Specialist e-Consultations Improve Care, Reduce Costs

Tara Haelle

March 15, 2016

Primary care providers' use of e-consultations for specialist referrals not only cut the waiting time compared with traditional referrals but also safely reduced the overall need for in-person specialist visits, according to a study published in the March/April 2016 issue of the Annals of Family Medicine.

"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," write J. Nwando Olayiwola, MD, MPH, from San Francisco General Hospital in California, and colleagues. "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."

The researchers randomly assigned nine primary care providers to a control group who followed usual referral strategies and 17 to a group using e-consultations for referrals to cardiologists from the University of Connecticut Health Center. The e-consultations were reimbursed at $25 each.

The primary care clinicians, from a dozen practice sites in a community health center in Connecticut, referred 590 mostly underserved patients during the 12 months of the study's intervention. More than 90% of the patients were at or below the 200% federal poverty level, more than 60% used Medicaid, more than 60% were racial or ethnic minorities, and 25% lacked any health insurance.

The asynchronous e-consultations took place between the primary care provider and the cardiologist, using a secure peer-to-peer messaging module within the shared electronic health record system. The cardiologists responded within 2 days. "Responses were case-specific and generally contained recommendations for management, additional testing, or a face-to-face cardiologist's visit," the authors write. "The clinician was responsible for considering and acting upon recommendations and determining when an e-consultation was complete."

Just more than half (52%) of cardiology referrals in the intervention group were sent as an e-consultation, and 69.2% did not require an in-person visit to the cardiologist to resolve. In just more than a quarter (27.5%) of the e-consultations, the cardiologist recommended a face-to-face visit. A relatively small proportion (3.3%) of e-consultations failed because of technical difficulties.

Those not referred as an e-consultation either involved a preexisting patient relationship with the cardiologist or an urgent situation. Abnormal electrocardiogram findings made up the most commonly referred e-consultations, followed by chest pain, preoperative assessment, and hypertension. Coronary artery disease was the most common reason patients were referred for face-to-face consultations with cardiologists, followed by chest pain, heart failure, hypertension, and abnormal electrocardiogram findings.

Although it took a median 24 days to see a cardiologist for patients of physicians in the control group, it took only a median 5 days for patients whose physicians used e-consultations. Patients of the intervention group physicians were also approximately 1.5 times more likely to receive a consultation than those of the control group physicians.

"Patients referred via the traditional consultation pathway had higher rates of emergency department utilization than those receiving e-consultation referrals during the 6-month follow-up," including six patients whose visits occurred during their wait for the cardiologist consultation, the authors report. Primary care providers' responses to surveys indicated high satisfaction with e-consultation response quality and timeliness.

"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," the authors write. The researchers also compared adverse outcomes among all the patients, including death, myocardial infarction, coronary artery bypass grafting, urgent or emergent cardiac catheterization and/or angioplasty, and emergency department or hospital visits for cardiac problems or events.

"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," the authors write.

The research was funded by the Connecticut Health Foundation. The authors have disclosed no relevant financial relationships.

Ann Fam Med. 2016;14:133-140. Full text

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