Electronic Consultations to Improve the Primary Care-specialty Care Interface for Cardiology in the Medically Underserved

A Cluster-Randomized Controlled Trial

J. Nwando Olayiwola, MD, MPH; Daren Anderson, MD; Nicole Jepeal, BA; Robert Aseltine, PhD; Christopher Pickett, MD; Jun Yan, PhD; Ianita Zlateva, MPH


Ann Fam Med. 2016;14(2):133-140. 

In This Article


The results from the first randomized study of referrals for an e-consultation reveal the potential to improve safely and efficiently the primary care–specialty consultation process using an electronic communication platform. Approximately one-half of all cardiology referrals met our criteria to be sent via e-consultation, and two-thirds of those did not require a face-to-face visit. Moreover, e-consultation reviews were completed, on average, almost a month sooner than those sent for a face-to-face consultation, even those deemed urgent by the referring clinician. Although there was some variability in use of the e-consultation pathway by individual clinicians, likely reflecting differences in case mix (more cases of urgent or established disease in some clinicians' panels) or in a clinician's comfort and assessment of the urgency of the requested consultation, most of the clinicians used that pathway for one-half or more referrals. Either way, these results show that a substantial number of consultations can be safely and more efficiently managed though a secure electronic exchange of information, with improved convenience for the patient as well. Careful evaluation of the impact of e-consultation on patient safety and quality of care was undertaken through detailed reviews of the clinical records, including hospital and emergency department documentation, in the 6 months after the intervention (Table 4). We did not find any evidence that patients managed by clinicians who requested an e-consultation had more adverse cardiac outcomes than patients of clinicians in the control group. These findings, coupled with the reduction in waiting time for appointments and need for face-to-face specialist consultation suggest that e-consultation referrals may improve efficiency without compromising the quality of care.

This study has several limitations. The study focused on a single specialty, and the impact of e-consultations could vary among specialties.[10] In addition, analysis of the clinical outcomes of patients relied on chart review of faxed documents to determine rates of hospitalization and emergency department use, and it is possible that not all records were in the EHR. This problem, however, would affect findings equally in both groups. Studies using claims-level data may provide more accurate information. In addition, the study had a small sample size of primary care clinicians and patients, so broad conclusions cannot be drawn. Further research should be done to assess e-consultations in settings other than federally qualified health centers, though the benefits of waiting time reduction and equivalent quality are likely applicable to other settings. Patients' experience was not assessed and is an area for future exploration. Finally, technical problems with the e-consultation system led to 3.3% of e-consultation requests not receiving a specialist review. The study was not designed to formally detect adverse events. Further studies on safety and adverse events, particularly exploring the potential challenges of technology, are needed.

We found that e-consultation referrals are effective at increasing access to specialty care for underserved populations, reducing need for face-to-face specialty care, streamlining specialty referrals, and potentially reducing emergency department utilization. These findings have critical policy implications as health systems seek new ways to improve quality and reduce cost. There is also growing recognition that the e-consultation pathway may be fundamental to the success of accountable care organizations as part of a comprehensive strategy to streamline costs, improve quality, and better coordinate care.[22] Though further research is needed to recommend e-consultations for wide use across settings and specialties, e-consultations showed great promise in advancing integration of the patient-centered medical home into the larger medical neighborhood and potentially mitigating health disparities in access and treatment in our study population.