E-Consults Offer Accessible Way to See Specialists

Salman Ahmed, MD, MPH

Electronic consultations (e-consults) can serve as an alternate way for patients to access specialists, according to the findings of a new study.

Salman Ahmed, MD, MPH, and colleagues from Brigham and Women’s Hospital and Massachusetts General Hospital reviewed medical records across 5 specialties with a high volume of e-consult requests—psychiatry, hematology, dermatology, infectious diseases, and rheumatology—to assess novel metrics of appropriateness and e-consult utility. The findings could provide insight into practice, provide a rubric for future studies, and suggest areas to improve resource use and patient care.

Ahmed, a nephrologist at Brigham and Women’s, and the team of investigators used an e-consult program developed by Partners HealthCare System, a nonprofit hospital and provider network in Massachusetts. The purpose of the program was to increase access to specialty care, reduce unnecessary in-person visits, and improve patient experience by avoiding travel.

Since July 2019, >100 practices participated in e-consults across the Partners HealthCare System network. There were close to 45,000 e-consults completed, with a median response time of 1.64 days. The e-consults were submitted throughout the network.

The team obtained data on visit avoidance and demographic characteristics from 6512 e-consults during the study period (October 2017-November 2018.

Ahmed and the investigators measured utility by defining an avoided visit as a specialty-directed e-consult ordered followed by absence of an in-person visit in the same specialty for 120 days. Appropriateness was meeting all 4 pre-specified criteria. The 4 criteria were: the point-of-care resource test, if an e-consult sought logistic information, whether the question was of high urgency, and whether the medical complexity of the clinical situation was important enough that the question could not be answered via an e-consult format and needed an in-person visit.

Across all specialties, the team found that dermatology e-consult patients were younger (mean age, 38.6 years old) than those with consults in other specialties, and a lower percentage were female (55.3%). Most e-consults were completed within 1 day or less (range, 73.1% for psychiatry to 87.8% for infectious disease).

Among all e-consults, 70.2% met all 4 criteria for appropriateness, with the frequency of unmet criteria varying across specialties. Raters agreed on the appropriateness of 94% of e-consults (95% CI, .36-.79), which investigators suggested was indicative of moderate agreement. The proportion of appropriate consults ranged from 60.5% (rheumatology) to 77.9% (psychiatry).

The most common reason an e-consult was not considered appropriate was failing the point-of-care resource test and asking a question of inappropriately high complexity.

The rate of avoided visits across the 5 specialties was 81.2%. The highest rate was in psychiatry (92.6%) and the lowest was in dermatology (61.9%).

The study findings may inform other health systems or practices considering expanding their e-consult program. What’s more, the results could guide those considering implementation.

Overall, such programs represented an effective, patient-centered approach to improving access to specialists in integrated health systems.

“Used alongside telemedicine and face-to-face visits, e-consults offer immense promise for increasing access to high-quality care while controlling the costs of health care delivery,” Varsha Vimalananda, MD, MPH, and B. Graeme Fincke, MD, both from Boston University School of Public Health, wrote in an accompanied editorial commentary.

The study, “Utility, Appropriateness, and Content of Electronic Consultations Across Medical Subspecialties,” was published online in Annals of Internal Medicine.