Bjarni Haraldsson, MS

 To evaluate the growth and variation of electronic consultation, or e-consult, use in the Veterans Health Administration (VHA) across regions and specialties.

 Observational cohort study using administrative data of all veterans who received an e-consult for 41 specialties across 1269 VHA medical centers and associated clinical sites from January 1, 2012, through December 31, 2018.

 Assessments included (1) the number and characteristics of all e-consults, (2) growth of e-consult use, (3) e-consults as a proportion of all consults by region and by specific specialty, (4) need for an in-person visit with the same specialty within 12 months after an e-consult, and (5) potential miles of driving saved for patients and mileage reimbursement costs avoided for VHA due to e-consult use.

 Over the 7-year study period, VHA providers completed 3,117,998 e-consults (5.5% of all specialty consults). e-Consults increased by 309% for all specialties. By 2018, for 16 of 41 specialties, e-consults accounted for greater than 10% of all consults. Overall, 21.5% of e-consults resulted in an in-person visit with the same specialty within 12 months. On average, each e-consult resulted in approximately 84.3 (SD, 89.9; interquartile range, 25.1-115.0) miles in driving saved, equating to potential driving reimbursement savings of $46 million.

 Use of e-consults in the VHA grew substantially between 2012 and 2018, with variability across specialties. In-person follow-up after an e-consult was low, suggesting that e-consults may substitute for in-person visits and reduce considerable patient travel burden.

Use of electronic consultations, or e-consults, has been implemented in many medical systems in the United States, but further evaluation of its impact on care is needed.

This work evaluates e-consult use within the Veterans Health Administration, the nation’s largest health care system. This the largest cohort of e-consults for which results are available.

For many medical and surgical subspecialties, more than 10% of total consults are now completed as e-consults. Substantial e-consult growth was seen across regions and specialties over 7 years.

Many clinical questions can be answered through e-consults without need for in-person follow-up over a 12-month period.

Electronic consultations, or e-consults, allow health care providers—primarily primary care providers (PCPs)—to receive guidance virtually from specialists about patient-specific issues. A number of health systems

 in the United States have implemented e-consults using 2 primary designs with the potential of obviating the need for in-person specialty visits: (1) a “single pathway,” where the consultant performs a preliminary evaluation and decides whether an e-consult or in-person visit is most appropriate, or (2) the “optional pathway,” where the referring provider chooses to obtain advice through an e-consult rather than referring for a traditional in-person specialty evaluation (

 The enhanced communication facilitated by e-consults between specialists and PCPs provides education, reduces patient burdens, and improves comprehensiveness, coordination, and access to care.

 Given the promise of e-consults as a potentially efficient and cost-saving care modality, there is growing interest in their use both in the US health care system and worldwide.

Since 2011, the Veterans Health Administration (VHA) has implemented and expanded the use of e-consults with the aim of improving specialty care access and coordination. VHA, the largest integrated health care system in the United States, serves a geographically and demographically diverse population of more than 6 million patients in primary care annually. The e-consult system is decentralized, allowing for each regional service network or health care system to design and implement its own e-consult process to serve its population of patients and providers. An evaluation of the VHA’s e-consult implementation from May 2011 through December 2013 demonstrated an increase in the total number of e-consults without a plateau, enhanced care access for rural veterans, and potential reductions in travel and associated costs.

 During this period, e-consults were completed at an adjusted rate of 1.9 per 100 total consults across 13 specialty clinics. The highest rates were among endocrinology (5.0/100), hematology (3.0/100), and gastroenterology (3.0/100).

 Since this evaluation, e-consults have expanded to all VHA outpatient clinics, electronically connecting them to specialty care at medical center hubs. Details of e-consult use since this expansion have not yet been reported.

The primary objective of this study was to describe e-consult use and growth across regions and specialties in the VHA from 2012 through 2018. Secondary aims were to examine potentially avoidable in-person specialty care visits within 12 months of an e-consult and to describe potential driving distance and cost savings associated with e-consults.

