Analysis of an electronic consultation program at an academic medical centre: Primary care provider questions,specialist responses,and primary care provider actions

Abstract

Introduction

Electronic consultations (eConsults) increase access to specialty care, but little is known about the types of questions primary care providers (PCPs) ask through eConsults, and how they respond to specialist recommendations.

Methods

This is a retrospective descriptive analysis of the first 200 eConsults completed in the UCSF eConsult program. Participating PCPs were from eight adult primary care sites at the University of California, San Francisco (UCSF), USA. Medicine subspecialties participating were Cardiology, Endocrinology, Gastroenterology/hepatology, Hematology, Infectious diseases, Nephrology, Pulmonary medicine, Rheumatology, and Sleep medicine. We categorized eConsult questions into “diagnosis,” “treatment,” and/or “monitoring.” We performed medical record reviews to determine the percentage of specialist recommendations PCPs implemented, and the proportion of patients with a specialist visit in the same specialty as the eConsult, emergency department visit, or hospital admission during the subsequent six months.

Results

PCP questions related to diagnosis in 71% of cases, treatment in 46%, and monitoring in 21%. Specialist responses related to diagnosis in 76% of cases, treatment in 64%, and monitoring in 40%. PCPs ordered 79% of all recommended laboratory tests, 86% of recommended imaging tests and procedures, 65% of recommended new medications, and 73% of recommended medication changes. In the six months after the eConsult, 14% of patients had a specialist visit within the UCSF system in the same specialty as the eConsult.

Discussion

eConsults provide guidance to PCPs across the spectrum of patient care. PCPs implement specialists’ recommendations in the large majority of cases, and few patients subsequently require in-person specialty care related to the reason for the eConsult.

Keywords

Electronic consultation referral primary care

Introduction

As the US population ages, patient complexity increases, and the burden on primary care grows, there is an increasing demand for specialty care.¹ Primary care providers (PCPs) must meet the clinical needs of this population amidst a concurrent expansion of medical knowledge, diagnostic choices, and treatment options. Currently, more than one-third of patients are referred to a specialist each year,^1,2 and predictions are that demand for specialty care will only increase.^1,3 There are concerns about timely access to specialty care, particularly among low-income patients.^4,5 There are also concerns about the quality of communication between PCPs and specialists, and the appropriateness of certain referrals.^4–8 In some cases, a specialist may be able to answer clinical questions without the need for in-person consultation.

With the adoption of electronic health records (EHRs), electronic referral and electronic consultation (eConsult) programs have emerged as a strategy to meet the increasing mismatch between supply and demand for specialty care, and to provide improved communication between PCPs and specialists.^9–12 “eReferral” is a term that typically refers to an electronic referral initiated by a PCP that could be either an “eTransfer,” in which the PCP intends to transfer care to the specialist and for the patient to have an in-person visit with that specialist, or an “eConsult.”^13,14 An “eConsult” typically refers to an asynchronous communication between a PCP and specialist for selected clinical questions that can be accomplished without an in-person consultation; and which can be initiated by the PCP at the point of referral, or by the specialist upon reviewing the eReferral.^13,14 Analyses of eReferral and eConsult systems have found evidence of patient, PCP, and specialist satisfaction,^{4,11,12,15–19} but less is known about how PCPs use the recommendations conveyed by specialists in eConsults.

The University of California, San Francisco (UCSF) launched an eConsult program in 2012 in which PCPs, at the point of referral, have the option to submit an eConsult request, using a structured template, if they believe the specialist could address the clinical question without an in-person evaluation. Specific structured referral templates exist for the most common clinical problems referred to each specialty, which incorporate relevant laboratory data from the EHR, allow PCPs to identify if relevant imaging data is available, and ask the PCP to provide a recent assessment and a specific clinical question. PCPs also have the option to choose an “unspecified” referral template, if the clinical question does not fit in with any of the specific templates for that specialty. The PCP must ensure that an eConsult would meet the patient’s needs, and that the clinical question would typically justify an office-based visit in the absence of the eConsult program. The specialist has the option to complete the eConsult and receive modest payment for the service, or convert the request to a traditional office-based visit, if deemed inappropriate for eConsult. If the specialist chooses to covert the eConsult request to an office-based visit, the specialist does this through the referral platform, and the PCP does not need to initiate a new referral. The expected response time is three business days, and PCPs are expected to communicate the result of the eConsult to the patient and implement any recommendations. Initial evaluations of the program have shown high levels of adoption and satisfaction among participating PCPs and specialists.²⁰

However, there is little information about how the eConsult program affects clinical management of patients in primary care. In this study, our primary objectives were to describe the types of clinical questions PCPs ask through eConsults, what management recommendations specialists provide, and the extent to which PCPs implement specialist recommendations. In addition, we investigated downstream healthcare utilization, including specialist office visits, emergency department (ED) visits, and hospital admissions following eConsults.

Methods

Study setting

UCSF is a multi-site urban academic medical centre that includes eight primary care practice sites and uses a shared electronic health record (EHR) (Epic Systems, Inc.). Prior to the implementation of the eReferral and eConsult programs, the overall referral rate from PCPs to specialists was approximately 12.4 referrals per 100 primary care visits per month.

