A 28-year-old man with mild hypertension asked his primary care physician (PCP) to order a basic metabolic panel, and the doctor agreed. To the doctor's surprise, the man's creatinine level came back at 1.5 mg/dL. Although the doctor suspected this reading might be in error, he knew he needed to look into it further.
Rather than referring the patient, the PCP used an e-consult to get the opinion of a nephrologist. By exchanging messages, the two doctors ruled out serious renal disease and ordered 24-hour urine studies, determining that the patient was a prodigious producer of creatinine despite having a normal body habitus. The issue was resolved without the patient seeing a nephrologist in person.
This isn't a unique story—it's routine for users of remote consultations, also called e-consults, said Michael L. Barnett, MD, MS, an assistant professor of health policy and management at Harvard University's T.H. Chan School of Public Health in Boston.
E-consults, which occur via a shared electronic medical record or other secure platform, have become more common in recent years, especially in underserved areas. Such systems increase patient access to subspecialty expertise, but a recent qualitative study published April 12 by JAMA Internal Medicine, with Dr. Barnett as the corresponding author, found that they also can increase stress on PCPs due to the administrative time and clinical effort that they require.
In the study, which focused on the use of e-consults in safety-net health systems, qualitative interviews were conducted with 40 safety-net PCPs who use the Los Angeles County Department of Health Services e-consult system. They were asked about their perception of clinical workflow, access to and relationships with subspecialists, and referral decision-making.
Many of the participants had positive things to say about how the system increased their ability to get timely subspecialty input, and they reported receiving clinical and educational value from the interactions. However, they also consistently perceived that some of the work involved in subspecialty care had been shifted to them.
Dr. Barnett said he was interested in undertaking the study at least partly because he believes the process by which PCPs make subspecialty referrals is one of the least studied aspects of modern medical practice.
“A lot of the way that the specialty referral system currently exists is just an accident of how our payment system works, and a historical vestige of how physicians used to operate many decades ago. It doesn't really satisfy the needs of patients to match the right level of care with the critical need,” he said.
E-consults improve that match, helping subspecialists and PCPs communicate without translating everything into a face-to-face visit, he said. They increase access to subspecialists, save patients time and money, and improve outcomes by making it less likely that care will be fragmented or delayed.
Dr. Barnett's study looked at the Department of Health Services in Los Angeles because it has possibly the largest implementation of e-consults in the safety-net system and also is the largest in which e-consult is the only mechanism to initiate a referral. (Some systems offer e-consult as an option to PCPs to help them continue managing a challenging case, while others require an e-consult to happen before a traditional referral can be made.)
He stressed that the study looked at perceptions of workloads but did not actually quantify them. However, not surprisingly, respondents consistently reported that e-consults are more work for them than simply telling the patient to call a subspecialist.
“With e-consult, you actually have to think of and compose a request for the specialist to have enough information to make some kind of clinical decision. Then, when the specialist gets back to you, you have to manage your in-box,” he said.
Jean Glossa, MD, MBA, FACP, an internist who works as a consultant for Health Management Associates, a national firm focusing primarily on government-financed health care, said that e-consults not only benefit patients, they also benefit PCPs and subspecialists.
While e-consults can be more work upfront for PCPs or their staff, those extra “clicks” can save time on the back end, Dr. Glossa said. For example, in the traditional system, the patient may return to the PCP's office but the report from the subspecialist may not. In this case, the PCP can't move forward until a staff member tracks down the information—a waste of everyone's time.
“Pay [the time] now, or pay it later,” she said.
Also, she said e-consults can make PCPs' days more fulfilling because they give PCPs the access to the subspecialty expertise and resources they may need to manage some of the more complex and interesting issues they encounter, instead of having to send them to others. E-consults can also support comanagement of complex conditions so that more care can be provided in the medical home.
For subspecialists, she said, e-consults mean their waiting room isn't full of people who may not need to be seen in person.
“Specialists want to see the high-acuity patients, not ones whose problems can be handled in the primary care office. It opens up availability to see the more complex patients in their area of expertise,” she said.
E-consults essentially replace one age-old method by which PCPs once got subspecialty input: “curbsiding,” or asking a colleague for help in an informal way, said Nathaniel Gleason, MD, FACP, medical director for practice innovation and associate professor of clinical medicine in the division of general internal medicine at University of California San Francisco. He coauthored a commentary that accompanied Dr. Barnett's study in JAMA Internal Medicine.
