Unique Educational Opportunities for PCPs and Specialists Arising From Electronic Consultation Services

A Systematic Review on the Impact of Electronic Consultations on Diabetes Care

OBJECTIVES

Primary care physicians (PCPs) are increasingly challenged with managing glycemic control in people with diabetes (PWD), especially in the setting of a shortage in endocrinologists. Electronic consultations (e-consults), which enable asynchronous communication between PCPs and specialists through electronic health records, have been introduced to address these issues. This systematic review aims to evaluate the impact of e-consults on glycemic control in PWD, focusing on changes in HbA1c levels.

METHODS

Two independent reviewers searched PubMed, EMBASE, and the Cochrane Library, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. The review encompasses randomized controlled trials and observational studies. Two reviewers extracted data pertaining to prespecified outcomes of each interest from each included study.

RESULTS

Summary tables and narrative synthesis were used (PROSPERO 2024 CRD42024503278). Six studies were included, -two randomized controlled trials and 4 observational studies-assessing the role of e-consults in diabetes care. Most studies did not report significant differences in HbA1c levels between e-consult and control groups. However, benefits such as improved medication usage, reduced costs, enhanced access to specialist care, shorter wait times for in-person visits, and better educational opportunities for PCPs were noted. Implementation barriers included PCP familiarity with e-consults and patient adherence. Limitations include inclusion of only 2 trials and 4 observational studies and heterogeneity between them.

CONCLUSIONS

E-consults provide valuable benefits in managing diabetes, particularly in resource-limited settings. E-consults offer a promising solution to the endocrinologist shortage, though further research is needed to identify which PWD would benefit most.

Exploring Patterns and Disparities in E-Consult Referrals: An Analysis of Patient and Community Factors in Colorado Health Care

Objective: Electronic consultations (e-consults) provide a strategic solution to address challenges in health care systems related to cost management and access to care. This study aims to investigate the multilevel patient characteristics associated with higher frequency of receiving e-consults and increased likelihood of completion. Materials and Methods: University of Colorado's electronic medical record were analyzed to study factors influencing referral types (e-consult vs. standard) and their completion rates from April 2018 to September 2023. Multivariate probit regression assessed the impact of patient-level and community-level factors (urban-rural classification, Social Vulnerability Index, and technology accessibility) on e-consult referrals and completion. Results: In 263,882 records, 92.5% were standard referrals, and 7.4% were e-consult referrals. Analysis showed that females were less likely than males (OR = 0.95, 95%CI[0.93, 0.96]), and Blacks were more likely than Whites (OR = 1.03, 95%CI[1.01,1.06]) to receive e-consult referrals. Medicaid patients had lower odds compared to those with Medicare only (OR = 1.04, 95%CI[1.00,1.07]), and rural residency was associated with lower odds (OR = 0.80, 95%CI[0.73,0.88]) of e-consult referral. Factors such as areas with higher population without internet subscription (OR = 1.03, 95%CI[1.01,1.04]) and higher social vulnerabilities (OR = 1.26, 95%CI[1.16,1.37]) increased e-consult odds. Black patients were less likely to have their referrals completed compared to Whites. Patients who resided in regions with limited computer and smartphone access, as well as higher social vulnerabilities, showed decreased odds of referral completion. Discussions and Conclusion: This study highlights the need for partnering with a variety of health care organizations, especially those serving low-income and disadvantaged populations, to enhance health care access equity through the use of e-consults.

Developing an Interprofessional e-Consult Checklist for Family Nurse Practitioner Students

ABSTRACT

Family nurse practitioners (FNPs) are filling the provider gaps in primary care. Primary care patients require referrals to different types of specialty providers that are not always readily available. The use of electronic consultations (e-consults) can fill this gap. FNPS may not be aware of e-consults or may feel they are not beneficial in their practice, likely because of a lack of training. This article details the development of an e-consult checklist for graduate FNPs.

Electronic consultation use by advanced practice nurses in older adult care-A descriptive study of service utilization data

AIMS AND OBJECTIVES

To describe characteristics of service utilization by advanced practice nurses (APNs) employing an electronic consultation (eConsult) service in their care for older adults.

BACKGROUND

Canada's aging population is projected to place unprecedented demands on the healthcare system. APNs, which include clinical nurse specialists (CNSs) and nurse practitioners (NPs), are nurses with advanced knowledge who can independently provide age-appropriate care. eConsult is a secure web-based platform enabling asynchronous, provider-to-provider communication. APNs can send and receive eConsults to address patient-specific concerns.

