Prospective comparison of curbside versus formal consultations

"Can you help me think this through?" How pediatric hospitalists learn from informal peer consultation

Informal peer consultation (IPC), also called curbside consultation, is a common practice in medicine. Research has shown that physicians use IPC but how this learning occurs during the process has not been studied. This basic qualitative study describes how pediatric hospitalists learn during IPC, framed by Kolb's (2015) Experiential Learning Theory of Growth and Development. Eleven pediatric hospitalists were interviewed. Deidentified transcripts were coded for key themes using inductive methods. The main prompt for informal peer consultation was the perception of uncertainty. Three themes describe the learning process: "Eliciting Perspectives," "Thinking Aloud Together," and "Experiencing Validation. A fourth theme, "Acknowledging Value," described the importance of IPC for modeling how to manage uncertainty with patients' caregivers and medical trainees. By describing the learning process, the results have implications for physicians who engage in IPC and may inform faculty-level professional development initiatives to improve the IPC process.

Cognitive perspectives on maintaining physicians' medical expertise: I. Reimagining Maintenance of Certification to promote lifelong learning

Until recently, physicians in the USA who were board-certified in a specialty needed to take a summative test every 6-10 years. However, the 24 Member Boards of the American Board of Medical Specialties are in the process of switching toward much more frequent assessments, which we refer to as longitudinal assessment. The goal of longitudinal assessments is to provide formative feedback to physicians to help them learn content they do not know as well as serve an evaluation for board certification. We present five articles collectively covering the science behind this change, the likely outcomes, and some open questions. This initial article introduces the context behind this change. This article also discusses various forms of lifelong learning opportunities that can help physicians stay current, including longitudinal assessment, and the pros and cons of each.

Impact of Gastroenterology Consultation on the Clinical Outcomes of Patients Admitted With Hepatic Encephalopathy

Introduction Hepatic encephalopathy (HE) is a common complication of cirrhosis and a common reason for hospital admission. We aimed to determine whether expert consultation from gastroenterology (GI) leads to better clinical outcomes for inpatients with HE. Methods A retrospective review was performed of all adult patients (age ≥ 18) admitted with HE to a tertiary care hospital between January 2013 and April 2018. Patients who received a GI consult were compared to patients who did not receive a GI consult (No consult group). The primary outcome was hospital length of stay (LOS); secondary outcomes were rates of 30-day hospital readmission and 90-day mortality. Multivariate analysis was conducted to adjust for known confounders.  Results Four hundred and twenty-five patients (814 encounters) were included in the study; of these, 236 patients had received a GI consultation for HE. Patients in the GI consult group were younger (mean age 55 vs 58 years, p= 0.02) and had higher Model For End-Stage Liver Disease-sodium (MELD-Na) score (mean MELD-Na 23.5 vs 17.5, p<0.01) compared to patients who did not receive GI consultation. The precipitants of HE were significantly different between the groups: there was more spontaneous bacterial peritonitis (SBP) and GI bleeding (GIB) in the GI consult group and more lactulose non-adherence in the no consult group. There was no difference in the etiology of liver disease between the two groups. Median LOS for the GI consult group was six days vs three days in the no consult group (p<0.01); the incidence rate ratio was 1.79 (95%CI 1.59-2.02, p<0.01) on multivariate analysis. There was no difference in 30-day readmission or 90-day mortality between the two groups.  Conclusion GI consultation for patients with HE admitted to a hospital medicine service may be associated with longer LOS. In selected patients admitted with HE, GI consultation may not be necessary to achieve good clinical outcomes.

Development and Implementation of a Peer Curbside Consult Service for Pediatric Hospitalists

OBJECTIVE

To describe the development and implementation of a Peer Curbside Consult Service (PCCS) for a pediatric hospital medicine (PHM) division.

METHODS

We developed a pilot intervention with hospitalists at a freestanding children's hospital to provide peer consultation services for challenging clinical cases. Postconsultation surveys collected from both the requesting and consulting hospitalists provided feedback about the program. The 12-point Template for Intervention Description and Replication (TIDieR) checklist is used to describe the process for program creation and implementation.

