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The American Journal of Managed Care May 2019
Evaluation of Value-Based Insurance Design for Primary Care
Qinli Ma, PhD; Gosia Sylwestrzak, MA; Manish Oza, MD; Lorraine Garneau; and Andrea R. DeVries, PhD
The Presurgical Episode: An Untapped Opportunity to Improve Value
Erika D. Sears, MD, MS; Rodney A. Hayward, MD; and Eve A. Kerr, MD, MPH
Clarification of References to Medication Adherence Scale
Open Doors to Primary Care Should Add a “Screen” to Reduce Low-Value Care
Betsy Q. Cliff, MS; and A. Mark Fendrick, MD
From the Editorial Board: Daniel B. Wolfson, MHSA
Daniel B. Wolfson, MHSA
Cost-Effectiveness of DPP-4 Inhibitor and SGLT2 Inhibitor Combination Therapy for Type 2 Diabetes
Manjiri Pawaskar, PhD; S. Pinar Bilir, MS; Stacey Kowal, MS; Claudio Gonzalez, MD; Swapnil Rajpathak, MD; and Glenn Davies, DrPH
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Michael Adelberg, MA, MPP; Austin Frakt, PhD; Daniel Polsky, PhD; and Michelle Kitchman Strollo, DrPH, MHS
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Electronic Consults for Improving Specialty Care Access for Veterans
David E. Winchester, MD, MS; Anita Wokhlu, MD; Juan Vilaro, MD; Anthony A. Bavry, MD, MPH; Ki Park, MD; Calvin Choi, MD; Mark Panna, MD; Michael Kaufmann, MD; Matthew McKillop, MD; and Carsten Schmalfuss, MD
Producing Comparable Cost and Quality Results From All-Payer Claims Databases
Maria de Jesus Diaz-Perez, PhD; Rita Hanover, PhD; Emilie Sites, MPH; Doug Rupp, BS; Jim Courtemanche, MS; and Emily Levi, MPH
Beyond Satisfaction Scores: Exploring Emotionally Adverse Patient Experiences
Laura M. Holdsworth, PhD; Dani L. Zionts, MScPH; Karen Marie De Sola-Smith, PhD; Melissa Valentine, PhD; Marcy D. Winget, PhD; and Steven M. Asch, MD
Patient-Centered Medical Homes and Preventive Service Use
Joel F. Farley, PhD; Arun Kumar, PharmD, MS; Benjamin Y. Urick, PharmD, PhD; and Marisa E. Domino, PhD
Pilot of Urgent Care Center Evaluation for Acute Coronary Syndrome
Ryan P. Radecki, MD, MS; Kevin F. Foley, PhD; Timothy S. Elzinga, MD; Cynthia P. Horak, MD; Thomas E. Gant, MS; Heather M. Papp, BA; Adam J. Morris, BS; Natalie R. Hauser, BA; and Briar L. Ertz-Berger, MD, MPH

Electronic Consults for Improving Specialty Care Access for Veterans

David E. Winchester, MD, MS; Anita Wokhlu, MD; Juan Vilaro, MD; Anthony A. Bavry, MD, MPH; Ki Park, MD; Calvin Choi, MD; Mark Panna, MD; Michael Kaufmann, MD; Matthew McKillop, MD; and Carsten Schmalfuss, MD
The combination of electronic consultations and active triage of specialty care consults effectively reduces wait times for outpatient clinics.

Objectives: We adopted e-consults within an active referral management (ARM) process for our Veterans Health Administration (VHA) outpatient cardiology clinic to reduce clinic wait times.

Study Design: Prospective multiphase cohort study.

Methods: Our ARM process consisted of reviewing all incoming consult requests for our outpatient clinic and triaging the requests to either an e-consult or a clinic visit. The primary outcome was wait time for an appointment in our clinic.