METHODS

This is a retrospective analysis of eConsult utilization and user survey data for cases completed in 2019, reported in line with the STROBE guidelines. Eligible eConsults included those that had APN involvement (as a referrer or responder) and were concerning an older patient (≥65 years). Descriptive statistics were used to analyse service utilization and survey response data.

RESULTS

Of 430 eligible eConsults, 421 (97.9%) were initiated by NPs and the rest by physicians. 23 (5.3%) were received by a CNS, of which 14 (3.3%) involved an NP-to-CNS exchange. Median specialist response interval was 0.9 days. 53% of eConsults was for dermatology, haematology, cardiology, gastroenterology and endocrinology. 73% of eConsults avoided a face-to-face referral after the consultation. In 90% of eConsults, APNs rated the service as helpful and/or educational.

CONCLUSIONS

Through eConsult, APNs can collaborate with each other and physicians to access and provide a breadth of advice facilitating timely specialist-informed care for older patients, thus helping to alleviate some of the demands placed on the healthcare system.

RELEVANCE TO CLINICAL PRACTICE

There is an opportunity for APNs to further adopt eConsult into their clinical practice, and this can, in turn, support the integration of the APN role in the health workforce.

PATIENT OR PUBLIC CONTRIBUTION

Current APN eConsult users were involved in the study design and interpretation of results.

Mapping Health Professions Education: Using Complexity Science to Make Sense of Learning Through Electronic Consultations

Phenomena studied within health professions education are often complex and multifaceted. This article describes a complexity science-informed theoretical framework that was developed for exploring how electronic consultations support learning among primary care providers, as well as within the larger organizations or systems in which they practice. This framework enables researchers to investigate learning occurring simultaneously at multiple levels (including individuals and social groups), without simplistically conflating levels or theories. The various levels of learning and associated theories are illustrated using examples from electronic consultations. This complexity science-inspired framework can be used for studying learning in complex, multilayered systems.

Development of eConsult reflective learning tools for healthcare providers: a pragmatic mixed methods approach

BACKGROUND

Electronic consultation (eConsult) programs are crucial components of modern healthcare that facilitate communication between primary care providers (PCPs) and specialists. eConsults between PCPs and specialists. They also provide a unique opportunity to use real-world patient scenarios for reflective learning as part of professional development. However, tools that guide and document learning from eConsults are limited. The purpose of this study was to develop and pilot two eConsult reflective learning tools (RLTs), one for PCPs and one for specialists, for those participating in eConsults.

METHODS

We performed a four-phase pragmatic mixed methods study recruiting PCPs and specialists from two public health systems located in two countries: eConsult BASE in Canada and San Francisco Health Network eConsult in the United States. In phase 1, subject matter experts developed preliminary RLTs for PCPs and specialists. During phase 2, a Delphi survey among 20 PCPs and 16 specialists led to consensus on items for each RLT. In phase 3, we conducted cognitive interviews with three PCPs and five specialists as they applied the RLTs on previously completed consults. In phase 4, we piloted the RLTs with eConsult users.

RESULTS

The RLTs were perceived to elicit critical reflection among participants regarding their knowledge and practice habits and could be used for quality improvement and continuing professional development.

CONCLUSION

PCPs and specialists alike perceived that eConsult systems provided opportunities for self-directed learning wherein they were motivated to investigate topics further through the course of eConsult exchanges. We recommend the RLTs be subject to further evaluation through implementation studies at other sites.

Impact of eConsults on Clinical Care in Primary Care: A Cross-Sectional Analysis of Primary Care Provider Behavior

INTRODUCTION/OBJECTIVES

Asynchronous electronic consultations (eConsults) support primary care providers (PCPs) by providing rapid specialist feedback and improve medically underserved patients' access to care.

METHODS

This cross-sectional study assessed all eConsults requested over a one-year period at a multi-site federally qualified health center in Texas. We analyzed eConsult content and quality and conducted chart reviews for a randomly selected subsample (n = 100) to determine whether PCPs implemented specialists' recommendations within 90 days. Semi-structured interviews with PCPs assessed their ability and willingness to follow recommendations.

