Utility, Appropriateness, and Content of Electronic Consultations Across Medical Subspecialties A Cohort Study
- 19 May 2020
- journal article
- research article
- Published by American College of Physicians in Annals of Internal Medicine
- Vol. 172 (10), 641-+
- https://doi.org/10.7326/M19-3852
Abstract
Background: Electronic consultations (e-consults) can facilitate patient access to specialists, minimize travel, and reduce unnecessary in-person visits. However, metrics to enable study of e-consults and their effect on processes and patient care are lacking. Objective: To assess novel metrics of e-consult appropriateness and utility. Design: Retrospective cohort study. Setting: Primary and specialty care practices at 2 large academic and 2 community hospitals of an integrated health system. Participants: Patients with e-consult requests to 5 specialties-hematology, infectious disease, dermatology, rheumatology, and psychiatry-between October 2017 and November 2018. Measurements: The appropriateness of e-consult inquiries was assessed by review of medical records and defined as meeting the following 4 criteria: not answerable by reviewing evidence-based summary sources ("point-of-care resource test"), not merely requesting logistic information, having appropriate clinical urgency, and having appropriate patient complexity. Interrater agreement in assessments of e-consult appropriateness was assessed by the kappa statistic. Utility of e-consults was assessed by the rate of avoided visits (AVs), defined by the absence of an in-person visit to the same specialty within 120 days. Results: Overall, 6512 eligible e-consults were made by 1096 referring providers to 121 specialist consultants. Inquiries were characterized as diagnostic, therapeutic, for provider education, or at the request of the patient. Most consultations were answered within 1 day, with variation across specialties (73.1% for psychiatry to 87.8% for infectious disease). Overall, 70.2% of e-consults met all 4 criteria for appropriateness; the frequency of unmet criteria varied among specialties. Raters agreed on the appropriateness of 94% of e-consults (kappa = 0.57 [95% CI, 0.36 to 0.79]), indicating moderate agreement. The overall rate of AVs across the 5 specialties was 81.2%; the highest rate was in psychiatry (92.6%) and the lowest in dermatology (61.9%). Limitation: Generalizability is unknown outside a single integrated health system, where requesting and consulting providers share a common electronic health record. Conclusion: Novel metrics to assess the appropriateness and utility of e-consults provide meaningful insight into practice, provide a rubric for comparison in future studies in additional settings, and suggest areas to improve resource use and patient care.This publication has 16 references indexed in Scilit:
- Los Angeles Safety-Net Program eConsult System Was Rapidly Adopted And Decreased Wait Times To See SpecialistsHealth Affairs, 2017
- What are the cost savings associated with providing access to specialist care through the Champlain BASE eConsult service? A costing evaluationBMJ Open, 2016
- Electronic Consultations to Improve the Primary Care-Specialty Care Interface for Cardiology in the Medically Underserved: A Cluster-Randomized Controlled TrialAnnals of Family Medicine, 2016
- Longer-term impact of cardiology e-consultsAmerican Heart Journal, 2016
- Taxonomy of the burden of treatment: a multi-country web-based qualitative study of patients with chronic conditionsBMC Medicine, 2015
- Leveraging an electronic referral system to build a medical neighborhoodHealthcare, 2015
- Utilization, Benefits, and Impact of an e-Consultation Service Across Diverse Specialties and Primary Care ProvidersTelemedicine and e-Health, 2013
- A Safety-Net System Gains Efficiencies Through ‘eReferrals’ To SpecialistsHealth Affairs, 2010
- Provider Satisfaction With Virtual Specialist Consultations in a Family Medicine DepartmentThe Health Care Manager, 2009
- Access To Specialty Care And Medical Services In Community Health CentersHealth Affairs, 2007