This is an observational, retrospective analysis of e-consult use from January 1, 2012, through December 31, 2018. The initial run-in period of e-consult implementation of May through December 2011 was excluded. We examined data across the VHA’s 18 regional Veteran Integrated Service Networks (VISNs), including all 170 Veterans Affairs Medical Centers (VAMCs) and their 1269 associated clinical sites. The study population included all VHA patients receiving primary care during the observation period. Data were obtained from the VA Service Support Center, VHA’s Corporate Data Warehouse, and the VA Planning Systems Support Group.

We identified specialty type, date, and location of all e-consults by clinical “stop code,” which included 41 unique clinical care specialties, categorized within 3 subgroups as medical (n = 16), surgical (n = 12), and other (n = 13) specialties. e-Consults for mental health services were not included. e-Consult originating site was designated as the VAMC or an associated clinical site.

We identified date and type of all in-person specialty consults occurring across the same 41 medical, surgical, and other specialties as e-consults. For patients with an e-consult, we identified any in-person visit to that specialty clinic occurring within 3, 6, and 12 months after the e-consult was placed. Individual patients could have more than 1 e-consult in any given year. For each specialty and specialty category, we determined the annual proportion of e-consults performed of the total electronic and in-person consults.

Demographics including age, gender, and rurality are described. Patient rurality was defined by the Rural-Urban Commuting Area classification, which creates 30 mutually exclusive categories representing population density and proximity to urban centers using the patient’s residential zip code.

 These categories were condensed to urban, rural, and highly rural.

Geocoded addresses of patients’ home addresses and VHA locations of specialty care were used to calculate the shortest drive distance using Bing maps.

All analyses were performed using SAS version 7.1 (SAS Institute) and R software. The study was reviewed by the University of Iowa Institutional Review Board and the Iowa City VA Healthcare System Research and Development Committee.

Between January 1, 2012, and December 31, 2018, we identified a total of 3,230,566 e-consults, representing 3.9% of 83,271,378 total electronic and in-person consults. We narrowed our analysis to 41 specialties of interest, which encompassed 96.5% of all e-consults. Over the 7-year period, e-consults across these specialties increased by 309% from 151,984 e-consults in 2012 to 621,2013 e-consults in 2018, representing 2.2% and 7.0% of total electronic and in-person consults, respectively (

e-Consult use increased within 17 of the 18 regional networks (ie, VISNs). Across VISNs, e-consults as a proportion of all consults increased from a range of 0.2% to 7.0% (mean, 2.4%) in 2012 to 3.8% to 14.1% (mean, 5.0%) in 2018 (

). The majority of this increase was experienced by 2014. However, VISN 9, serving primarily Kentucky, Tennessee, and northern Mississippi, experienced rapid and sustained e-consult growth, starting in 2013 (5.2%) and continuing through 2018 (14.1%).

Over the period of analysis, the number of facilities ordering e-consults increased from 553 (57%) to 774 (61%). By 2018, 179 (98.8%) of the 181 VAMCs, 55.5% of associated outpatient clinics, and 8.4% of other facilities ordered e-consults. With the expansion of 296 additional outpatient clinics over this time period, the percentage of clinics using e-consults increased from 49.8% to 55.5%. The distribution of e-consults across clinical sites remained similar, with 83% from VAMCs and 17% from associated outpatient clinics. However, the proportion of e-consults relative to in-person consults increased across all sites, with the greatest increase among associated outpatient clinics (2.4% in 2012 to 8.9% in 2018) followed by VAMCs (2.2% to 6.6%).

The number of unique patients receiving at least 1 e-consult increased from 131,403 in 2012 to 494,253 in 2018, representing 6.7% of the enrolled veteran population and 84 e-consults per 1000 enrolled patients. By 2018, veterans receiving an e-consult had a mean (SD) age of 63.1 (14.7) years, 90.1% identified as male, and 31.7% and 1.1% resided in rural and highly rural areas, respectively (Table).

e-Consults for medical specialties accounted for 59.5% (n = 1,855,521) of all e-consults and 10.0% of all medical consults. Over the 7 years of observation, the number of medical e-consults increased 4.6-fold, with the relative percentage of e-consults of all medical consults increasing from 3.9% to 12.8%. e-Consult use grew across all medical subspecialties (

). The top 5 specialties performing e-consults were cardiology (n = 332,216), gastroenterology (n = 243,020), sleep medicine (n = 209,073), endocrinology (n = 204,509), and pulmonary (n = 181,430). For 11 of 16 medical specialties, more than 10% of all consults within the given specialty were completed as e-consults: hematology (38.7%), infectious diseases (23.5%), endocrinology (21.1%), nephrology (19.5%), pulmonary (17.4%), oncology (16.4%), gastroenterology (16.2%), geriatrics (12.7%), sleep medicine (11.8%), neurology (10.8%), and immunology (10.4%). By 2018, more than 1 in 5 consults for hematology, infectious diseases, endocrinology, pulmonology, nephrology, and gastroenterology were e-consults.