RESULTS

There were 367 eConsults submitted by 25 PCPs across 15 adult medical and surgical specialties. Of the 100 charts reviewed n = 77 (77.0%) contained documentation indicating that the PCP had followed at least 1 of the specialist's recommendations within 90 days. In two-thirds of the cases (n = 66, 66%) the reviewing specialist indicated that a face-to-face referral was not needed. PCPs were most likely to follow recommendations for new medications and least likely to document that they had obtained additional patient history. PCPs noted that they were sometimes unable to follow recommendations when patients could not afford or access treatment or did not return for follow up care, or when they felt that the specialist did not address their specific question.

CONCLUSIONS

eConsults delivered to medically underserved patients in primary care help PCPs provide timely care for their patients. PCPs utilized a broad range of eConsult specialties and generally implemented eConsult specialists' recommendations within 90 days.

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.

Electronic consultations and clinician burnout: An antidote to our emotional pandemic?

Health information technology is a major source of clinician burnout due to increased administrative burden and inefficient work processes. Electronic consultations (eConsults) represent a promising innovation to improve access to specialty care by reducing wait times for specialist visits and reducing unnecessary in-person specialist visits. While eConsults have clear benefits for patients and healthcare systems, their potential effects on provider burnout should be considered. Using a framework which outlines that the loss of autonomy, competence, and relatedness as the main contributing factors to clinician "amotivation" and burnout, we discuss the use of eConsults and their potential to mitigate or exacerbate burnout for primary care providers and specialists, as well as recommendations for implementation of eConsults to reduce burnout.

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.

Electronic consultations and economies of scale: a qualitative study of clinician perspectives on scaling up e-consult delivery

OBJECTIVE

To explore Veterans Health Administration clinicians' perspectives on the idea of redesigning electronic consultation (e-consult) delivery in line with a hub-and-spoke (centralized) model.

MATERIALS AND METHODS

We conducted a qualitative study in VA New England Healthcare System (VISN 1). Semi-structured phone interviews were conducted with 35 primary care providers and 38 specialty care providers, including 13 clinical leaders, at 6 VISN 1 sites varying in size, specialist availability, and e-consult volume. Interviews included exploration of the hub-and-spoke (centralized) e-consult model as a system redesign option. Qualitative content analysis procedures were applied to identify and describe salient categories.

RESULTS

Participants saw several potential benefits to scaling up e-consult delivery from a decentralized model to a hub-and-spoke model, including expanded access to specialist expertise and increased timeliness of e-consult responses. Concerns included differences in resource availability and management styles between sites, anticipated disruption to working relationships, lack of incentives for central e-consultants, dedicated staff's burnout and fatigue, technological challenges, and lack of motivation for change.

DISCUSSION

Based on a case study from one of the largest integrated healthcare systems in the United States, our work identifies novel concerns and offers insights for healthcare organizations contemplating a scale-up of their e-consult systems.

CONCLUSIONS

Scaling up e-consults in line with the hub-and-spoke model may help pave the way for a centralized and efficient approach to care delivery, but the success of this transformation will depend on healthcare systems' ability to evaluate and address barriers to leveraging economies of scale for e-consults.

eConsult Specialist Quality of Response (eSQUARE): A novel tool to measure specialist correspondence via electronic consultation

High-quality correspondence between healthcare providers is critical for effective patient care. We developed an assessment tool to measure the quality of specialist correspondence to primary care providers (PCPs) via electronic consultation (eConsult), where specialists provide advice without specialist-patient interactions. We incorporated fourteen previously described features of high-quality eConsult correspondence into an assessment tool named the eConsult Specialist Quality of Response (eSQUARE). Six PCPs and two specialists applied the 10-item eSQUARE tool to 30 eConsults of varying quality as informed by PCP survey data. Content, response process, and internal structure validity evidence was gathered. Psychometric properties were calculated using descriptive statistics and generalizability analyses. Mean total score for low-quality eConsults (M = 24 ± 5.6) was significantly lower than moderate-quality eConsults (M = 38 ± 4.7; p<0.001) which was significantly lower than high-quality eConsults (M = 46 ± 3.0; p = 0.002). Reliability measures were high, including generalizability coefficient (0.96), inter-item (≥0.55) and item-total correlations (≥0.68). A decision study demonstrated that a single rater was adequate to achieve a reliability measure of ≥0.70. This study demonstrates initial validity evidence including multiple reliability measures for the eSQUARE. A single rater is adequate to achieve reliability measures for formative feedback. Future studies can apply the eSQUARE when planning educational initiatives aiming to improve specialist-to-PCP correspondence via eConsult.

