Impact of an Opt-In eConsult Program on Primary Care Demand for Specialty Visits: Stepped-Wedge Cluster Randomized Implementation Study

Formalizing the curbside: digitally enhancing access to specialty care

Asynchronous medical care has increased in utilization, patient interest, and industry demand. While E-consults have been discussed extensively in the literature, there are rare examples of a multispecialty implementation within a large health system. Here, we describe our experience in implementing an internal E-consult program for asynchronous, nonurgent communication between ambulatory specialists and primary care providers in our large multispecialty regional health system. To ensure adoption of the program, patient, specialist, and primary care physician concerns were systematically addressed. The program commenced in February 2022 with three high referral rate specialties: cardiology, orthopedics, and dermatology. In the 12 months after implementation, 2243 total E-consults were ordered among 505 ordering providers. Dermatology received the most consultations, and we have expanded to 19 specialties and subspecialties available in the program in the first year. Our E-consult implementation experienced substantial growth in a short time period, demonstrating the viability of E-consult utilization for increasing asynchronous access to ambulatory specialists' expertise in a large healthcare system.

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.

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.

Rapid implementation of Inpatient eConsult Programme addresses new challenges for patient care during COVID-19 pandemic

INTRODUCTION

At the early epicentre of the COVID-19 crisis in the USA, our institution saw a surge in the demand for inpatient consultations for areas impacted by COVID-19 (eg, infectious diseases, nephrology, palliative care) and shortages in personal protective equipment (PPE). We aimed to provide timely specialist input for consult requests during the COVID-19 pandemic by implementing an Inpatient eConsult Programme.

METHODS

We used the reach, effectiveness, adoption, implementation and maintenance implementation science framework and run chart analysis to evaluate the reach, adoption and maintenance of the Inpatient eConsult Programme compared with traditional in-person consults. We solicited qualitative feedback from frontline physicians and specialists for programme improvements.

RESULTS

During the study period, there were 46 available in-person consult orders and 21 new eConsult orders. At the peak of utilisation, 42% of all consult requests were eConsults, and by the end of the study period, utilisation fell to 20%. Qualitative feedback revealed subspecialties best suited for eConsults (infectious diseases, nephrology, haematology, endocrinology) and influenced improvements to the ordering workflow, documentation, billing and education regarding use.

DISCUSSION

When offered inpatient eConsult requests as an alternative to in-person consults in the context of a surge in patients with COVID-19, frontline physicians used eConsult requests and decreased use of in-person consults. As the demand for consults decreased and PPE shortages were no longer a major concern, eConsult utilisation decreased, revealing a preference for in-person consultations when possible.

CONCLUSIONS

Lessons learnt can be used to develop and implement inpatient eConsults to meet context-specific challenges at other institutions.

Evaluation of the Effects of the COVID-19 Pandemic on Electronic Consultation Use in Primary Care

Background: Little is known about electronic consultation (e-consult) utilization during the COVID-19 pandemic when health systems rapidly implemented and scaled telehealth alternatives to in-person care. It is also unknown if e-consult utilization during the pandemic replaced or merely deferred the need for a specialty appointment. We evaluated if primary care providers' (PCPs) e-consult utilization and specialists' recommendations for specialty appointments changed after the transition to telemedicine during the COVID-19 pandemic. Methods: This cohort study used an interrupted time series analysis of e-consult utilization in a large, urban academic health care system between December 1, 2019, and June 27, 2020; the post-telemedicine time period began March 15, 2020. The primary outcome measure was the odds of an e-consult ordered during a PCP appointment; the secondary outcome measure was the odds of a specialist recommending a specialty appointment in an e-consult. Results: During 193,263 PCP appointments, 1,318 e-consults were placed to internal medicine subspecialties. Compared to the pre-telemedicine time period, the odds of a PCP ordering an e-consult increased (OR 1.04, 95% CI [1.02-1.07]) and the odds of specialists recommending specialty appointments increased (OR 1.11, 95% CI [1.06-1.15]). Conclusions: E-consult use increased following the transition to telemedicine in the context of the COVID-19 pandemic, suggesting that PCPs consider the e-consult a valuable tool for patient care when there is limited availability of specialty appointments. However, recommendations for specialty appointments following an e-consult also increased, suggesting that the e-consult may not replace the need for a specialty appointment.

Medical student remote eConsult participation during the COVID-19 pandemic

BACKGROUND

Undergraduate medical education was severely impacted by the COVID-19 pandemic. As traditional clinical rotations were suspended, medical students quickly began alternative, novel educational experiences. Third-year medical students at an academic medical center were given the opportunity to join inpatient eConsult teams within the department of medicine. This study describes the development and implementation of this program as well as the experiences of student and faculty participants.

METHODS

Student eConsult participation was rapidly developed and implemented within medical subspecialty teams in either infectious diseases (ID) or nephrology. Twelve third-year medical students and 15 subspecialty attendings participated in this program during an eight-week period from April 6 through May 29, 2020. Breadth of student clinical experience was assessed via review of clinical documentation and surveys. Participating students and attending physicians completed surveys to reflect upon their impressions of the program. Surveys were returned by nine students and eight faculty members. Survey responses were summarized with descriptive statistics.

RESULTS

Over an eight-week period, student consultants wrote 126 notes on 100 patients; 74 of these patients (74%) were hospitalized with COVID-19. Student experiences were largely positive with most strongly agreeing that attendings promoted interactive and engaged learning (N = 8 of 8, 100%), that the experience helped to expand their knowledge about consultant roles (N = 6, 75%), and that they would participate in a remote eConsult program again if given the opportunity (N = 6, 75%). Faculty also were largely positive about the experience with most agreeing or strongly agreeing with the importance of teaching medical students about telehealth (N = 7 of 8, 88%) and eConsults (N = 6, 75%). In narrative responses, students and faculty agreed that teaching was a strength of the program whereas lack of in-person contact was a challenge.

CONCLUSIONS

Rapid development of an inpatient eConsult-based educational experience for third-year medical students was feasible and successful. Student-consultants saw a range of pathology including COVID-19 and related complications. Students were satisfied with the program. They were able to develop a strong relationship with attendings while learning about the role of a consultant. Faculty agreed with the importance of teaching students about telehealth and eConsults specifically.