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

Nine months after full implementation, perceptions of e-Consult processes were solicited. All PCPs, staff physicians, nurse practitioners, and internal medicine residents assigned to a VABHS primary care clinic were surveyed. Eligible specialist consultants included attending physicians and fellows who were identified by the specialty chief as potentially having responded to an e-Consult in the past 6 months. The survey was administered in June 2012 and queried the previous 6 months’ experience.

The monthly number of e-Consults ranged from 96 to 137 over the 6-month study period. Cardiology and hematology were the most commonly requested e-Consults, with > 20 per specialty per month. The 146 cardiology e-Consults during those 6 months represented 20% of all new cardiology consults, whereas the 159 e-Consults to hematology represented 53% of their new consults. The least used specialties for e-Consults were allergy, oncology, palliative care, and rheumatology, each averaging < 2 e-Consults per month.

Provider Perceptions

Overall, 85 of the 163 providers completed the survey (52%). Permanent staff had a better response rate than did trainees: 58% vs 33% among PCPs (P < .02), and 71% vs 44% among specialists (P = .03).

Of the 47 primary care respondents, 4 residents and 2 staff physicians had not previously used e-Consults; all 4 residents and 1 staff physician stated that this was due to lack of awareness of the system. The remaining 41 PCPs had requested ≥ 1 e-Consult in the past 6 months. All 38 specialist provider respondents had answered ≥ 1 e-Consult in study period, with 9 providers completing > 20.

e-Consult Satisfaction

Overall, 93% of PCPs were satisfied with e-Consults, and none were dissatisfied, compared with 53% of specialty providers who were satisfied and 26% who were dissatisfied (P < .001) (Figure 1). All specialists who were dissatisfied were in the sections of cardiology or gastroenterology. Further inspection identified several differences between those specialty providers who were generally satisfied with e-Consults (n = 20) compared with those providers who were dissatisfied (n = 10). Eight PCPs reported being neither satisfied nor dissatisfied.

In analyses comparing satisfied specialists (n = 20) with dissatisfied specialists (n = 10), excluding the 8 respondents who were neither satisfied nor dissatisfied, those who were satisfied reported a lower rate of conversion of e-Consults to FTF visits than did their dissatisfied peers, 26% vs 52%, respectively (P = .01). Satisfied specialists were more likely to view e-Consults as replacing work they otherwise would have done, such as a replacement for a FTF consult and prior informal “curbside” consults, 79% vs 50%, respectively (P < .02). Satisfied specialists were somewhat more likely to complete their e-Consults, on average, in ≤ 15 minutes, compared with dissatisfied specialists, although this trend did not reach statistical significance (59% vs 49%, respectively; (P = .07) (Figure 2).

Improving Quality of Care

PCPs were asked to note which benefits were realized among patients for whom e-Consults replaced FTF visits. Nearly all (98%) indicated that the e-Consults enabled patients to avoid unnecessary travel, and 95% of PCPs indicated that they requested e-consults to receive faster clinical input about a patient. A total of 59% believed e-Consults helped their patients avoid additional copays, and 56% obtained specialty input for a patient who would otherwise refuse to travel. When an e-Consult did not avoid a FTF visit (ie, despite the e-Consult, the patient ultimately proceeded to a FTF consultation with the specialist), the majority of PCPs believed that the e-Consult provided them with reassurance and initiated diagnostic testing that would be useful during the patient’s subsequent FTF consult (Figure 3).

Overall, 61% of specialists agreed with the statement, “e-Consults improve the quality of care VA Boston Healthcare System provides.” Even when specialists perceived that e-Consults did not avoid FTF visits, most agreed that e-Consults helped initiate diagnostic testing prior to a FTF visit. In addition, satisfied specialists saw the benefit in reassuring the PCP and initiating additional management prior to a FTF visit.

Dynamics of e-Consults

Primary care providers reported that 78% of their requested e-Consults were completed within 2 days and 95% of all e-Consults were completed by day 3. In aggregate, primary care clinicians estimated that about one-third of their e-Consults replaced FTF visits; one-third replaced prior mechanisms for informal consultation (eg, “curbside” or e-mail); and one-third of e-Consults represented new requests that would not have involved specialty consultation in the absence of the e-Consult mechanism.

Specialists estimated that 27% of e-Consults were new work (ie, consultations that would not have occurred formally or informally in the absence of the e-Consult mechanism); 32% replaced FTF visits; and 42% were substitutes for prior informal communications. Specialists reported a wide range of time required to answer e-Consults. For specialists, on average, 54% of e-Consults took < 15 minutes to complete, but 20% took > 25 minutes, with 6% requiring ≥ 45 minutes to complete (Figure 2).