Knowing What We Do Not Know: Analysis of an Online Consultation Service to Identify Provider Knowledge Gaps in Sexually Transmitted Disease Care

The national Sexually Transmitted Diseases (STD) Clinical Consultation Network receives requests regarding complex STD cases. A total of 927 requests from Western states, 2017 to 2019, were analyzed for STD of inquiry and syphilis-specific subtopics. Syphilis requests accounted for most queries, and the number and proportion of syphilis-related requests increased significantly over time.

Internal medicine residents identify gaps in medical education on outpatient referrals

BACKGROUND

Relevant clinical information is often missing when a patient sees a specialist after being referred by another physician in the ambulatory setting. This can result in missed or delayed diagnoses, delayed treatment, unnecessary testing, and drug interactions. Residents' attitudes toward providing clinical information at the time of referral and their perspectives toward training on referral skills are not clear. We sought to assess internal medicine residents' attitudes toward and experiences with outpatient referrals.

METHODS

We conducted a cross-sectional survey in October-December 2018 of all internal medicine interns and residents affiliated with a large, urban internal medicine residency program in New York, NY. We used a novel survey instrument that included 13 questions about attitudes toward and experiences with outpatient referrals. We used descriptive statistics to characterize the results.

RESULTS

Overall, 122 of 132 residents participated (92% response rate). Respondents were approximately equally distributed across post-graduate years 1-3. Although 83% of residents reported that it is "always" important to provide the clinical reason for a referral, only 11% stated that they "always" provide a sufficient amount of clinical information for the consulting provider when making a referral. Only 9% of residents "strongly agree" that residency provides sufficient training in knowing when to refer patients, and only 8% "strongly agree" that residency provides sufficient training in what information to provide the consulting physician.

CONCLUSIONS

These results suggest a substantial discrepancy between the amount of information residents believe they should provide at the time of a referral and the amount they actually provide. Many residents report not receiving adequate training during residency on when to refer patients and what clinical information to provide at the time of referral. Improvements to medical education regarding outpatient referrals are urgently needed.

Impact of Endocrinology eConsults on Access to Endocrinology Care for Medicaid Patients

Background: Access to endocrinologists is a particular challenge for medically underserved populations. Introduction: Electronic consultations (eConsults) are a promising tool to help address this problem. Materials and Methods: This retrospective cohort study compared two groups: (1) Medicaid patients referred to an endocrinologist 1 year before the implementation of eConsults and (2) those referred in the 1 year after implementation. Data included patient demographics, dates of referral requests, appointment dates, eConsult response dates and times, diagnosis codes, and consultants' recommendations. Provider perspectives of eConsults were determined by using a survey. Results: Before eConsult implementation, only 138 out of 365 (37.8%) of referrals to endocrinology were completed. Postimplementation, 281 out of 469 (59.9%) of referrals were completed either by a confirmed face-to-face visit with an endocrinologist or by an eConsult, of whom 194 (41.4%) did not require a face-to-face visit. Thyroid conditions were the most common reason for a consult, accounting for roughly 40% of all consults. Overall, 32 out of 36 (89%) primary care providers (PCPs) indicated that they were satisfied with eConsults and 19 out of 36 (53%) felt that the process did not create additional work or burden for them. Discussion: These findings demonstrate that eConsult use can help address poor access to specialty care for Medicaid-insured patients. eConsults were able to significantly decrease the need for face-to-face visits and enabled PCPs to address specialty-related issues in primary care. Conclusions: Widespread adoption of eConsults could be a potential solution for major challenges that our health care system faces today.

What should primary care look like after the COVID-19 pandemic?

The response to COVID-19 transformed primary care: new telehealth items were added to the Medicare Benefits Schedule, and their use quickly escalated, general practices and community health centres developed new ways of working and patients embraced the changes. As new coronavirus infections plummet and governments contemplate lifting spatial distancing restrictions, attention should turn to the transition out of pandemic mode. Some good things happened during the pandemic, including the rapid introduction of the new telehealth items. The post-pandemic health system should learn from the COVID-19 changes and create a new normal.

