic medications. We measured performance for each using standardized metrics, defined as the proportion of eligible patients receiving recommended care.

RESULTS

There were 1205 patients seen in the clinic between 2015 and 2017. Regarding demographics, 71% were women, 88% identified as racial/ethnic minorities, and 45% were eligible for at least 1 of the quality measures. Shewart charts for the PCV13 and CDAI measures showed evidence of improved healthcare delivery over time. Benchmarks were achieved for the CDAI and LTBI measures with 93% and 91% performance, respectively. Performance for the PCV13 and reproductive health counseling measures was 78% and 46%, respectively, but did not meet prespecified improvement targets.

CONCLUSION

Through an interprofessional approach, we were able to achieve durable improvements in key rheumatology quality measures largely by enhancing workflow, engaging nonphysician providers, and managing practice variation.

E-consults: an effective way to decrease clinic wait times in rheumatology

Background

To evaluate the effect of E-consults on wait times and resource utilization for positive antinuclear antibody (ANA) referrals in outpatient rheumatology.

Methods

We conducted a pre-post study of E-consult implementation for positive ANA referrals. We retrospectively reviewed “positive ANA” referrals from 1/2015–3/2017. A statistical process control chart was created to display monthly average wait times for in-person clinic visits and to identify special cause variation. Final diagnoses, wait times and resource utilization were recorded and compared between E-consults and in-person referrals.

Results

There were 139 referrals for positive ANA with 126 occurring after E-consult implementation in August 2015. Forty-four percent (55/126) of referrals were E-consults; 76% did not have an in-person visit after initial electronic rheumatology recommendation. A control chart demonstrated special cause variation in the form of a shift from June 2016 – January 2017, suggesting a temporal association between decreased wait times and the implementation of E-consults. Eleven patients were diagnosed with ANA-associated rheumatic disease; the majority of patients (73%, 86/139) did not have a rheumatologic diagnosis. Overall E-consults utilized more labs than in-person visits, but this was not statistically significant. In-person visits utilized more imaging studies, which was statistically significant.

Conclusion

E-consults are an effective way to address positive ANA consults without significant increase in resource utilization and were temporally associated with decreased wait times for in-person visits.

Blockchain-Enabled iWellChain Framework Integration With the National Medical Referral System: Development and Usability Study

Background

Medical referral is the transfer of a patient’s care from one physician to another upon request. This process involves multiple steps that require provider-to-provider and provider-to-patient communication. In Taiwan, the National Health Insurance Administration (NHIA) has implemented a national medical referral (NMR) system, which encourages physicians to refer their patients to different health care facilities to reduce unnecessary hospital visits and the financial stress on the national health insurance. However, the NHIA’s NMR system is a government-based electronic medical referral service, and its referral data access and exchange are limited to authorized clinical professionals using their national health smart cards over the NHIA virtual private network. Therefore, this system lacks scalability and flexibility and cannot establish trusting relationships among patients, family doctors, and specialists.

Objective

To eliminate the existing restrictions of the NHIA’s NMR system, this study developed a scalable, flexible, and blockchain-enabled framework that leverages the NHIA’s NMR referral data to build an alliance-based medical referral service connecting health care facilities.

Methods

We developed a blockchain-enabled framework that can integrate patient referral data from the NHIA’s NMR system with electronic medical record (EMR) and electronic health record (EHR) data of hospitals and community-based clinics to establish an alliance-based medical referral service serving patients, clinics, and hospitals and improve the trust in relationships and transaction security. We also developed a blockchain-enabled personal health record decentralized app (DApp) based on our blockchain-enabled framework for patients to acquire their EMR and EHR data; DApp access logs were collected to assess patients’ behavior and investigate the acceptance of our personal authorization-controlled framework.

Results

The constructed iWellChain Framework was installed in an affiliated teaching hospital and four collaborative clinics. The framework renders all medical referral processes automatic and paperless and facilitates efficient NHIA reimbursements. In addition, the blockchain-enabled iWellChain DApp was distributed for patients to access and control their EMR and EHR data. Analysis of 3 months (September to December 2018) of access logs revealed that patients were highly interested in acquiring health data, especially those of laboratory test reports.