RESULTS

The PCCS has provided 60 consultations in the first 2 years since implementation in April 2020 and supports a large PHM division with >75 members who practice at a tertiary care, freestanding children's hospital and 7 affiliate sites. Hospitalists request peer consultation for challenging clinical cases. The consultations were typically conducted in person or via telephone. Currently, 11 PHM faculty members within the division volunteer as consultants, with 2 assigned per week. Electronic postconsultation experience surveys were received from 70% of requesting and 89% of consultant hospitalists. We also provide preliminary data from this pilot intervention in the Supplemental Information.

CONCLUSIONS

We successfully established a peer consult service that provided just-in-time clinical decision support across the various practice sites. Through transparent reporting using the TIDieR checklist, other divisions may be able to replicate and adapt their own peer consult program.

Implications of Electronic Consultations for Clinician Communication and Relationships: A Qualitative Study

BACKGROUND

Strong relationships and effective communication between clinicians support care coordination and contribute to care quality. As a new mechanism of clinician communication, electronic consultations (e-consults) may have downstream effects on care provision and coordination.

OBJECTIVE

The objective of this study was to understand primary care providers' and specialists' perspectives on how e-consults affect communication and relationships between clinicians.

RESEARCH DESIGN

Qualitative study using thematic analysis of semistructured interviews.

SUBJECTS

Six of 8 sites in the VISN 1 (Veterans Integrated Service Network) in New England were chosen, based on variation in organization and received e-consult volume. Seventy-three respondents, including 60 clinicians in primary care and 3 high-volume specialties (cardiology, pulmonology, and neurology) and 13 clinical leaders at the site and VISN level, were recruited.

MEASURES

Participants' perspectives on the role and impact of e-consults on communication and relationships between clinicians.

RESULTS

Clinicians identified 3 types of e-consults' social affordances: (1) e-consults were praised for allowing specialist advice to be more grounded in patient data and well-documented, but concerns about potential legal liability and increased transparency of communication to patients and others were also noted; (2) e-consults were perceived as an imperfect modality for iterative communication, especially for complex conversations requiring shared deliberation; (3) e-consults were understood as a factor influencing clinician relationships, but clinicians disagreed on whether e-consults promote or undermine relationship building.

CONCLUSIONS

Clinicians have diverse concerns about the implications of e-consults for communication and relationships. Our findings may inform efforts to expand and improve the use of e-consults in diverse health care settings.

Barriers and Benefits of the Scheduled Telephone Referral Model (DETELPROG): A Qualitative Approach

The recently developed scheduled mobile-telephone referral model (DETELPROG) has achieved especially important results in reducing waiting days for patients, but it has been decided to explore what barriers and positive aspects were detected by both primary care physicians (PCPs) and hospital attending physicians (HAPs) regarding its use. For this, a qualitative descriptive study was carried out through six semi-structured interviews and two focus groups in a sample of eleven PCPs and five HAPs. Interviews were carried out from September 2019 to February 2020. Data were analysed by creating the initial categories, recording the sessions, transcribing the information, by doing a comprehensive reading of the texts obtained, and analysing the contents. The results show that DETELPROG gives the PCP greater prominence as a patient’s health coordinator by improving their relationship and patient safety; it also improves the relationship between PCP and HAP, avoiding unnecessary face-to-face referrals and providing safety to the PCP when making decisions. The barriers for DETELPROG to be used by PCP were defensive medicine, patients’ skepticism in DETELPROG, healthcare burden, and inability to focus on the patient or interpret a sign, symptom, or diagnostic test. For HAP, the barriers were lack of confidence in the PCP and complexity of the patient. As a conclusion, DETELPROG referral model provides a lot of advantages and does not pose any new barrier to face-to-face referral or other non-face-to-face referral models, so it should be implemented in primary care.