Results: Median wait time prior to the ARM process was 24 days. After implementation of the ARM process, wait times decreased to 13 days (46% reduction). Approximately 60% of incoming consults could be triaged into e-consults, predominantly by managing stable diseases or minor symptoms.

Conclusions: E-consults and ARM of clinical referrals were effective at reducing wait times for our outpatient VHA cardiology clinic. The majority of clinical referrals could be handled through an e-consult and did not require an in-person clinic visit.

Am J Manag Care. 2019;25(5):250-253
Takeaway Points
  • E-consults are an efficient healthcare delivery strategy.
  • Active management of incoming consults improves triage of electronic and in-person consultations.
  • When combined, these strategies can reduce wait times for outpatient specialty clinics.
  • Triage of consults can be performed by advanced practice providers as well as physicians.
For decades, physicians have provided outpatient medical care almost exclusively through clinic-based encounters. A typical encounter includes taking a history from the patient, reviewing the medical record, performing a physical examination, checking the vital signs, formulating a plan of care, writing any needed medical orders, and documenting the encounter. This model of care delivery has predominated because the rules and regulations governing reimbursement for care are built around a standard outpatient clinic encounter. Delivering care in the standard outpatient clinic encounter is comprehensive, but this model may include more than is actually necessary to answer certain clinical questions. Alternative models of care delivery, such as telemedicine and e-consults, are sometimes not reimbursed or rules and reimbursement rates are barriers to adoption.1,2

Problems with prompt access to healthcare have garnered substantial attention in both lay and medical publications recently.3,4 Concerns about veterans’ access are widely known, although many non–Veterans Health Administration (VHA) primary care and specialty care clinics around the country have long wait times as well. One potential solution that the VHA has adopted to improve access to care is encouraging the use of e-consults.5 An e-consult is similar to a clinic visit in that both consist of reviewing the medical record, formulating a plan of care, and providing care guidance through notes in the electronic health record. They differ in that e-consults do not include taking a history directly from the patient or performing a physical examination. E-consults share some similarity with informal “curbside” consultations but differ in that they are documented within the medical record. Despite the limitations, many clinical questions can be adequately answered without these care elements.

At our VHA facility, wait times for cardiology clinic appointments were steadily increasing and threatened to limit timely access to care. We adopted the use of e-consults in a multiphase process and tracked the impact on clinic wait times. We hypothesized that, when clinically appropriate, diverting consult requests from providers away from in-person clinic appointments to e-consults would reduce wait times for clinic appointments.


Our facility provides comprehensive cardiology care for veterans in the north Florida/south Georgia region in the outpatient, inpatient, and critical care settings. Specific services include implanted cardiac device monitoring and management, echocardiography, nuclear cardiology, cardiac computed tomography and magnetic resonance imaging, evaluation and management of coronary disease and heart failure, telemedicine, home-based cardiac rehabilitation, and electrophysiology management of dysrhythmias including complex ablation, percutaneous coronary intervention, and transcatheter structural procedures. This comprehensive suite of cardiovascular services places a high demand on access to our outpatient clinic for evaluation and management of heart disease. Any clinician in our system is capable of ordering cardiology consultation either as an in-person clinic visit or as an e-consult.

We studied the implementation of a 2-phase active referral management (ARM) process in a pre–post observational design. The goals of the ARM process were to perform more e-consults and reduce wait times. In phase 1, all incoming clinic consult requests from providers were reviewed by a cardiologist. The cardiologist reviewed the medical record and all available relevant results, such as cardiac stress testing, electrocardiograms, echocardiograms, coronary angiography, and recent laboratory findings, applying their individual judgment to determine if the patient should be seen in person or if an e-consult would be sufficient to provide direction for the consulting provider. If an e-consult was sufficient, the physician would complete the consult immediately; otherwise, the patient would be referred to the clinic scheduler to come for an in-person appointment. Responsibility for consult review was shared by all staff physicians (n = 10). Phase 1 was conducted from November 1, 2015, to October 31, 2016. During phase 1, we monitored the types of clinical questions that physicians felt were appropriate for e-consults. These clinical judgments were used to develop clinical consult triage recommendation tables directing incoming consults toward either e-consults or clinic visits (eAppendix [available at]). Phase 2 was conducted from November 1, 2016, to March 1, 2017. In phase 2, nurse practitioners and physician assistants (NPs/PAs) with full-time assignment in the cardiology section performed the initial review of consult requests and referred a subset of requests to a physician for further review.