Conclusions

This study is a pioneer of blockchain applications for medical referral services, and the constructed framework and DApp have been applied practically in clinical settings. The iWellChain Framework has the scalability to deploy a blockchain environment effectively for health care facilities; the iWellChain DApp has potential for use with more patient-centered applications to collaborate with the industry and facilitate its adoption.

Case Series and Literature Review of Ophthalmologic Disorders Seen in a Specialist Rheumatology Clinic in Lagos, Nigeria

Purpose: To highlight the pattern and treatment outcomes of ophthalmologic disorders referred to a private specialist rheumatology clinic. Methods: Retrospective review (January 2015-December 2016) of referrals from Eye Foundation Hospital, Lagos to Arthrimed Specialist Clinic, Lagos. Case records were retrieved and relevant information extracted. Ethical standards were observed. Results: Twenty-two referrals (35 eyes) were received out of 643 patients (3.4%) seen during the study period. The majority were female (63.6%) with mean age 48.9 ± 19.3 years and bilateral disease (59%). Diagnoses included uveitis (45.5%), optic neuritis (36.4%), non-specific autoimmune eye disease (9.1%), keratoconjunctivitis sicca (4.5%), and giant cell arteritis (4.5%). Treatment was with steroids and immunosuppressive agents. Fourteen patients improved (63.6%), five remained unchanged (22.7%), while three worsened (13.6%). Conclusions: Our patients were mostly fourth-decade females with bilateral disease. Uveitis was the commonest presentation, and two-thirds of the treated patients improved after treatment. Early specialist referral and co-management of severe autoimmune eye diseases are desirable.

Electronic referral systems in health care: a scoping review

Introduction: Electronic referral (eReferral) systems have been designed with the dual purpose of decreasing wait times and improving workflow efficiency. Evidence about the clinical and economic value enabled through the use of eReferral systems is limited. Our objective was to review the evidence base for the effectiveness and cost-effectiveness of eReferral systems. This review is part of a bigger project to inform the economic benefits of a regional eReferral implementation program.

Material and methods: A systematic search was conducted to capture the available literature on the effectiveness and cost-effectiveness of eReferral system interventions. Evaluation of eReferral system for cost or outcome(s) were included. Strictly e-consultation systems were excluded. We only included publications in English.

Results: We found 274 citations. After removing duplicates and conducting levels one and two screenings, nine publications qualified. Results were divided into four categories: cost or cost-effectiveness analysis, changes in workflow efficiency, the quantity of referrals, and the quality of referrals. A full economic evaluation, conducted in Denmark, found that an eReferral system was cost-effective compared with a paper-based referral system. Of the other eight studies, three demonstrated positive changes in referral processing; two evaluated changes in the quality of the referrals, and three evaluated if the eReferral system increased the quantity of referrals.

Discussion: The evidence base on the effectiveness of eReferral systems to improve communication between primary care and specialists and to decrease wait times is positive but limited. Economic evaluations are needed to examine the clinical and economic value of eReferral systems in health care.

Innovative Use Of Electronic Consultations In Preoperative Anesthesiology Evaluation At VA Medical Centers In New England

Electronic consultations (e-consults) improve access to specialty care without requiring face-to-face patient visits. We conducted a mixed-methods descriptive study to understand the variability in e-consult use across anesthesiology departments in the Veterans Affairs New England Healthcare System (VANEHS). In the period 2012-15, the system experienced a rapid increase in the use of anesthesiology e-consults: 5,023 were sent in 2015, compared with 103 in 2012. Uptake across sites varied from near-universal use of e-consults for preoperative assessment to use for only selected low-risk patients or no use. Interviews with stakeholders revealed considerable differences in the perceived impact of e-consults on workflow and patient-centeredness. Clinicians at sites with high use of e-consults noted that they improved workflow efficiency. In comparison, clinicians at sites with low use preferentially valued face-to-face visits for some or all patients. The adoption of a health information technology innovation can alter the process of care delivery, depending on perceptions of its value by key stakeholders.