How COVID-19 has impacted integrated care practice: lessons from the frontlines

Primary care systems are a mainstay for how many Americans seek health and behavioral health care. It is estimated that almost a quarter of behavioral health conditions are diagnosed and/or treated in primary care. Many clinics treat the whole person through integrated models of care such as the Primary Care Behavioral Health (PCBH) model. COVID-19 has disrupted integrated care delivery and traditional PCBH workflows requiring swift adaptations. This paper synthesizes how COVID-19 has impacted clinical services at one federally qualified health center and describes how care has continued despite the challenges experienced by frontline behavioral health providers.

Curbside Consults in Clinical Medicine: Empirical and Liability Challenges

In most U.S. jurisdictions, clinicians providing informal "curbside" consults are protected from medical malpractice liability due to the absence of a doctor-patient relationship. A recent Minnesota Supreme Court case, Warren v. Dinter, offers the opportunity to reassess whether the majority rule is truly serving the best interests of patients.

Curbside consultation: A means to promote quality patient care

The objective of this descriptive, cross-sectional study was to describe curbside consultation, a bidirectional informal discussion with a colleague "expert" concerning patient care, among nurse practitioners. Curbside consultations are valuable, yet little is known about this process use for nurse practitioners. A national convenience sample was recruited using online social media platforms and email. Data were collected in June 2019 via Qualtrics survey software. Web-based survey included 80 questions concerning use and definition of curbside consultation, and followed STROBE guidelines for reporting. Questions also concerned work environment, personal and interpersonal qualities, communication modality and patient engagement. Descriptive and survey item analyses including frequency, percentage, means and standard deviation, Chi-square and Fisher's Exact Test, Pearson's correlation analysis, and one-way independent t-tests. Participants included nurse practitioners (N = 402) in primary (51.2%, N = 206) and specialty care (46%, N = 185). Nurse practitioners reported positive experiences with curbside consultations (96.8%, N = 384) and that reliable access to colleagues was correlated with multiple variables, including practice culture (r = 0.494, p = .001). Most reported (99%, N = 387) patients receive better care with successful curbside consultation. Curbside consultations provide nurse practitioners information access at point-of-care for implementation of evidence-based practice to promote quality patient care. Addition of curbside consultation education is a compelling consideration of nurse practitioner curriculum.

Telemedicine Infectious Diseases Consultations and Clinical Outcomes: A Systematic Review

Background

Telemedicine use is increasing in many specialties, but its impact on clinical outcomes in infectious diseases has not been systematically reviewed. We reviewed the current evidence for clinical effectiveness of telemedicine infectious diseases consultations, including outcomes of mortality, hospital readmission, antimicrobial use, cost, length of stay, adherence, and patient satisfaction.

Methods

We queried Ovid MEDLINE 1946-, Embase.com 1947-, Scopus 1823-, Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov 1997- through August 5, 2019, for studies looking at clinical outcomes of infectious diseases in the setting of telemedicine use. We did not restrict by language or year of publication. Clinical outcomes searched included 30-day all-cause mortality, 30-day readmissions, patient compliance/adherence, patient satisfaction, cost or cost-effectiveness, length of hospital stay, antimicrobial use, and antimicrobial stewardship. Bias was assessed using standard methodologies. PROSPERO CRD42018105225.

Results

From a search pool of 1154 studies, only 18 involved telemedicine infectious diseases consultation and our selected clinical outcomes. The outcomes tracked were heterogeneous, precluding meta-analysis, and the majority of studies were of poor quality. Overall, clinical outcomes with telemedicine infectious diseases consultation seem comparable to in-person infectious diseases consultation.

Conclusions

Although in widespread use, the clinical effectiveness of telemedicine infectious diseases consultations has yet to be sufficiently studied. Further studies, or publication of previously collected and available data, are warranted to verify the cost-effectiveness of this widespread practice.

Systematic review registration

PROSPERO CRD42018105225.