Payment for PCP and specialist visits is on a fee-for-service basis, and there is a diverse payer mix including capitated insurance plans, commercial insurance plans, Managed Medi-Cal, Managed Medicare, Standard Medi-cal, Standard Medicare, and self-pay. Payment for eConsults is separate, supported by the Delivery System Reform Incentive Payment (DSRIP) Medicaid Waiver program. The specialist receives a payment of 0.5 work relative value units (wRVU) for the completed eConsult, and the PCP receives a 0.5 wRVU credit toward their annual productivity measures. At the time the eConsult program was implemented, the specialist payment was approximately US$30.68, based on UCSF’s weighted reimbursement rate across all payers. If the patient has a specialist visit within 30 days of the eConsult completion, the specialist does not receive this fee. There is no co-payment required from the patient.

PCPs in the system who participate in the eConsult program include general internists, internal medicine residents, family and community medicine physicians, geriatricians, HIV PCPs, and nurse practitioners. In the first phase of the eConsult program's implementation, the following medicine subspecialties participated: Cardiology, Endocrinology, Gastroenterology/hepatology, Hematology, Infectious diseases, Nephrology, Pulmonary medicine, Rheumatology, and Sleep medicine.

Content analysis

We analysed the clinical documentation of the first consecutive 200 eConsults completed during the initial months of the program (Figure 1).

Figure 1.

Electronic consultation (eConsult) selection for analysis.

Content analysis included both PCP questions and specialist responses. We established the following categories for questions posed in each eConsult and in specialist responses: “Diagnosis,” “Treatment,” and/or “Monitoring” based on literature review of general referral and eConsult literature, and following discussion at a UCSF Faculty Research Seminar.^8,18,21 eConsults could be classified under more than one category, depending on the type of question asked or response given.

The principal investigator (KW) reviewed all 200 eConsults. A second independent reviewer (MC) coded 30 eConsults and responses using coding instructions created by the first reviewer, to check for inter-rater reliability. Kappa statistics ranged between 0.61 (specialist “Diagnosis”) and 1.0 (specialist “Monitoring” categories).

Medical record review

We performed EHR review of subsequent test ordering, referrals, and medication prescribing/changes to determine the proportion of specialist recommendations that PCPs implemented over the six months following completion of the eConsult. If the specialist recommended specific laboratory testing, imaging, or a procedure, we noted if the PCP ordered some, all, or none of those recommendations. We noted if the PCP ordered recommended new medications or medication changes.

We also performed the EHR review to determine the proportion of patients with a subsequent specialist visit in the same specialty as the eConsult, ED visit, or hospital admission within the six months following the eConsult. Four eConsults were excluded from this part of the analysis. In one case, a specialist visit for a separate question was already planned at the time the eConsult was ordered. In another case, an ED provider referred the patient to the specialist, outside the care of the PCP. In two cases, the eConsult had been converted to a formal consultation at a later date after the specialist had initially provided the PCP with recommendations. We chose to exclude these two cases, as the specialist made the decision to convert the eConsult to a formal consultation based on the information contained in the initial eConsult, before waiting for the PCP to act on the recommendations provided in the eConsult response. Therefore, we analysed 196 eConsults in this part of the study. We determined whether specialist visits, ED visits, and hospital admissions were related to the medical condition discussed in the eConsult. One reviewer (RG) reviewed all medical records. A second independent reviewer (SC) reviewed 30 medical records of patients who had a subsequent specialist visit, ED visit, or hospital admission, to check for inter-rater reliability. The Kappa statistic for ascertaining if the subsequent specialist, ED, or hospital visits were related to the medical conditions discussed in the eConsult was 0.9.

The UCSF Committee on Human Research deemed this evaluation exempt from institutional review and patient identifiers were removed prior to review by the primary investigator.

Results

The first 200 completed eConsults were submitted between August 2012 and January 2013. The average response time for these eConsults was 2.5 business days, with 79% completed within three business days.

PCP characteristics

The first 200 eConsults were submitted by 86 individual PCPs (60% women). Of these 35% were residents (n = 30), 5% were fellows (n = 4), 16% were assistant professors (n = 14), 21% were associate professors (n = 18), 17% were professors (n = 15), and 6% (n = 5) were nurse practitioners. A total of 17% of eConsult orders were from the Department of Family and Community Medicine (n = 15), 2% were from the Department of Geriatrics (n = 2), 77% were from the Department of General Internal Medicine (n = 66), and 4% were from HIV PCPs (n = 3). The mean number of clinic sessions per week for PCPs submitting eConsults was 2.9 half-day clinics.

Patient characteristics

Demographic data is available for the 195 patients who were the subjects of the first 200 completed eConsults. Several patients were the subjects of multiple eConsults. Patient characteristics are presented in Table 1.

Table 1.