Shared Care: Using an Electronic Consult Form to Facilitate Primary Care Provider-Specialty Care Coordination

OBJECTIVE

The quality of children's health is compromised by poor care coordination between primary care providers (PCPs) and specialists. Our objective was to determine how an electronic consultation and referral system impacts referral patterns and PCP-specialist communication.

METHODS

The primary care clinic at Boston Children's Hospital piloted an electronic referral and consultation system with the neurology and gastroenterology departments from April 1, 2014, to October 31, 2016. PCPs completed an electronic consult form, and if needed, specialists replied with advice or facilitated expedited appointments. Specialist response times, referral rates, wait times, and completion rates for specialty visits were tracked. PCPs and specialists also completed a survey to evaluate feasibility and satisfaction.

RESULTS

A total of 82 PCPs placed 510 consults during the pilot period. Specialists responded to 88% of requests within 3 business days. Eighteen percent of specialty visits were deferred and 21% were expedited. Wait times for specialty appointments to both departments significantly decreased, from 48 to 34 days (P < .001), and completion rates improved from 58% to 70% (P < .01), but referral volumes remained stable (25 per month to 23 per month; P = .29). Most PCPs said the Shared Care system facilitated better communication with specialists (89%) and enabled them to provide superior patient care (92%). Specialists reported that the system required a minimal amount of time and enabled them to educate PCPs and triage referrals.

CONCLUSIONS

Implementation of an electronic referral and consultation system was feasible and provided timely access to specialty care, but did not affect referral volume. This system could serve as a model for other health care organizations and specialties.

e-Consults in gastroenterology: An opportunity for innovative care

Background and aim

Deploy and evaluate a gastroenterology (GI) electronic consultation (e-consult) program. E-consults are a promising approach to enhance provider communication, facilitate timely specialty advice and may replace some outpatient visits.

Study

As part of our health system’s efforts to provide more cost-effective care under risk-based contracts, we implemented an e-consult program where referring providers submit patient-specific clinical questions electronically via an electronic referral system. A GI consultant then reviews the patient’s record and provides a written recommendation back to the referring physician. For our program evaluation, we conducted chart reviews of each e-consult to understand how the program was being used and surveyed the participating providers and consultants.

Results

From September 2015 to March 2016, we received 144 e-consults, with most questions concerning GI symptoms or abnormal hepatology labs. Only 36% of e-consults recommended an in-person GI consult or procedure. In our survey of participating providers, referring providers strongly agreed that the GI e-consults promoted good patient care (88%) and were satisfied with the program (84%). The majority of GI consultants felt strongly that e-consults were useful for referring providers and their patients, but that current reimbursement and time allotted were not adequate.

Conclusions

We report on the implementation of a GI e-consult program within an ACO, showing that many clinical questions could be answered using this mechanism. E-consults in gastroenterology have the potential to reduce unnecessary visits and/or procedures for patients who can be managed by their primary provider, potentially increasing access for other patients.

Improving Access to Rheumatologists: Use and Benefits of an Electronic Consultation Service

Objective.

To describe the use and benefits of an innovative eConsult service to improve access to rheumatologists.

Methods.

There were 225 eConsults directed to rheumatology that were categorized by type of question and effect on face-to-face referral rates.

Results.

The median response time by the rheumatologists was 1.9 days. Clinical questions included drug treatment (34%), diagnosis (26%), or management (14%). Osteoporosis was the most common diagnosis (22%), followed by pain in multiple joints (11%), and polyarthritis (10%). A face-to-face referral was avoided in 38% of cases.

Conclusion.

There are clinical questions that can be answered quickly by an eConsult, improving access to rheumatologists.