What Are We Really Talking About? An Organizing Framework for Types of Consultation and Their Implications for Physician Communication

Consultation amongst providers is a foundation of modern health care and one of the most frequent means of interdisciplinary communication. Accordingly, clear and efficient communication between providers and across medical specialties during consultation is essential to patient care and a collegial work environment. Traditionally, consultation requests are felt to require a clear question that falls within the purview of the consultant's expertise. However, this narrow constraint is often lacking in the real-world clinical environment and may in fact be detrimental to physician communication and patient care. In this Perspective, the authors propose an organizing framework of seven specific consultation types, which apply broadly across disciplines: ideal, obligatory, procedural, S.O.S., confirmatory, inappropriate, and curbside. The authors describe what factors define each type and the benefits and pitfalls of each. The proposed framework may help providers have more productive, efficient, and collegial conversations about patient care, which may facilitate improved work satisfaction and an enhanced learning environment.

The Consultation Observed Simulated Clinical Experience: Training, Assessment, and Feedback for Incoming Interns on Requesting Consultations

PROBLEM

Formal education in requesting consultations is inconsistent in medical education. To address this gap, the authors developed the Consultation Observed Simulated Clinical Experience (COSCE), a simulation-based curriculum for interns using Kessler and colleagues' 5Cs of Consultation model to teach and assess consultation communication skills.

APPROACH

In June 2016, 127 interns entering 12 University of Chicago Medicine residency programs participated in the COSCE pilot. The COSCE featured an online training module on the 5Cs and an in-person simulated consultation. Using specialty-specific patient cases, interns requested telephone consultations from faculty, who evaluated their performance using validated checklists. Interns were surveyed on their preparedness to request consultations before and after the module and after the simulation. Subspecialty fellows serving as consultants were surveyed regarding consultation quality before and after the COSCE.

OUTCOMES

After completing the online module, 84% of interns (103/122) were prepared to request consultations compared with 52% (63/122) at baseline (P < .01). After the COSCE, 96% (122/127) were prepared to request consultations (P < .01). Neither preparedness nor simulation performance differed by prior experience or training. Over 90% (115/127) indicated they would recommend the COSCE for future interns. More consultants described residents as prepared to request consultations after the COSCE (54%; 21/39) than before (27%; 11/41, P = .01).

NEXT STEPS

The COSCE was well received and effective for preparing entering interns with varying experience and training to request consultations. Future work will emphasize consultation communication specific to training environments and evaluate skills via direct observation of clinical performance.

A Handshake From Antimicrobial Stewardship Opens Doors for Infectious Disease Consultations

Implementation of a unique in-person pediatric antimicrobial stewardship program was associated with a significant increase in infectious disease consultations at a quaternary care children's hospital. This study demonstrates that antimicrobial stewardship programs support, and do not compete with, infectious disease programs.

Interdependence in decision-making by medical consultants: implications for improving the efficiency of inpatient physician services

OBJECTIVES

Hospital administrators are seeking to improve efficiency in medical consultation services, yet whether consultants make decisions to provide more or less care is unknown. We examined how medical consultants account for prior consultants' care when determining whether to provide intensive consulting care or sign off in the treatment of complex surgical inpatients. We applied three distinct theoretical frameworks in the interpretation of our results.

METHODS

We performed a retrospective cohort study of consultants' care intensity, measured alternately using a dummy variable for providing two or more days consulting (versus one) and a continuous measure of total days consulting, with 100% Medicare claims data from 2007-2010. Our analytic samples included consults for beneficiaries undergoing coronary artery bypass grafting (n = 61,785) or colectomy (n = 33,460) in general acute care hospitals. We compared the care intensity of consultants who observed different patterns of consulting care before their initial consults using ordinary least squares regression models at the patient-physician dyad level, controlling for patient comorbidity and many other patient- and physician-level factors as well as hospital region and year fixed effects.

RESULTS

Consultants were less likely to provide intensive consulting care with each additional prior consultant on the case (1.2-1.7 percent) or if a prior consultant rendered intensive consulting care (20.6-21.5 percent) but more likely when prior consults were more concentrated across consultants (2.9-3.1 percent). Effects on consultants' total days consulting were similar.

CONCLUSION

On average, consultants appeared to calibrate their care intensity for individual patients to maximize their value to all patients. Interventions for improving consulting care efficiency should seek to facilitate (not constrain) consultants' decision-making processes.

