Electronic Consultations (eConsults) for safe and equitable coordination of virtual outpatient specialty care

Abstract

Poor access to timely, high-quality specialty care remains a significant challenge, especially for patients with barriers to health care access, and can result in high rates of preventable morbidity and mortality.[ 1 ] [ 2 ] [ 3 ] The health disparities of the COVID-19 pandemic have further underscored the need for improved access to remote specialty care and reduction of in-person visits, especially for vulnerable patients with barriers to care such as uninsured, minority, and rural patients.[ 4 ] [ 5 ] Indeed, the patients most susceptible to adverse outcomes during the pandemic due to higher rates of comorbidities and structural difficulties with social distancing are also those who may face the most barriers in accessing specialty services.[ 5 ] The COVID-19 pandemic has presented a unique set of challenges for the specialty care delivery system, including increased volumes of consultations and referrals to infectious disease and pulmonary specialists for potential COVID-19 cases, as well as an increased need for virtual specialty care access for management of other conditions in particularly at-risk patients.[ 4 ] [ 6 ] Coordination and transition of care between primary and specialty care are of utmost importance at a time when in-person communication may be more fragmented and more patients need timely input from specialists without putting themselves at unnecessary risk of exposure to COVID-19 through in-person visits. While much recent attention has been given to the benefit of live synchronous telehealth video visits especially in the inpatient and emergency department settings,[ 7 ] less attention has been given to the burgeoning role of asynchronous methods such as electronic consultations (eConsults) in outpatient specialty care. eConsults present an additional tool in the growing telehealth armamentarium of technology-facilitated communication modalities for the innovative delivery of patient care.[ 8 ] [ 9 ] [ 10 ] We believe eConsults are a sustainable solution to improve overall coordination of care between outpatient primary care providers (PCPs) and specialists and ensure safe, timely, and equitable outpatient specialty care. eConsults are a method of asynchronous consultation that facilitates direct communication, typically between PCPs and specialists, over a secure shared electronic platform or electronic health record. Through rapid communication between primary care and specialists, eConsults allow for quick access to specialist input while averting the need for face-to-face in-person or virtual specialty visits, allowing for more cost-effective and convenient care for patients.[ 11 ] [ 12 ] Studies have shown that eConsults can decrease wait times for specialty input by 17.4% and reduce unnecessary specialty in-person visits especially in safety-net health systems, with patient satisfaction rates of 78 to 93% across various sites.[ 13 ] [ 14 ] eConsults also can serve a particular benefit for underserved patients with barriers to specialty care; a study of electronic dermatology consultations showed that eConsults served more nonwhite patients, more Medicaid enrollees, and also decreased the rate of patient no-shows.[ 15 ] In the context of the pandemic, eConsults can serve an even more essential role in helping patients receive safe specialty care and avoid coming to the office for unnecessary visits. eConsults provide a different role from telehealth visits in that they eliminate the time, costs, and resources needed in a direct specialist-to-patient encounter. Over the past several years, the adoption of eConsults has expanded to major public and private health systems across the United States and the rates of adoption and use have increased during the pandemic.[ 16 ] eConsults facilitate transitions between PCPs and specialists through several mechanisms, including improved relationships and communication, education of PCPs on how to manage specialized conditions, increased timeliness and access of care, and standardization of the referral process. First, they improve communication and relationships between PCPs and specialists through ongoing dialogue and education. One study found that over 80% of specialists also felt that eConsults result in improved communication between providers and that specialists appreciated the feedback received from PCPs.[ 17 ] Standardized methods of communication between providers are increasingly important during the pandemic, when there may be additional barriers to in-person interactions due to social distancing measures and a more fragmented workforce as clinicians face shifting duties and redeployment. Second, because PCPs are often asked to perform additional work-up for patients, eConsults transition some specialty care management to PCPs, who can gain increased comfort managing conditions and optimizing preliminary work-up. In addition, the dialogue with specialists can have educational value to PCPs, particularly for trainees and clinician