Implementation and Evaluation of the Safety Net Specialty Care Program in the Denver Metropolitan Area

OBJECTIVES

In response to limited access to specialty care in safety-net settings, an integrated delivery system and three safety-net organizations in the Denver, CO, metropolitan area launched a unique program in 2013. The program offers safety-net providers the option to electronically consult with specialists. Uninsured patients may be seen by specialists in office visits for a defined set of services. This article describes the program, identifies aspects that have worked well and areas that need improvement, and offers lessons learned.

METHODS

We quantified electronic consultations (e-consults) between safety-net clinicians and specialists, and face-to-face specialist visits between May 2013 and December 2014. We reviewed and categorized all e-consults from November and December 2014. In 2015, we interviewed 21 safety-net clinicians and staff, 12 specialists, and 10 patients, and conducted a thematic analysis to determine factors facilitating and limiting optimal program use.

RESULTS

In the first 20 months of the program, safety-net clinicians at 23 clinics made 602 e-consults to specialists, and 81 patients received face-to-face specialist visits. Of 204 primary care clinicians, 103 made e-consults; 65 specialists participated in the program. Aspects facilitating program use were referral case managers' involvement and the use of clear, concise questions in e-consults. Key recommendations for process improvement were to promote an understanding of the different health care contexts, support provider-to-provider communication, facilitate hand-offs between settings, and clarify program scope.

CONCLUSION

Participants perceived the program as responsive to their needs, yet opportunities exist for continued uptake and expansion. Communitywide efforts to assess and address needs remain important.

A cohort study of a general surgery electronic consultation system: safety implications and impact on surgical yield

BACKGROUND

Electronic consultation (eConsult) systems have enhanced access to specialty expertise and enhanced care coordination among primary care and specialty care providers, while maintaining high primary care provider (PCP), specialist and patient satisfaction. Little is known about their impact on the efficiency of specialty care delivery, in particular surgical yield (percent of ambulatory visits resulting in a scheduled surgical case).

METHODS

Retrospective cohort of a random selection of 150 electronic consults from PCPs to a safety-net general surgery clinic for the three most common general surgery procedures (herniorrhaphy, cholecystectomy, anorectal procedures) in 2014. Electronic consultation requests were reviewed for the presence/absence of consult domains: symptom acuity/severity, diagnostic evaluation, concurrent medical conditions, and attempted diagnosis. Logic regression was used to examine the association between completeness of consult requests and scheduling an ambulatory clinic visit. Surgical yield was also calculated, as was the percentage of patients requiring unanticipated healthcare visits.

RESULTS

In 2014, 1743 electronic consultations were submitted to general surgery. Among the 150 abstracted, the presence of consult domains ranged from 49% to 99%. Consult completeness was not associated with greater likelihood of scheduling an ambulatory visit. Seventy-six percent of consult requests (114/150) were scheduled for a clinic appointment and surgical yield was 46%; without an eConsult system, surgical yield would have been 35% (p=0.07). Among patients not scheduled for a clinic visit (n=36), 4 had related unanticipated emergency department visits.

CONCLUSION

Econsult systems can be used to safely optimize the surgical yield of a safety-net general surgery service.

Effects of electronic psychiatric consultations on primary care provider perceptions of mental health care: Survey results from a randomized evaluation

BACKGROUND

Primary care is the main point-of-entry for identifying and treating mental health problems. This research examines the effect of a new model of supporting primary care providers (PCPs) treating mental health disorders, the electronic consultation (eConsults), a standard process for communication between PCPs and psychiatrists through an electronic health records system.

METHODS

A cluster-randomized evaluation of the psychiatric eConsults model, as implemented in a large integrated delivery system. Web survey data before and after the implementation of psychiatric eConsults were collected on PCPs' perceptions of their capability and skill to deliver mental health services, and analyzed with linear regression models.

RESULTS

At baseline PCPs had mixed assessments of perceived support for delivering mental health services and of the availability of specialist consultations, but had relatively high perceived self-efficacy and skill for identifying, diagnosing and treating depression. PCPs in the Treatment group had statistically significant 18%, 13%, and 16% improvements in perceived support for diagnosing mental health problems, making treatment decisions, and changing treatment regimens, respectively; and 24% improved perceived ease of access to consultations for mental health, compared to the Control group. Evidence of effects on self-efficacy and perceived skill around depression was more limited.