Pilot of integrated, colocated neurology in a primary care medical home

RATIONALE, AIMS, AND OBJECTIVES

Novel health care delivery models are needed to reduce health care use while delivering effective and safe care. We developed a model of a neurologist integrated and colocated in primary care leveraging "curbside," electronic, and traditional consultations. Our objective was to examine the impact on health care resource use of diagnostic testing and referrals for face-to-face neurological consultation and adverse outcomes associated with electronic and curbside consultations.

METHODS

Consecutive patients from December 1, 2014, to March 13, 2015, were included in the analysis about whom contact was made between a primary care clinician and a colocated neurologist.

RESULTS

Over 3.5 months of the pilot, 359 unique patients generated 429 consultations (179 curbsides, 68 electronic consultations, and 182 face-to-face visits). The integrated model resulted in avoidance of 78 face-to-face tertiary neurology consultations, 39 brain magnetic resonance imaging, 50 electromyograms, and 53 other advanced imaging studies. Earlier curbside consultation may have prevented unnecessary testing or face-to-face tertiary neurology consultations in 40 (22%) patients. Earlier face-to-face consultation may have avoided expensive testing in 31 (17%) patients. No cases met criteria for an adverse outcome. The number of referrals to tertiary neurology declined by 64%, and the total number of face-to-face visits per month declined by 25%.

CONCLUSION

Colocated neurology in a primary care medical home offers a promising intervention to deliver high-value care.

It All Just Clicks: Development of an Inpatient E-Consult Program

Although the use of electronic consultations (e-consults) in the outpatient setting is commonplace, there is little evidence of their use in the inpatient setting. Often, the only choice hospitalists have is between requesting a time-consuming in-person consultation or requesting an informal, undocumented "curbside" consultation. For a new, remote hospital in our healthcare system, we developed an e-consult protocol that can be used to address simple consultation questions. In the first year of the program, 143 e-consults occurred; the top 5 consultants were infectious disease, hematology, endocrinology, nephrology, and cardiology. Over the first 4 months, no safety issues were identified in chart review audits; to date, no safety issues have been identified through the hospital's incident reporting system. In surveys, hospitalists were universally pleased with the quality of e-consult recommendations, though only 43% of consultantsagreed. With appropriate care for patient selection, e-consults can be used to safely and efficiently provide subspecialty expertise to a remote inpatient site Journal of Hospital Medicine 2017;12:332-334.

Interprofessional Curbside Consults to Develop Team Communication and Improve Student Achievement of Learning Outcomes

Objective. To design and implement a series of activities focused on developing interprofessional communication skills and to assess the impact of the activities on students' attitudes and achievement of educational goals. Design. Prior to the first pharmacy practice skills laboratory session, pharmacy students listened to a classroom lecture about team communication and viewed short videos describing the roles, responsibilities, and usual work environments of four types of health care professionals. In each of four subsequent laboratory sessions, students interacted with a different standardized health care professional role-played by a pharmacy faculty member who asked them a medication-related question. Students responded in verbal and written formats. Assessment. Student performance was assessed with a three-part rubric. The impact of the exercise was assessed by conducting pre- and post-intervention surveys and analyzing students' performance on relevant Center for the Advancement of Pharmacy Education (CAPE) outcomes. Survey results showed improvement in student attitudes related to team-delivered care. Students' performance on the problem solver and collaborator CAPE outcomes improved, while performance on the educator outcome worsened. Conclusions. The addition of an interprofessional communication activity with standardized health care professionals provided the opportunity for students to develop skills related to team communication. Students felt the activity was valuable and realistic; however, analysis of outcome achievement from the exercise revealed a need for more exposure to team communication skills.

Minding the Gaps: Assessing Communication Outcomes of Electronic Preconsultation Exchange

BACKGROUND

Effective communication between referring and specialty providers is key to optimizing patient safety. Communication was assessed in an electronic referral system by review of referrals to a public urban health care system's gastroenterology clinic that were not scheduled for appointments.