Implementing an Opt-in eConsult Program at Seven Academic Medical Centers: a Qualitative Analysis of Primary Care Provider Experiences

BACKGROUND

Electronic consultation (eConsult), which involves primary care provider (PCP)-to-specialist asynchronous consultation, is increasingly used in health care systems to streamline care and to improve patient access. The Association of American Medical Colleges (AAMC) formed a collaborative to support the implementation of an electronic medical record (EMR)-based, opt-in eConsult program across multiple academic medical centers (AMCs). In this model, PCPs can elect to send either an eConsult or a traditional referral.

OBJECTIVE

We sought to understand the PCP experience with eConsult to identify facilitators of and barriers to the successful adoption of the model.

DESIGN AND PARTICIPANTS

We conducted 35 semi-structured interviews and 6 focus groups with a range of primary care providers at 7 AMCs participating in the AAMC collaborative.

APPROACH

Interviews were recorded and transcribed or detailed field notes were taken. We used the constant comparative method to identify recurring themes within and across sites, and resolve interpretive discrepancies.

KEY RESULTS

We identified three major themes related to the eConsult program: (1) eConsult increases the comprehensiveness of primary care and fills PCPs' knowledge gaps through case-based learning. (2) Factors that influence PCPs to order an eConsult rather than a traditional referral include patient preference, case complexity, and need for expert guidance. (3) Implementation challenges included increasing PCPs' awareness of the program, addressing PCPs' concerns about increased workload, recruiting engaged specialist consultants, and ensuring high quality eConsult responses. Implementation success relied on PCP ownership of the consultation process, mitigating unintended consequences, ongoing education about the program, and mechanisms for providing feedback to clinicians.

CONCLUSIONS

Our findings demonstrate that an opt-in eConsult program at AMCs has the potential to increase PCP knowledge and enhance the comprehensiveness of primary care. For these benefits to be realized, program implementation requires sustained efforts to overcome barriers to use and establish norms guiding eConsult communication.

Primary Care Clinician Adherence to Specialist Advice in Electronic Consultation

PURPOSE

Electronic consultation (eConsult) services can improve access to specialist advice. Little is known, however, about whether and how often primary care clinicians adhere to the advice they receive. We evaluated how primary care clinicians use recommendations conveyed by specialists via the Champlain BASE (Building Access to Specialists through eConsultation) eConsult service and how eConsult affects clinical management of patients in primary care.

METHODS

This is a descriptive analysis based on a retrospective chart audit of 291 eConsults done between January 20, 2017 and August 31, 2017 at the Bruyère Family Health Team, located in Ottawa, Canada. Patients' charts were reviewed until 6 months after specialist response for the following main outcomes: implementation of specialist advice by primary care clinicians, communication of the results to the patients, method, and time frame of communication.

RESULTS

Primary care clinicians adhered to specialist advice in 82% of cases. Adherence ranged from 62% to 93% across recommendation categories. Questions asked by primary care clinicians related to diagnosis (63%), management (27%), drug treatment (10%), and procedures (1%). Recommendations of the eConsult were communicated to patients in 79% of cases, most often by face-to-face visit (38%), telephone call (32%), or use of the patient portal (9%). Communication occurred in a median of 5 days.

CONCLUSIONS

We found little evidence of barriers to implementing specialist advice with use of eConsult, which suggests recommendations given through service were actionable. With a high primary care clinician adherence to specialist recommendations and primary care clinician-to-patient communication, we conclude that eConsult delivers good-quality care and improves patient management.

What makes a high-quality electronic consultation (eConsult)? A nominal group study

INTRODUCTION

Poor communication between health professionals can compromise patient safety, yet specialists rarely receive feedback on their written communication. Although worldwide implementation of electronic consultation (eConsult) services is rising rapidly, little is known about the features of effective communication when specialists provide online advice to primary care providers (PCP). To inform efforts to ensure and maintain high-quality communication via eConsult, we aim to identify features of high-quality eConsult advice to incorporate into an assessment tool that can provide specialists with feedback on their correspondence.

METHODS

Initial items for the tool were generated by PCPs and specialists using the nominal group technique (NGT). Invited PCPs were above-median eConsult users between July 2016 and June 2017. Specialists were purposively recruited to represent the range of available specialties. Participants individually wrote down items they felt should be included in the tool. A moderator with consensus group expertise then led a round-robin discussion for each item. Items were ranked anonymously and included if highly-ranked by over 70% of participants.