CONCLUSIONS

The psychiatric eConsults model improved PCPs' perceptions of support for delivering mental health care and perceptions of access to specialist consultations.

IMPLICATIONS

Electronic consultations may be a promising approach to support the delivery of mental health services in primary care settings.

LEVEL OF EVIDENCE

Pre- and post-intervention web surveys from a cluster-randomized trial.

Longer-term impact of cardiology e-consults

AIMS

Cardiac e-consults may be an effective way to deliver value-oriented outpatient cardiology care in an accountable care organization. Initial results of cardiac e-consults have demonstrated high satisfaction among both patients and referring providers, no known adverse events, and low rates of diagnostic testing. Nevertheless, differences between e-consults and traditional consults, effects of e-consults on traditional consult volume, and whether patients seek traditional consults after e-consults are unknown.

METHODS AND RESULTS

We established a cardiac e-consult program on January 13, 2014. We then conducted detailed medical record reviews of all patients with e-consults to detect any adverse clinical events and detect subsequent traditional visits to cardiologists. We also performed 2 comparisons. First, we compared age, gender, and referral reason for e-consults vs traditional consults. Second, we compared changes in volume of referrals to cardiology vs other medical specialties that did not have e-consults. From January 13 to December 31, 2014, 1,642 traditional referrals and 165 e-consults were requested. The proportion of e-consults of all evaluations requested over that period was 9.1%. Gender balance was similar among traditional consults and e-consults (44.8% male for e-consults vs 45.0% for traditional consults, P = .981). E-consult patients were younger than traditional consult patients (55.3 vs 60.4 years, P < .001). After the introduction of cardiac e-consults, the increase in traditional cardiac visit requests was less than the increase in traditional visit requests for control specialties (4.5% vs 10.1%, P < .001). For e-consults with at least 6 months of follow-up, 75.6% patients did not have any type of traditional cardiology visit during the follow-up period.

CONCLUSION

E-consults are an effective and safe mechanism to enhance value in outpatient cardiology care, with low rates of bounceback to traditional consults. E-consults can account for nearly one-tenth of total outpatient consultation volume at 1 year within an accountable care organization and are associated with a reduction in traditional referrals to cardiologists.

Asynchronous vascular consultation via electronic methods: A feasibility pilot

Management of chronic disease often requires multidisciplinary clinical efforts and specialist care. With the emergence of Accountable Care Organizations (ACOs), health care systems are incentivized to evaluate methods of information exchange between generalists and specialists in order to provide value while preserving quality. Our objective was to evaluate patient and referring provider satisfaction and outcomes of asynchronous electronic consultations in vascular care in a large tertiary academic medical center. Referring providers were offered a vascular 'e-consult' option through an electronic referral management system. We conducted chart review to understand the downstream effects and surveyed patients and referring providers to assess satisfaction. From 24 March 2014 to 1 March 2015, 54 e-consults were completed. Additional testing and recommendations were made in 49/54 (90.7%) e-consults, including lower-extremity venous duplex ultrasonography with reflux testing, duplex ultrasonography of the carotid artery, computed tomography, magnetic resonance imaging, non-invasive physiology arterial studies, laboratory tests, medications, compression stockings, and sequential lymphedema compression therapy. Referring providers were compliant with recommendations in 40/49 (81.6%) of e-consults. A total of 17/54 (31.5%) patients were surveyed with a median patient satisfaction score of 13.7/15 (91.3%) (SD ± 6.4). The program was associated with high referring provider satisfaction, with 87.0% finding the e-consult very helpful and 80.0% stating it averted the need for a traditional visit. Our experience suggests that e-consults are an effective way to provide vascular care in some patients and are associated with high patient and provider satisfaction. E-consults may therefore be an efficient method of care delivery for vascular patients within an ACO.