METHODS

All electronic referrals to a publicly funded, urban health care system's adult gastroenterology clinic from November 1, 2009, to November 30, 2010, were reviewed that did not result in scheduling of appointments. An assessment was made of whether in-person visits were unnecessary by preconsultation exchange or whether the referrals remained unscheduled for other reasons. For the latter group, reasons why the referrals remained unscheduled were examined, and medical records were reviewed for actual patient harm when sufficient information was present in the chart or for potential harm when no further information about the referral complaint was available.

RESULTS

Eighty-six (32%) of 266 not-scheduled referrals were resolved via preconsultation exchange. For another 96 (36%), patients were not ultimately considered to require appointments or were scheduled via other routes. Nine patients received unplanned care while awaiting scheduling decisions, 5 of whom had harm that was related to referral complaints, although scheduling of appointments may not have avoided this harm. Of 75 patients for whom further information was not available about the referral complaints, most were not seen back in primary care, and 55 (73%) had potential for major harm.

CONCLUSION

Few adverse outcomes in electronic referrals not scheduled for in-person gastroenterology visits were found, and none were clearly due to communication lapses in the referral process. Contributors to the potential for harm in referrals that were unintentionally left unscheduled included discontinuity of care and lack of patient or provider follow-up.

Prevalence of Barriers and Facilitators to Enhancing Conservative Kidney Management for Older Adults in the Primary Care Setting

BACKGROUND AND OBJECTIVES

Conservative management of adults with stage 5 CKD (eGFR<15 ml/min per 1.73 m2) is increasingly being provided in the primary care setting. We aimed to examine perceived barriers and facilitators for conservative management of older adults by primary care physicians.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

In 2015, we conducted a cross-sectional, population-based survey of all primary care physicians in Alberta, Canada. Eligible participants had experience caring for adults ages ≥75 years old with stage 5 CKD not planning on initiating dialysis. Questionnaire items were on the basis of a qualitative descriptive study informed by the Behavior Change Wheel and tested for face and content validity. Physicians were contacted via postal mail and/or fax on the basis of a modified Dillman method.

RESULTS

Four hundred nine eligible primary care physicians completed the questionnaire (9.6% response rate). The majority of respondents were men (61.6%), were ages 40-60 years old (62.6%), and practiced in a large/medium population center (68.0%). The most common barrier to providing conservative care in the primary care setting was the inability to access support to maintain patients in the home setting (39.1% of respondents; 95% confidence interval, 34.6% to 43.6%). The second most common barrier was working with nonphysician providers with limited kidney-specific clinical expertise (32.3%; 95% confidence interval, 28.0% to 36.7%). Primary care physicians indicated that the two most common strategies that would enhance their ability to provide conservative management would be the ability to use the telephone to contact a nephrologist or clinical staff from the conservative care clinic (86.9%; 95% confidence interval, 83.7% to 90.0% and 85.6%; 95% confidence interval, 82.4% to 88.9%, respectively).

CONCLUSIONS

We identified important areas to inform clinical programs to reduce barriers and enhance facilitators to improve primary care physicians' provision of conservative kidney care. In particular, primary care physicians require additional resources for maintaining patients in their home and telephone access to nephrologists and conservative care specialists.

Results from the First Year of Implementation of CONSULT: Consultation with Novel Methods and Simulation for UME Longitudinal Training

Introduction

An important area of communication in healthcare is the consultation. Existing literature suggests that formal training in consultation communication is lacking. We aimed to conduct a targeted needs assessment of third-year students on their experience calling consultations, and based on these results, develop, pilot, and evaluate the effectiveness of a consultation curriculum for different learner levels that can be implemented as a longitudinal curriculum.

Methods

Baseline needs assessment data were gathered using a survey completed by third-year students at the conclusion of the clinical clerkships. The survey assessed students’ knowledge of the standardized consultation, experience and comfort calling consultations, and previous instruction received on consultation communication. Implementation of the consultation curriculum began the following academic year. Second-year students were introduced to Kessler’s 5 Cs consultation model through a didactic session consisting of a lecture, viewing of “trigger” videos illustrating standardized and informal consults, followed by reflection and discussion. Curriculum effectiveness was assessed through pre- and post- curriculum surveys that assessed knowledge of and comfort with the consultation process. Fourth-year students participated in a consultation curriculum that provided instruction on the 5 Cs model and allowed for continued practice of consultation skills through simulation during the Emergency Medicine clerkship. Proficiency in consult communication in this cohort was assessed using two assessment tools, the Global Rating Scale and the 5 Cs Checklist.