Surgical specialties accounted for 20.0% (n = 624,879) of all e-consults and 2.0% of all surgical consults. From 2012 through 2018, the number of surgical e-consults grew 8.0-fold, with the relative percentage of e-consults increasing from 0.8% to 5.8% of all surgical consults. The top 5 surgical specialties performing e-consults were preoperative evaluation (n = 144,838), urology (n = 99,584), orthopedics (n = 97,803), neurosurgery (n = 65,790), and vascular (n = 58,872). Four surgical specialties completed greater than 10% of all consults as e-consults: preoperative evaluation (22.0%), neurosurgery (20.4%), vascular surgery (14.6%), and cardiothoracic surgery (14.6%) (Figure 3 [B]).

Other specialties accounted for 20.4% (n = 637,698) of all e-consults. By 2018, the number of other consults grew by 2.0-fold. The most e-consults performed among other specialties were pharmacy (n = 369,413), physiatry (n = 108,654), and pain (n = 81,611). Two specialties (genomic medicine, 19.3%; pain medicine, 11%) completed greater than 10% of all consults as e-consults (Figure 3 [C]).

Overall, 56.2% of e-consults were requested by physicians, 23.4% by nonphysician providers (NPPs; ie, physician assistants or nurse practitioners), 8.9% by residents or fellows, 3.3% by pharmacists and other providers, 0.8% by nurses, and 7.5% by unknown provider type. With regard to providers completing e-consults, 53.4% were completed by physicians, 21.8% by NPPs, 11.4% by pharmacists, 4.7% by other, 4.7% by residents or fellows, and 3.2% by nurses; 0.8% were completed by missing provider type. For medical specialties, 65.1% of e-consults were completed by physicians and 21.9% by NPPs. Over time, the proportion of e-consults completed by physicians decreased from 67.0% to 63.6% and by NPPs increased from 18.9% to 23.9%. For surgical specialties, 50.9% of e-consults were completed by physicians and 37.2% by NPPs. For other specialties, pharmacists completed 56.0% of the e-consults, followed by physicians (21.7%).

For all 41 specialties over the 7 years of observation, 13.1% of e-consults resulted in an in-person visit within 3 months, 16.7% within 6 months, and 21.5% within 12 months. Across categories, in-person follow-up after e-consults was lowest among surgical specialties (3 months, 6.0%; 6 months, 8.1%; 12 months, 10.7%) followed by medical (7.0%, 9.4%, and 12.5%, respectively) and other specialties (23.1%, 26.9, and 32.3%) (

We tracked only 1-year in-person follow-up visits for e-consults until the end of 2018. From 2012 to 2017, in-person specialty visits within 12 months after an e-consult increased from 16.4% to 23.0% for all specialties, increased from 15.6% to 23.9% for medical specialties, decreased from 18.8% to 9.8% for surgical specialties, and increased from 12.1% to 18.6% for other specialties.

The mean (SD) drive distance to the nearest tertiary care facility among patients who did not have an in-person visit with the same specialty within 12 months of an e-consult was 84.3 (89.9) miles. Over the study time period, 170,658,048 total miles of travel for in-person specialty care visits were potentially “saved.” At the VHA mileage reimbursement rate of 41.5 cents per mile, this equates to an estimated savings of $70,823,090 in travel expenses. Considering that approximately 65% of veterans are eligible for travel reimbursement, e-consults potentially saved VHA more than $46 million in travel costs.

From 2012 to 2018, VHA clinicians adopted e-consults for specialty care, resulting in more than 3 million e-consults and potentially avoiding hundreds of thousands of in-person clinic visits, saving more than 170 million driving miles (and associated costs), and enhancing convenience for patients and family members. By 2018, e-consults represented 12.8% of medical, 5.8% of surgical, and 3.0% of all “other” specialty consults. For the majority of medical specialties, at least 10% of total consults are now e-consults. With the substantial growth of e-consults, a few findings and considerations are worth highlighting.