RESULTS

Eight PCPs (six family physicians, two nurse practitioners) and three specialists (dermatology, hematology, pediatric orthopedics) produced 49 items that were refined to 14 after group discussion and two rounds of ranking. Highly-ranked items encompassed specific, up-to-date, patient-individualized, and practical advice that the PCP could implement.

DISCUSSION

Features of high-quality eConsult correspondence derived from consensus methods highlight similarities and differences between face-to-face consultation letters and eConsult. Our findings could be used to inform feedback and education for eConsult specialists on their advice to PCPs.

Evaluation of an electronic consultation service in psychiatry for primary care providers

BACKGROUND

This study explores the effectiveness of an electronic consultation (eConsult) service between primary care providers and psychiatry, and the types and content of the clinical questions that were asked.

METHODS

This is a retrospective eConsult review study. All eConsults directed to Psychiatry from July 2011 to January 2015 by Primary care providers were reviewed. Response time and the amount of time reported by the specialist to answer each eConsult was analyzed. Each eConsult was also categorized by clinical topic and question type in predetermined categories. Mandatory post-eConsult surveys for primary care providers were analyzed to determine the number of traditional consults avoided and to gain insight into the perceived value of eConsults.

RESULTS

Of the 5597 eConsults, 169 psychiatry eConsults were completed during the study period. The average response time for a specialist to a primary care provider was 2.3 days. Eighty-seven percent of clinical responses were completed by the psychiatrist in less than 15 min. The primary care providers most commonly asked clinical questions were about depressive and anxiety disorders. 88.7% of PCPs rated the eConsult service a 5 (excellent value) or 4.

CONCLUSIONS

This study indicates that an eConsult psychiatry service has tremendous potential to improve access to psychiatric advice and expand the capacity to treat mental illness in primary care. Future research may include follow-up with PCPs regarding the implementation of specialist advice.

Expanding incentives for coordinated, patient-centered care: Implications for neurologists

Historically, payment for cognitive, nonprocedural care has required provision of face-to-face evaluation and management as part of general ambulatory or inpatient care. Although non-face-to-face patient care (e.g., care via electronic means or telephone) is commonly performed and is integral to patient-centered care, appropriate reimbursement for this type of care is lacking. Beginning in 2017, Centers for Medicare and Medicaid (CMS) has taken a large step forward in reimbursing an increased number of cognitive care and non-face-to-face codes. CMS has also included language indicating that nonphysician providers (i.e., nurse practitioners and physician assistants) can perform many of these services independently. The 2017 and now the 2018 fee schedules thus create new payments for non-face-to-face, patient-centered services, and may allow neurologists to reach out to more patients through nonphysician providers. As health care in the United States moves toward value-based incentives, these newly supported non-face-to-face services will provide neurologists with new tools to deliver sustainable, high-value care.

A New Community Health Center/Academic Medicine Partnership for Medicaid Cost Control, Powered by the Mega Teaching Health Center

Community health centers (CHCs), a principal source of primary care for over 24 million patients, provide high-quality affordable care for medically underserved and lower-income populations in urban and rural communities. The authors propose that CHCs can assume an important role in the quest for health care reform by serving substantially more Medicaid patients. Major expansion of CHCs, powered by mega teaching health centers (THCs) in partnership with regional academic medical centers (AMCs) or teaching hospitals, could increase Medicaid beneficiaries' access to cost-effective care. The authors propose that this CHC expansion could be instrumental in limiting the added cost of Medicaid expansion via the Affordable Care Act (ACA) or subsequent legislation. Nevertheless, expansion cannot succeed without developing this CHC-AMC partnership both (1) to fuel the currently deficient primary care provider workforce pipeline, which now greatly limits expansion of CHCs; and (2) to provide more CHC-affiliated community outreach sites to enhance access to care. The authors describe the current status of Medicaid and CHCs, plus the evolution and vulnerability of current THCs. They also explain multiple features of a mega THC demonstration project designed to test this new paradigm for Medicaid cost control. The authors contend that the demonstration's potential for success in controlling costs could provide help to preserve the viability of current and future expanded state Medicaid programs, despite a potential ultimate decrease in federal funding over time. Thus, the authors believe that the new AMC-CHC partnership paradigm they propose could potentially facilitate bipartisan support for repairing the ACA.