“The downsides of ‘curbsides' are many,” Dr. Gleason said. “The specialist is not likely to have the full story or relevant data. The conversation is rarely captured in the record for people who will take care of that patient subsequently. A PCP who is new to an organization won't have a network of specialists to turn to or can feel like he or she is imposing and therefore only does it in limited situations.”
A formal e-consult system avoids all of that, Dr. Gleason said.
However, participants in Dr. Barnett's study reported numerous stresses related to e-consults beyond time and effort. For instance, many felt like their judgment was being scrutinized by subspecialists.
Because the system in the study required an e-consult before an actual referral was made, many physicians reported feeling like an e-consult was only successful if the subspecialist agreed the patient needed to be seen in person without any other further dialogue. Some did not appreciate being asked to answer more questions or to continue to manage the case themselves, seeing it as an obstruction to their desire to make a referral, Dr. Barnett said.
Other PCPs were frustrated by subspecialists' communication styles, reporting that some were abrupt or unfriendly. Some compared it to communicating with somebody via text message, which is not a medium that everyone can use effectively.
“The way we interpret this dynamic in the paper is that e-consults in [Los Angeles] really unmask a previously unaddressed problem. In the past, PCPs and specialists didn't really communicate with each other [directly], so we weren't really aware of the fact they are not always very good at working together as a team,” Dr. Barnett said. “But now that we have this new system, and PCPs and specialists are talking to each other, we have seen that some are actually not very good at it. It can cause a lot of workplace friction.”
Where it works best
Dr. Barnett said that anecdotally, subspecialties such as endocrinology, infectious disease, neurology, and rheumatology seem best suited for e-consults. The questions PCPs would ask a subspecialist in these situations are more typically about how to respond to specific test results and are less likely to require a physical exam, he said.
“It seems to be a little less applicable in specialties such as ophthalmology or podiatry, which tend to involve more transactional procedures and physical exams that can be hard for a PCP to replicate, although there definitely are uses in those fields as well,” he said.
Dr. Glossa said that people may think e-consults don't have a role in surgical care, but in fact they can be used to expedite preoperative and postoperative care. When patients arrive with the right tests already completed and the PCP knows what to monitor for postoperatively, patients can be spared many visits to the surgeon's office, she noted.
The experts offered some ideas for how to make the e-consult process go more smoothly.
Define expectations. Dr. Barnett's paper outlines about 25 questions that health systems should consider when they are developing e-consult systems. For instance, how quickly can a PCP expect a response? Is an e-consult required before an in-person referral is made? Should PCPs be able to override a subspecialist's recommendation? Are there separate pathways for urgent problems versus more routine ones?
“These are issues that are going to be resolved either explicitly or by default, in which case the outcomes may not be ideal for anyone,” he said.
Delegate. Delegating some aspects of the process can help PCPs make the most efficient use of e-consults, Dr. Glossa said. For example, other members of the care team can be trained to upload test results. It isn't very different from faxing them, she noted.
Build rapport. Over time, the e-consult process typically becomes more efficient as PCPs and subspecialists develop a relationship and perfect their approach, Dr. Glossa said. For example, the PCP will learn what tests that subspecialist typically wants to see and can have that information ready, making the best use of the e-consult time, she said.
Account for time. Dr. Gleason said it is important that health systems account for the fact that a PCP is being asked to own the management of something that would have been delegated to someone else in a referral. In systems where PCPs work on a relative-value-unit-based structure and have productivity targets, PCPs should receive “meaningful credit” to account for the extra time and effort involved, he said. In systems with salaried physicians, the time must be accounted for in other ways.
“It's incumbent upon a practice or health system to help offload tasks that do not require the clinician-level skills or experience to manage, making room for high-level clinical reasoning and communication tasks such as e-consults,” Dr. Gleason said. He gave several examples: replying to phone calls or patient portal messages concerning non-clinical questions, handling refills, and managing normal test results.
“The bottom line is e-consults don't come for free,” Dr. Barnett said. “They take time, they take energy, and utilizing them needs to come with some kind of allowance that PCPs only have a limited capacity to deliver the care they currently have. Piling it on more is only going to create more frustration.”