Most specialty e-consults appropriate, reduced in-person visits in one health system

A study found that about 70% of electronic consultations to five high-volume specialties were appropriate, ranging from 61% for rheumatology to 78% for psychiatry.


Most specialty consultations completed through an electronic consult program at one health system were appropriate in nature and reduced in-person visits, although appropriateness and utility varied by specialty, a study found.

Researchers retrospectively assessed e-consults to five high-volume specialties (hematology, infectious diseases, dermatology, rheumatology, and psychiatry) at primary and specialty care practices affiliated with two large academic hospitals and two community hospitals of an integrated health system. They reviewed medical records to assess e-consult appropriateness, which was defined as meeting the following four criteria: not answerable by reviewing evidence-based summary sources, not merely requesting logistic information, having appropriate clinical urgency, and having appropriate patient complexity. Agreement between raters about appropriateness was assessed by the κ statistic. The researchers assessed the rate of avoided visits to assess e-consult utility, which was defined by the absence of an in-person visit to the same specialty within 120 days. Results were published online on April 14 by Annals of Internal Medicine.

From October 2017 through November 2018, 6,512 eligible e-consults were made by 1,096 referring clinicians to 121 specialists. Inquiries were characterized as diagnostic, therapeutic, for clinician education, or at the request of the patient. Therapy and diagnosis questions were most common, at 49.9% and 46.2% of e-consults, respectively. Most consults were answered within one day, with variation across specialties (73.1% for psychiatry to 87.8% for infectious disease). Overall, 70.2% of e-consults met all four criteria for appropriateness, ranging from 60.5% for rheumatology to 77.9% for psychiatry. Raters agreed on the appropriateness of 94% of the e-consults (κ=0.57; 95% CI, 0.36 to 0.79), indicating moderate agreement. The overall rate of avoided visits across the five specialties was 81.2%, with the highest rate in psychiatry, infectious diseases, and hematology (range, 86.9% to 92.6%) and the lowest in dermatology and rheumatology (61.9% and 65.2%, respectively).

No standard, consensus metrics exist for evaluating e-consult programs, and the metrics used in the study may benefit from revision, the study authors noted. Other limitations include the fact that the results may not be generalizable to health systems in which specialists and primary care physicians do not share a common electronic health record and that data were limited on rural and various minority patient populations, they said.

While single-system studies are useful for local evaluation and quality improvement efforts, future studies should estimate the effect of e-consults on quality and cost of care across health systems and over time, an accompanying editorial noted. “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,” the editorialists wrote.