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The American Journal of Managed Care January 2020
Using Applied Machine Learning to Predict Healthcare Utilization Based on Socioeconomic Determinants of Care
Soy Chen, MS; Danielle Bergman, BSN, RN; Kelly Miller, DNP, MPH, APRN, FNP-BC; Allison Kavanagh, MS; John Frownfelter, MD, MSIS; and John Showalter, MD
Eliminating Barriers to Virtual Care: Implementing Portable Medical Licensure
Pooja Chandrashekar, AB; and Sachin H. Jain, MD, MBA
Trust in Provider Care Teams and Health Information Technology–Mediated Communication
Minakshi Raj, MPH; Jodyn E. Platt, PhD, MPH; and Adam S. Wilk, PhD
The Health IT Special Issue: Enduring Barriers to Adoption and Innovative Predictive Methods
Ilana Graetz, PhD
What Accounts for the High Cost of Care? It’s the People: A Q&A With Eric Topol, MD
Interview by Allison Inserro
Does Machine Learning Improve Prediction of VA Primary Care Reliance?
Edwin S. Wong, PhD; Linnaea Schuttner, MD, MS; and Ashok Reddy, MD, MSc
Health Information Technology for Ambulatory Care in Health Systems
Yunfeng Shi, PhD; Alejandro Amill-Rosario, MPH; Robert S. Rudin, PhD; Shira H. Fischer, MD, PhD; Paul Shekelle, MD; Dennis Scanlon, PhD; and Cheryl L. Damberg, PhD
The Challenges of Consumerism for Primary Care Physicians
Timothy Hoff, PhD
Advancing the Learning Health System by Incorporating Social Determinants
Deepak Palakshappa, MD, MSHP; David P. Miller Jr, MD, MS; and Gary E. Rosenthal, MD
Predicting Hospitalizations From Electronic Health Record Data
Kyle Morawski, MD, MPH; Yoni Dvorkis, MPH; and Craig B. Monsen, MD, MS
Opt-In Consent Policies: Potential Barriers to Hospital Health Information Exchange
Nate C. Apathy, BS; and A. Jay Holmgren, MHI
Currently Reading
e-Consult Implementation Success: Lessons From 5 County-Based Delivery Systems
Margae Knox, MPH; Elizabeth J. Murphy, MD, DPhil; Timi Leslie, BS; Rachel Wick, MPH; and Delphine S. Tuot, MDCM, MAS

e-Consult Implementation Success: Lessons From 5 County-Based Delivery Systems

Margae Knox, MPH; Elizabeth J. Murphy, MD, DPhil; Timi Leslie, BS; Rachel Wick, MPH; and Delphine S. Tuot, MDCM, MAS
This case study of 5 county-based delivery systems finds that existing specialty care relationships and information technology integration are important differentiating factors for e-consult implementation success.
System 3

System 3 provides care to more than 180,000 county residents at 8 clinic health centers and 2 regional medical centers, and it interfaces with 2 federally qualified health center networks. System 3 initiated implementation in February 2018 and reported 161 e-consults across 13 specialties as of June 2018. Average specialist response time was 12 days. About 41% of e-consults were comanaged without need for an in-person specialist visit. Uptake may actually be even greater because platform data may not capture e-consults occurring via older workflows. System 3 benefited from an experienced informatics leader guiding implementation. However, implementation also conflicted with the organization’s financial sustainability goals because e-consults are not financially recognized compared with in-person visits under current fee-for-service reimbursement structures. “We are more financially incentivized to open new clinics than build e-consult systems,” elaborated the ambulatory director.

Many specialists were supportive of, and even advocated for, program implementation. Yet specialists also desired greater compensation beyond the fee-for-service contract administrative review rate offered for each e-consult. As the ambulatory director, who met with each specialty reviewer during implementation, explained, “E-consults are no longer a simple review of a referral. Because it takes 15 to 20 minutes to write a whole consultation.” For some specialists, the relatively small compensation was a barrier to engaging.

System 3 deliberately built its e-consult program as a component of its existing EHR to avoid adding a secondary or tertiary platform. There nevertheless remains a sense that the technology is clumsy and still too cumbersome. Implementation leaders expressed frustration that the EHR vendor provided so little support and that there was no potential to integrate with third-party vendors.

System 4

System 4 provides care to more than 145,000 county residents at 6 locations. The main medical center includes primary care, specialty care, and hospital services. System 4 piloted e-consults with 1 primary care clinic (7 of 150 PCCs within the system) and specialists from 2 of 22 local specialty services. System 4 chose an external e-consult platform that could integrate with the 3 existing EHR systems, as leaders recognized that clinicians and staff would not likely use a fourth system for patient care. The selected e-consult vendor was chosen for its extensive experience with training users and developing workflow guidelines. However, contract negotiations to secure the vendor were slow, and specialists were difficult to engage. System 4 was ultimately unable to expand the pilot and faced a decreased appetite among executive leaders to further invest in potential e-consultative relationships.

System 5

System 5 serves more than 40,000 patients across 9 clinics, with 3 clinics located at a central medical center. Three PCC champions from 1 site agreed to pilot the program; however, the system was unable to engage local specialist clinicians. The selected e-consult platform was favored by external consultants and health plan stakeholders because it offered the potential for external specialists to respond to e-consults. However, the external platform did not integrate with the system’s EHRs. Despite strong executive leadership interest, system 5 did not pursue implementation amid weak clinician engagement.


Our analyses examine a spectrum of e-consult program implementation success among publicly financed, county-based health systems. Our study adds a unique contribution to the existing literature, which has described implementation in a single system1,13-15 or across diverse delivery systems.6,12 To our knowledge, only 1 study explores implementation across organizationally similar health systems, a study of implementation in 7 academic medical settings.9

To place our analysis in context, we discuss our results in relation to the CFIR’s inner setting domain. Salient CFIR inner setting concepts include networks and communication, implementation climate (including compatibility, relative priority, and organizational incentives), and implementation readiness (including available resources and access to information or knowledge).

All 5 systems in our study shared the ability to articulate compatibility with organizational goals, such as increasing operational efficiency and enhancing access to specialty care, decreasing wait times, and/or avoiding unnecessary specialist visits. This is consistent with findings of prior evaluations of e-consult implementation across diverse health delivery settings.6,9,12 Additional goals also consistent with prior literature included decreasing leakage to specialists in other systems (system 1) and capacity building for PCCs to manage more complex cases (system 4).6 System 5 cited connections to specialists in other regions across the United States, consistent with findings of a prior study that suggested higher odds of e-consult implementation in rural locations due to severely limited access to local specialists.16

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