Results

The targeted needs assessment of third-year students indicated that 93% of students have called a consultation during their clerkships, but only 24% received feedback. Post-curriculum, second-year students identified more components of the 5 Cs model (4.04 vs. 4.81, p<0.001) and reported greater comfort with the consultation process (0% vs. 69%, p<0.001). Post- curriculum, fourth-year students scored higher in all criteria measuring consultation effectiveness (p<0.001 for all) and included more necessary items in simulated consultations (62% vs. 77%, p<0.001).

Conclusion

While third-year medical students reported calling consultations, few felt comfortable and formal training was lacking. A curriculum in consult communication for different levels of learners can improve knowledge and comfort prior to clinical clerkships and improve consultation skills prior to residency training.

Providing specialty consultant expertise to primary care: an expanding spectrum of modalities

In most models of health care delivery, the bulk of services are provided in primary care and there is frequent request for the input of specialty consultants. A critical issue for current and future health care systems is the effective and efficient delivery of specialist expertise for clinicians and patients. Input on a patient's care from specialty consultants usually requires a face-to-face visit between the patient and the consultant. New and complementary models of knowledge sharing have emerged. We describe a framework assessment of a spectrum of knowledge-sharing methods in the context of a patient-centered medical home. This framework is based on our experience in the Veterans Health Administration and a purposive review of the literature. These newer modes of specialty consultation include electronic consultation, secure text messaging, telemedicine of various types, and population preemptive consults. In addition to describing these modes of consultation, our framework points to several important areas in which further research is needed to optimize effectiveness.

Provider impressions of the use of a mobile crowdsourcing app in medical practice

In our prior work, we conducted a field trial of the mobile application DocCHIRP (Crowdsourcing Health Information Retrieval Protocol for Doctors), designed to help clinicians problem-solve at the point of care by crowdsourcing their peers. Here, we present the results of our post-trial survey that investigated the impressions of participating clinicians regarding the use of medical crowdsourcing and to identify factors influencing adoption of the technology. In all, 72 valid surveys were received from 85 registered users (85% response rate). The majority of clinicians (>80%) felt crowdsourcing would be useful to diagnose unusual cases, facilitate patient referrals, and problem-solve at the point of care. Perceived barriers to adoption included interruptions in workflow and the reluctance to publicly expose knowledge gaps. While considered a useful alternative to existing methods, future studies are needed to investigate whether the approach and application can be modified to effectively address these barriers, and to determine whether crowdsourcing will enhance provider performance and the quality of care delivered.

Professional networks and EBM use: a study of inter-physician interaction across levels of care

Physicians around the globe are increasingly encouraged to adopt guidelines, protocols and other scientific material when making clinical decisions. Extant research suggests that the clinicians' propensity to use evidence-based medicine (EBM) is strongly associated with the professional collaborative networks they establish and maintain with peers. In this paper we explore whether and how the connectedness of primary care physicians with colleagues working in hospital settings is related to their frequency of EBM use in clinical practice. We used survey data from 104 pediatricians working in five local health authorities in the Italian NHS. Social network and attributional data concerning single physicians, as well as their self-reported frequency of EBM use, were collected for three major pathologies in pediatric care: asthmatic, gastro-enteric and urinary pathologies. Ordered regression analysis was employed. Our findings documented a positive association between the number of physicians' relationships with hospital colleagues and the frequency of use EBM. Results also indicated that physicians' organizational affiliations influence the frequency of EBM use. Finally, contrary to our expectations, it was found that clinicians' affiliation to formal collaborative arrangements is at odds with the likelihood of reporting higher frequency of EBM use.

Value and process of curbside consultations in clinical practice: a grounded theory study

OBJECTIVES

To clarify the value and process of the curbside consultation and identify ways to optimize this activity.