Using Clinical Questions Asked by Primary Care Providers Through eConsults to Inform Continuing Professional Development

INTRODUCTION

Continuing professional development (CPD) offerings should address the educational needs of health care providers. Innovative programs, such as electronic consultations (eConsults), provide unique educational opportunities for practice-based needs assessment. The purpose of this study is to assess whether CPD offerings match the needs of physicians by coding and comparing session content to clinical questions asked through eConsults.

METHODS

This study analyzes questions asked by primary care providers between July 2011 and January 2015 using a service that allows specialists to provide consultation over a secure web-based server. The content of these questions was compared with the CPD courses offered in the area in which these primary care providers are practicing over a similar period (2012-2014). The clinical questions were categorized by the content area. The percentage of questions asked about each content area was calculated for each of the 12 specialties consulted. CPD course offerings were categorized using the same list of content areas. Percentage of minutes dedicated to each content area was calculated for each specialty. The percentage of questions asked and the percentage of CPD course minutes for each content area were compared.

RESULTS

There were numerous congruencies and discrepancies between the proportion of questions asked about a given content area and the CPD minutes dedicated to it.

DISCUSSION

Traditional needs assessment may underestimate the need to address topics that are frequently the subject of eConsults. Planners should recognize eConsult questions as a valuable source of practice-associated challenges that can identify professional development needs of physicians.

The use of eConsults to improve access to specialty care in thrombosis medicine

INTRODUCTION

Electronic consultations (eConsults) are asynchronous, consultative electronic-based communications that are aimed to improve efficient and timely access to specialist advice. Our study aim was to evaluate the use and impact of the Canadian Champlain BASE™ (Building Access to Specialists through eConsultation) eConsult service in the specialty of thrombosis medicine.

METHODS

We conducted a cross-sectional study that included descriptive statistics of provider and patient demographic information and consultative-specific data. The impact of eConsults on primary care provider (PCP) referral patterns and satisfaction was assessed using a mandatory close-out survey upon completion of each eConsult.

RESULTS

There were 162 thrombosis eConsult cases completed between June 2012 and March 2016. The most common referral topics were for thrombophilia testing, management of superficial vein thrombosis, and the choice and duration of anticoagulation for venous thromboembolism. By completing an eConsult, PCPs reported 47.5% of face-to-face consultations were avoided, and 4.3% prompted a thrombosis referral that was not originally contemplated. Primary care providers' responses to a thrombosis eConsult service were overwhelmingly positive, which included appreciation for timely access for patients, expert guidance and providing additional educational opportunities.

CONCLUSION

An eConsult service in thrombosis medicine improved timely access to specialist advice and potentially reduces the number of face-to-face consultations needed. Further research is needed to understand how a thrombosis eConsult service affects thrombosis clinic performance data and patient outcomes.

Evaluating e-consultation implementations based on use and time-line across various specialties

BACKGROUND

Electronic Consultation (e-consults) can provide improved access, enhance patient and provider satisfaction, and reduce beneficiary travel expenses. We explored how e-consults were implemented across three specialty areas, diabetes (Diab), gastroenterology (GI), and neurosurgery (Neuro), at two Veterans Affairs hospitals in terms of strategies for use and time-lines.

METHODS

We conducted observations and electronically shadowed patient e-consultations submitted to a specialty care service by primary care provider(s) at the two sites during a thirteen-month period. We divided the e-consult process in each specialty into three broad milestones; Request (from primary to specialty), Response (from specialty back to primary), and Follow up (from primary to patient), and recorded the flow and time in each category. An overall hierarchy of e-consults was developed to illustrate the many ways an e-consult was used. The Kolmogorov-Smirnov test was used to compare the distribution of time across specialties.

RESULTS

A total of 394 consults submitted between April 14, 2012 and May 2, 2013 were reviewed (Diab=152, GI=169, Neuro=73). Of the 152 diabetes specialty clinic e-consults, 35% required some sort of direct contact with the patient by the specialty clinic before a recommendation was provided. Overall, 58% of the e-consults were completed within 20days, while 68% were completed within 30days. The Response times between Diab and GI were significantly different (median=0 vs. 3days; p<0.0001) and so were Follow up times (median=0 vs. 4days; p<0.0001). All three stages were statistically different between Diab and Neuro; however, there was not enough evidence to suggest any differences between GI and Neuro.

CONCLUSIONS

The use of an e-consult is likely to vary based on the specialty, but the often significant variations in time may continue to hinder prompt access to care. E-consult design, implementation, documentation, training, self-learning, and monitoring should be tailored to get the most benefit out of this system.