First, the reach and adoption of e-consults have been maintained. Our findings identified that e-consults reached a substantial portion of VHA clinics and maintained growth beyond the first years of implementation.

 Over the observation period, all but 1 region experienced growth in e-consults. The maintained use of e-consults highlights the value to both primary care providers and specialists to enhance communication and timeliness to specialty care.

 The integrated electronic health record (EHR) and e-consult platform within the VHA overcomes barriers experienced in other e-consult programs,

 easing access to specialist input. Across various settings, other programs experience similar rapid adoption and maintained use.

 Our evidence further supports e-consults as a sustainable model to potentially improve the comprehensiveness of and access to care.

Second, the differential growth of e-consult use across regions and specialties signifies further opportunity for expansion. Use of e-consults across most regions plateaued at around 6% of total in-person consults. However, we identified 1 region (VISN 9) where clinical champions promoted the implementation of the single pathway, requiring a preemptive e-consult to determine appropriateness and type of consultation. This region used e-consults for more than 25% of medical consults and more than 15% of surgical consults, with specific specialties exceeding 50%, including preoperative evaluations, hematology, neurosurgery, and sleep medicine. Although most locations have implemented the optional pathway, the single pathway has resulted in highest e-consult use at care facilities within

 the VHA. By changing the e-consult pathway or supporting physician champions and engaged management teams, regions and clinics may be able to further expand the reach and adoption of e-consults.

e-Consult expansion may be particularly valuable and achievable among specialties that depend more on interpretation of laboratory testing and imaging and less on physical examination. Across the 41 specialties examined, e-consults for hematology, preoperative evaluation, neurosurgery, endocrinology, and infectious diseases were the most frequently used relative to in-person consults among all regions and the regions of highest e-consult use. e-Consults for these specialties

 serve as examples of best practice dissemination.

 In certain regions, clinical champions have responded to unique local needs for improved access and care efficiency by expanding specific e-consult programs. Examples include programs for geriatric services,

 In addition, e-consults can be offered as a templated electronic interface to reduce unneeded in-person consults and enhance access among the most commonly ordered specialty consults (eg, cardiology).

Third, follow-up in-person visits to the same specialty up to 1 year after an e-consult were low and in line with those found in prior studies.

 However, we did observe an increase in follow-up at 3, 6, or 12 months for medical specialties over time. Low overall follow-up suggests that e-consults can substitute for in-person visits; however, the availability and ease of e-consults may result in a “lower bar” for consultation, resulting in e-consults for conditions that otherwise would be handled independently by the requesting provider. This study did not examine content or appropriateness of e-consults; however, in a recently published evaluation within a single health care system, more than 70% of e-consults were considered appropriate.

 The recent increase in in-person follow-up may be due to increased use of the single pathway. Facilities may mandate or providers may choose to place a preemptive e-consult to clarify proper evaluation (eg, imaging, laboratory studies) and facilitate an efficient in-person specialty consultation.

By averting in-person consultations, e-consults reduce unneeded travel to in-person specialty care. This travel for patients and caregivers incurs significant costs in time, money, and inconvenience. Across the 41 specialties, we estimated that, on average, an averted visit would save 84 miles of travel, a total exceeding 30 million miles annually, with significant potential savings to patient and the VHA. This is a benefit viewed by both providers and patients.

The benefit of e-consults also translates to providers and care delivery, offering opportunities to improve education, communication, and care coordination across disciplines. In this study, only half of e-consults were requested and completed by staff physicians. VHA has a history of incorporating a teaching mission

 as well as advancing the integration of NPPs into care.

 e-Consults provide requesting providers, NPPs, and trainees with readily accessible specialty advice and education, which may serve to channel learning health system goals of advancing timeliness and quality of care. This may be particularly important for NPPs, trainees, and physicians with less than 10 years of practice, who are more likely to report improved management skills as a result of e-consults.