At the time of this program, our cardiology service used “wait time” as defined later in this paragraph. Since that time, VHA has adopted definitions of wait times that are applied more universally across facilities and services. On a weekly basis, we reviewed the number of open clinic appointments and calculated the number of days necessary in order to fulfill the number of currently unscheduled clinic appointments. We use the term “days” to refer to clinic days (ie, Monday through Friday). For example, if 100 patients needed an appointment and each clinic day had 10 open slots to accommodate patients, our calculated wait time would be 10 days. Wait times were tracked on a continuous weekly runchart. We applied accepted rules of runchart analysis for determining when a significant change had occurred.6 We also tracked the number of clinic consult referrals. A subset of consult requests (from October 1, 2016, to November 15, 2016) was reviewed secondarily as an estimate of the source, clinical questions, and results of the ARM process. D.E.W. had full access to the study data and takes responsibility for data integrity and analysis. We did not perform any formal assessment of patient, cardiology provider, or referring provider satisfaction with the ARM process. The University of Florida Institutional Review Board approved the use of these data and waived the requirement for informed consent.


During this project, 4662 consult requests were evaluated. Phase 1 included 3116 total consults; 60.6% were clinic consults (n = 1887) and 39.4% were e-consults (n = 1229). Phase 2 included 1546 total consults; 70.4% were clinic consults (n = 1089) and 29.6% were e-consults (n = 457). The median number of weekly total (phase 1: n = 59; interquartile range [IQR], 17; phase 2: n = 66; IQR, 20.75; P = .006) and clinic (phase 1: n = 33; IQR, 15; phase 2: n = 49; IQR, 15.25; P ≤.0001) consults increased from phase 1 to phase 2; however, the median number of e-consults (phase 1: n = 24; IQR, 16; phase 2: n = 20.5; IQR, 9.75; P = .61) did not increase. At the beginning of phase 1, the median wait time was 24 days. Data on wait times prior to our intervention were not available to include in this report. After implementation of phase 1 of the ARM process, we observed 20 consecutive weeks in which wait times fell below the median, suggesting a statistically significant and sustained decrease (Figure 1). At this point, the median was recalculated (13 days) based on the newly achieved steady state of wait times. After implementation of phase 2 of the ARM process, we observed 17 consecutive weeks in which wait times exceeded the second calculated median, suggesting a statistically significant and sustained increase.

During the 2-phase ARM implementation, the total number of consult requests was tracked in a separate runchart (Figure 2). The weekly number of consult requests exhibited substantial volatility (median, 29; SD, 4.78). Starting in May 2016, we observed 35 consecutive weeks in which the number of consults exceeded the median, suggesting a statistically significant and sustained increase.

A review of a subset of consult requests (n = 332) found that the primary source of consults was primary care (42%), followed by other specialties (34%), emergency medicine (13%), inpatient requests for follow-up (7%), and other cardiologists in our network (4%). The largest identifiable categories of referrals were for arrhythmia management (19%), stable heart disease management (12%), and preoperative assessment (10%). Overall, it was determined that 60% of consults could be converted to e-consults. A substantial portion (30%) of the converted consults were administrative in nature (eg, request for non-VHA care, request for follow-up in already established/scheduled patient, referred to another cardiologist within our regional care network). Without ARM, many of these patients would have been scheduled into the clinic without any need to be seen in person. Of the 60% that could be converted, approximately half (28%) were for questions about minor symptoms or stable disease and were managed as e-consults.

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