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The American Journal of Managed Care May 2019
Evaluation of Value-Based Insurance Design for Primary Care
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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
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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
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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.
DISCUSSION

E-consults are an emerging form of care delivery that offer a number of potential advantages over traditional face-to-face clinic visits. Although clinicians at our facility are able to order e-consults directly, by using an ARM process, we observed an increase in the number of patients managed via e-consult that translated into a sustained improvement in wait times. This improvement was tempered when we implemented a process based on initial review by a nonphysician provider, but it remained an improvement over not using an ARM process at all. These findings are informative toward the adoption of e-consults and ARM processes.

The direct measure of our program was limited to wait times for the outpatient cardiology clinic, but we also observed a number of secondary benefits, beyond improvements in access to care. For example, we had a surplus of clinic appointments that allowed us to reserve 1 same-day appointment per day for walk-ins or urgent referrals. Another potential efficiency was in perioperative care; by eliminating the wait for an outpatient visit and evaluating preprocedural cardiac risk via e-consult, patients could reduce their time to the operating room by 2 to 3 weeks. The referral base for our facility stretches over roughly 200 miles from south Georgia to north Florida; handling outpatient referrals via e-consult substantially reduces travel burden for some of our veterans. In an early evaluation of e-consults, Kirsh et al found that the average travel avoided was 72.1 (IQR, 17.1-108) miles.5 Although we did not assess patient and provider satisfaction with e-consults, others have found high satisfaction in both groups.7,8

We observed a sustained reduction in wait times during phase 1 of our ARM process (cardiologist review). During phase 2 (nonphysician review), wait times increased again and then leveled off. There are a number of potential explanations for this observation. First, it is possible that our nonphysician providers did not have the same level of comfort with converting to e-consults as did our cardiologists. Second, we observed an increase in consult requests overall during phase 1; this may have taken time to manifest in an increase in the wait times. Third, we experienced a shortage of clinic coverage for our electrophysiology services due to loss of staffing, but no other staffing issues occurred during the observational period. Because we could not distinguish general from electrophysiology appointments within our clinic, this may have contributed to the increase in wait times. We should also note that cardiologists were skeptical of the design of our ARM process due to the potential for variation among cardiologists as they reviewed the consults. Although this is a possible downside to our ARM process, it did not appear to manifest in the wait times, possibly because of the substantial volatility in the weekly volume of consult requests (Figure 2).

Potential downsides to the use of e-consults include recidivism and patient safety. After a patient is seen electronically, they may still have a standard outpatient clinic visit within a short time frame. In some cases, this could provide the specialist an opportunity to review the chart beforehand and preorder diagnostic tests or laboratory tests that would improve efficiency of the visit. In other cases, the resources put into the e-consult may be squandered if the in-person visit readdresses the same problem. Wasfy et al found that 11.6% of the e-consults in their study had an unrecommended in-person visit within 6 months of the initial consult.9 Although it is difficult to say what would be a “right” proportion of patients to have in such a scenario, it seems reasonable that some proportion of patients would benefit from an in-person visit even if initial review of their chart suggested otherwise. Although safety may be an initial concern with the adoption of e-consults, both Wasfy et al and Olayiwola et al studied e-consult use within cardiology and found no signal of harm.9,10

Despite the evidence of benefit, e-consults face a multitude of barriers to adoption. First and foremost is that in many care settings, the effort is unfunded or not reimbursed. In some health systems with salaried physicians and providers, such as the VHA and accountable care organizations, the use of e-consults has been supported with protected time for providers.8,11 Formal assessments of ARM productivity were beyond the scope of our investigation; however, e-consults are recognized as clinical care within the VHA (each e-consult yields 0.64-1.38 relative value units). Episode-based payment bundles and other government-led payment reforms may accelerate the implementation of e-consults.12 The VHA is specifically supporting the widespread adoption of e-consults and ARM processes through the Diffusion of Excellence initiative.13 This initiative is based on implementation science that has shown that e-consults are more likely to be successful in environments with physician champions, high-quality communication among providers, and an engaged management team.14 Another substantial barrier is a lack of guidance from clinical thought leaders on what constitutes a safe and responsible e-consult. Anticipating greater adoption of e-consults, it would seem prudent for professional societies to develop principles and best practices for the use of e-consults.

Limitations

Our report is limited by the absence of balancing measures such as increases or decreases in consult levels as a result of our program. Conceivably, clinicians frustrated with our e-consults could have avoided requesting cardiology care or they might have requested more in order to address what they perceived as incomplete care. We did not formally track satisfaction, but we have not received negative feedback on the ARM process during the 2 years after implementation. Data from phase 2 are limited to 5 months. We used a metric for wait times that differs from more commonly used metrics, such as the third next available appointment, out of a desire for a metric that better captures the total unmet demand on our clinic.

CONCLUSIONS

In this investigation, we have shown that e-consults are an effective strategy for providing specialty medical care services, particularly when incoming consult requests are actively managed by the receiving service. This investigation adds to the existing literature by demonstrating that the strategy can be adopted using physicians or NP/PA team members when facilitated by documented standards of what care can be provided electronically. E-consults and ARM may be a solution for resource-limited environments experiencing care shortages, such as the VHA.

Author Affiliations: Malcom Randall VA Medical Center (DEW, AW, JV, AAB, KP, CC, MP, MK, MM, CS), Gainesville, FL; University of Florida College of Medicine (DEW, AW, JV, AAB, KP, CC, MP, MK, MM, CS), Gainesville, FL.

Source of Funding: This material is the result of work supported with the resources and the use of facilities at the Malcom Randall VA Medical Center in Gainesville, FL. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States Government.

Author Disclosures: 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.

Authorship Information: Concept and design (DEW, JV, MP, MM, CS); acquisition of data (DEW, AW, JV, CC, MP, MK, MM, CS); analysis and interpretation of data (DEW, CS); drafting of the manuscript (DEW, JV, AAB, CC, CS); critical revision of the manuscript for important intellectual content (DEW, AAB, KP, CC, MP, MK); statistical analysis (DEW, AAB); provision of patients or study materials (AW, KP, MK); administrative, technical, or logistic support (KP, MM); and supervision (MK).

Address Correspondence to: David E. Winchester, MD, MS, Malcom Randall VA Medical Center, 1601 SW Archer Rd, Box 111-D, Gainesville, FL 32608. Email: David.winchester@va.gov.
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