Despite the benefits, e-consults add tasks and responsibilities to the PCP. In our study, e-consults increased by 300% and in-person consults remained relatively stagnant. Many PCPs recognize the benefits of e-consults; however, they also have reported an added burden of increased administrative work and broadened clinical responsibility.

 If low-value tasks are not shifted and dedicated time for these non–in-person activities is not allocated,

 PCPs will likely face increasing task burden and higher potential for burnout.

Adoption and sustained use of e-consults across the national VHA implicates the value of this provision for integrating care and improving access.

 The shared EHR, limited third-party billing, lack of specialists in all clinic locations, and credentialing across care locations and states facilitate implementation within the VHA. Other regions and health systems have identified modalities to overcome barriers.

 With expansion of data sharing across health systems through direct EHR collaboration and health information exchanges,

 e-consults have the potential to enhance access in a timely and cost-effective manner.

 Despite broad uptake, evidence on the effectiveness of e-consults to improve quality of care and condition-specific outcomes has been modest.

 Further work looking at e-consult use in individual specialties and conditions is needed, including specific reasons for e-consults, potential risks, and opportunities for specialty-specific growth to improve access, quality, and costs. This research could inform guidelines for implementation and expansion of appropriate and high-quality e-consult use.

There were several limitations to this work. First, each VHA facility offering specialty care established e-consult services at its discretion and with different consultation processes. Second, there was no control group and the data were retrospective; thus, we cannot determine to what extent e-consults substituted for in-person visits, affected specialist workload, were used appropriately, and resulted in patient satisfaction with this form of care. Third, the VHA has separate teledermatology, teleradiology, and teleretinal programs that allow for store-and-forward image transmission, but these e-consults were not included in this analysis. Fourth, both drive time and dollars saved are idealized maximum estimates based on the assumption that an e-consult served as a complete substitution for an in-person consult. Lastly, the VHA’s experience with e-consults may not be generalizable to the broader diverse American health care landscape because of differences in insurance coverage, reimbursement for e-consult care, and other economic considerations that differentiate VHA from non-VHA care.

e-Consults have emerged as an important tool for improving access to specialty care, as is evidenced by their broad and sustained implementation and use across the VHA since 2012. Variation in e-consult growth across clinical sites and specialties suggests that there exists further potential for expansion and use of e-consults within and outside the VHA.

The authors would like to thank Emily Ashmore for helping to create Figure 1 of the manuscript.

 Division of Endocrinology, Rocky Mountain Regional Veterans Affairs Medical Center (DRS), Aurora, CO; Division of Endocrinology, Metabolism and Diabetes, University of Colorado, Anschutz Medical Campus (DRS), Aurora, CO; Center for Access and Delivery Research and Evaluation, Iowa City VA Healthcare System (PJK, BH, MO), Iowa City, IA; Department of Internal Medicine, University of Iowa Carver College of Medicine (PJK, MO), Iowa City, IA; Primary Care Analytics Team, VA Puget Sound Health Care System (CW), Seattle, WA; Department of Medicine, James J. Peters VA Medical Center (MRA), Bronx, NY; Department of Medicine, Icahn School of Medicine at Mount Sinai (MRA), New York, NY.

 This material is based upon work supported (or supported in part) by the Department of Veterans Affairs (VA), Veterans Health Administration, VA Office of Rural Health and the Office of Research and Development, Health Services Research and Development Service through the Center for Access and Delivery Research and Evaluation (CIN 13-412).

 The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

 Concept and design (DRS, PJK, MO, MRA); acquisition of data (PJK, BH, CW); analysis and interpretation of data (DRS, PJK, BH, CW, MRA); drafting of the manuscript (DRS, CW, MO, MRA); critical revision of the manuscript for important intellectual content (DRS, PJK, MO, MRA); statistical analysis (BH, CW); supervision (PJK); and software (CW).

 David R. Saxon, MD, MS, Division of Endocrinology, Metabolism and Diabetes, University of Colorado, Anschutz Medical Campus, 12801 E 17th Ave, Mail Stop 8106, Aurora, CO 80045. Email: david.saxon@cuanschutz.edu.

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Articles

This study evaluates the growth in electronic consultation use over the first 7 years after its implementation across the entire Veterans Health Administration system.

Bjarni Haraldsson, MS

Articles

Growth of Electronic Consultations in the Veterans Health Administration