Original Research

A Medical Specialty e-Consult Program in a VA Health Care System

Author and Disclosure Information

Utilization, satisfaction, and perceived benefits differed among primary care providers and specialists in this study of e-Consults across the VA Boston Healthcare System.


 

References

The VA is charged with providing high-quality, efficient care for those who have served in the armed forces. Starting in 2009, leadership within the VA articulated a set of “transformational” initiatives, which included greater implementation of telemedicine to improve the coordination of veterans’ care and access to specialty care.

The VA Boston Healthcare System (VABHS) consists of 3 major facilities and multiple community-based outpatient clinics (CBOCs) across eastern Massachusetts. Most medical specialty care is concentrated near the single acute-care site, resulting in a diffuse network of primary and specialty care providers. Consequently, many patients travel beyond their primary medical facility to access specialists. To address this fragmentation, the Medical Service at VABHS implemented a system of electronic chart review consultations (e-Consults) to provide high-quality, efficient care while maintaining the integrity of the patient’s medical home and improving access to specialty providers.

Designed to address clinical questions that may not require a face-to-face (FTF) encounter, e-Consults are a form of store-and-forward telemedicine (SAFT), with information-sharing between requesting providers (typically primary care) and answering specialists, using the VA’s existing electronic health record (EHR), the Computerized Patient Record System (CPRS). Store-and-forward telemedicine increases patient access to specialists and timeliness in initiating a consultation while decreasing patient travel and associated costs.1-15

Although previous studies have usually found high concordance between SAFT and FTF consultations in both diagnosis and disease management, the feasibility of SAFT has been historically limited by the lack of an integrated shared EHR.16-18 The VA implemented CPRS in 1996 and was soon recognized as a fully integrated EHR, allowing any VA clinician to view any veteran’s medical record nationwide. This technology, combined with the geographically dispersed population of veterans and the concentration of specialty services within mostly urban tertiary care centers, makes the VA an optimal environment to benefit from implementation of SAFT.

This study examines the implementation of e-Consults in a large VA medical service with the primary goal of facilitating timely specialty care access. This article details the initial experience of implementation and clinicians’ early perceptions of the system.

E-Consult Implementation

The VABHS provides tertiary specialty care for much of New England. It also serves a primary care population of more than 30,000 veterans in eastern Massachusetts through a network of 3 larger primary care practices based at 3 main campuses and 5 smaller CBOCs. Most specialty care is provided by the 2 campuses in Boston.

Discussions with primary care leadership and e-mail announcements to primary care providers (PCPs) throughout VABHS announced the availability and purpose of the new e-Consult. The initiative was initially piloted within 2 specialties, allergy and cardiology, beginning in January 2011. After establishing the logistics for routing, processing, and encounter data capture, e-Consults were expanded to the remaining subspecialties by December 2011.

Within 9 months, 12 different specialties had e-Consult options: endocrinology, gastroenterology, hematology, infectious disease, nephrology, oncology, palliative care, pulmonary disease, rheumatology, and sleep medicine. The e-Consult use was tracked for this study on a monthly basis.

Process and Work Flow

Any PCP with consult ordering privileges can request an e-Consult. Expectations were set that e-Consults should be used to request help with nonemergent clinical issues and be completed within 3 nonholiday weekdays.

The e-Consult uses CPRS modular programming to create an event-based electronic consultation request. Once initiated, the consult is routed to the consulting service. Each specialty defines how to triage the e-Consult request; computer alerts can be immediately generated to a single individual or a defined team within each specialty. Options to alert or print consult requests to administrative personnel also exist. As with requests for FTF consultation requests, e-Consults allow specialists the options to deny a request if they feel it is not appropriate for their specialty. In addition, specialists are able to convert the e-Consult request to a FTF encounter, to forward the e-Consult to another specialty, or to add a “comment” before proceeding. These comments generate an immediate electronic alert to the requestor, thus providing a forum for asynchronous preconsultation dialogue between providers. Once the consultation is complete, the requestor receives an alert that directs them to view the completed consultation note in the EHR.

The entirety of the EHR is accessible to the consultant, including all primary care and specialty progress notes, inpatient and outpatient laboratory testing, and all diagnostic testing performed nationally within the VA.

User Feedback

Based on the literature, separate online questionnaires were developed to ascertain primary care clinicians’ and specialists’ perceptions of the e-Consult system. This 26-item survey for PCPs and 13-item survey for specialists assessed use of e-Consults, satisfaction with the system, and for primary care clinicians, perceived benefits of the e-Consult process
and specific feedback by specialty.

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