PARTICIPANTS AND METHODS

We conducted 13 focus groups at an academic medical center and outlying community sites (September 2011 to January 2013), involving a purposive sample of 54 primary care and subspecialist internal medicine and family medicine physicians. Focus group discussions were transcribed and then analyzed using a constant comparative approach to identify benefits, liabilities, mechanisms, and potential improvements related to curbside consultations.

RESULTS

We developed a model describing the role and process of the curbside consultation. Focus group participants perceived that curbside consultations add particular value in offering immediate, individualized answers with bidirectional information exchange, and this in turn expedites patient care and elevates patient confidence. Despite the uncompensated interruption and potential risks, experts provide curbside consultations because they appreciate the honor of being asked and the opportunity to help colleagues, expedite patient care, and teach. Key decisions for the initiator (each reflecting a potential barrier) include whom to contact, how to contact that expert, and how to determine availability. Experts decide to accept a request on the basis of personal expertise, physical location, and capacity to commit time and attention. Participants suggested systems-level improvements to facilitate expert selection, clarify expert availability, enhance access to clinical information, and acknowledge the expert's effort.

CONCLUSIONS

Curbside consultations play an important role in enhancing communication and care coordination in clinical medicine, but the process can be further improved. Information technology solutions may play a key role.

Informal consultation at a teaching hospital infectious diseases department

INTRODUCTION

Informal consultations for advice in the infectious diseases department (IDD) induce a significant workload for physicians. Our aim was to retrospectively quantify and describe this activity in our institution.

METHOD

The data was obtained from files documented and faxed by physicians from October 2009 to May 2012. One thousand nine hundred and seventy-two files were included. The file was faxed to the IDD specialist, analyzed, then a telephone conversation allowed making precisions, and the documented form was faxed back.

RESULTS

The requests for advice concerned 39% of female and 61% of male patients with a mean age of 64±21 years. Twenty-nine percent of requests came from surgical departments and 71% from medical departments (P<0.01). The departments most frequently concerned were cardiology (10%), gastro-enterology (10%) and cardiovascular surgery (9.7%). The most frequent infections were urogenital (19%), osteoarticular (14%), and cardiovascular (11%). Forty-nine percent were considered as nosocomial and 25.3% were bacteremic. The requests concerned diagnostic aid in 16.2% of cases and therapeutic issues in 95.6%. The IDD specialist made therapeutic recommendation in 96.5% of cases and gave diagnostic advice in 43.7%. Treatment modification was suggested in 38.5% of cases. Twenty-two percent of consultations required a second one.

CONCLUSION

This study documented the importance of antibiotic changes among medical and surgical units, the increasing need of these units to be helped, and also the complexity of the medical cases, all requiring the advice of an ID specialist. Our fax-phone-fax procedure seems to prevent the bias associated with informal consultations by phone, which is the most commonly used in other institutions.

The impact of infectious diseases consultation on oncology practice

PURPOSE OF REVIEW

Traditional utilization of infectious diseases consultants by oncologists ranges from inpatient management of a variety of acute infectious syndromes to management of ambulatory patients with acute or chronic infections; however, there is a paucity of data to evaluate in which circumstances the impact of infectious diseases input may be most valuable.

RECENT FINDINGS

Data derived from the general population of patients emphasize the value of infectious diseases consultation in specific infections, such as Staphylococcus aureus bacteremia, candidemia, and hepatitis C virus infection. In addition, infectious diseases involvement has been associated with greater adherence to guidelines (up to 34% increase), more appropriate antibiotic utilization (up to 52% increase in appropriate duration), decreased cost and complications of care, and lower mortality (up to 17% decrease). Recent studies suggest that bedside, formal infectious diseases consultation is more optimal than informal interactions (e.g., e-mail, telephone, other). Furthermore, infectious diseases consultants play central roles in antibiotic stewardship, infection control, and quality improvement, particularly in oncology centers.

SUMMARY

Infectious diseases consultants contribute value in various inpatient and outpatient infections, decreasing mortality, cost, and complications.