Patient demographics (n = 195).

	n	Percentage
Gender
Male	71	36.4%
Female	124	63.6%
Age (years)
18–24	8	4.1%
25–39	25	12.8%
40–54	40	20.5%
55–64	38	19.5%
65+	84	43.1%
Race
White or Caucasian	105	53.8%
Asian	40	20.5%
Black or African American	19	9.7%
Native Hawaiian or Other Pacific Islander	1	0.5%
Other	23	11.8%
Unknown/declined	7	3.6%
Ethnicity
Not Hispanic or Latino	174	89.2%
Hispanic or Latino	11	5.6%
Unknown/declined	10	5.1%

eConsult content analysis

In our study sample, PCPs asked questions related to diagnosis in 71% of cases, treatment in 46% of cases, and monitoring in 21% of cases. The distribution of specific questions is presented in Table 2. Among diagnosis-related questions, those asking about pursuing diagnostic work-up were most common (53% of all eConsults). Among management-related questions, those asking for general guidance regarding current management (24% of all eConsults) or about starting treatment/choosing an initial medication (13% of all eConsults) were most common. In the monitoring category, questions regarding follow-up in the setting of abnormal tests were most frequently asked (16% of all eConsults). The types of questions varied based on the specialty consulted. Diagnosis-related questions were dominant (≥65%) for Cardiology, Gastroenterology/hepatology, Pulmonary medicine, and Rheumatology, whereas treatment-related questions were dominant (>65%) for Endocrinology (Table 3).

Table 2.

Types of questions asked by primary care providers (PCPs) in electronic consultations (eConsults) (n = 200).^a

Diagnosis	70.5%
Interpretation of specific labs and/or imaging results	11.0%
Interpretation of overall clinical presentation/ diagnosis	16.5%
Recommendations for pursuing (if/what) diagnostic work-up	52.5%
Recommendations for selecting best/appropriate test	7.0%
Management	45.5%
General guidance regarding current management	24.0%
Recommendations for starting treatment/ choosing initial medication	13.0%
Recommendations for starting specific medication	6.0%
Need to change the dose or stop a medication	7.0%
Discussion of medication safety/adverse effects	2.5%
Whether now is appropriate time to refer for treatment	2.0%
Need for referral to a different specialist	3.0%
Monitoring	21.0%
In setting of abnormal test/imaging, recommendations for follow-up	16.0%
Appropriate interval for screening tests	0.5%
Need for monitoring	4.0%

Denominator for all percentages in this table is 200.

Table 3.

Types of questions asked by primary care providers (PCPs) and content of responses from specialists completing electronic consultations (eConsults), by specialty of requested consultation.

		PCP questions			Specialist responses
Specialty^a	n	Diagnosis	Treatment	Monitoring	Diagnosis	Treatment	Monitoring
Cardiology	40	82.5%	40.0%	10.0%	90.0%	60.0%	17.5%
Endocrinology	61	60.7%	67.2%	23.0%	65.6%	83.6%	50.8%
Gastroenterology/hepatology	48	68.8%	22.9%	31.3%	70.8%	33.3%	50.0%
Nephrology	21	66.7%	66.7%	14.3%	76.2%	90.5%	28.6%
Pulmonary medicine	14	78.6%	21.4%	28.6%	78.6%	21.4%	42.9%
Rheumatology	11	100.0%	9.1%	18.2%	100.0%	81.8%	27.3%

Hematology, Infectious diseases, and Sleep medicine eConsults not reported (small n).

Among specialist responses, 76% related to diagnosis, 64% to treatment, and 40% to monitoring. The distribution of specific responses is presented in Table 4. Among diagnosis-related responses, recommendations for additional diagnostic testing were most common (43% of all responses). Specialists provided interpretation of prior diagnostic testing in 22% of responses, and interpretation of the overall clinical presentation/diagnosis in 25%. Among management-related responses, 19% recommended considering/starting new medication(s). Recommendations for the appropriate interval for follow-up of abnormal laboratory tests or imaging were the most common type of monitoring-related response (30% of all eConsults).

Table 4.

Content of responses from specialists completing electronic consultations (eConsults) (n = 200).^a

Diagnosis	75.5%
Interpretation of prior diagnostic testing	21.5%
Interpretation of overall clinical presentation/ diagnosis	25.0%
Guidance with choosing appropriate test	10.5%
Recommendation for additional diagnostic testing	42.5%
Gave conditions for additional testing	16.5%
Recommendation that no further diagnostic testing needed	10.0%
Management recommendations	63.5%
Consider/start new medication(s)	18.5%
Conditions for starting treatment	17.0%
Change current medication(s)	9.0%
Continue current medication(s)	8.5%
Stop medication(s)	5.0%
Non-pharmacologic management	11.5%
No additional treatment	6.0%
Consider other specialty consult	12.0%
Discuss adverse effects of medication(s)	7.0%
Counsel patient	9.0%
Monitoring recommendations	39.5%
Appropriate interval for screening tests	1.5%
Appropriate interval for follow-up of abnormal labs/imaging	29.5%
Symptom monitoring only	2.0%
Routine monitoring only	5.0%
No further monitoring	2.0%

Denominator for all percentages in this table is 200.

The majority of eConsults (65.5%) included only one type of question posed by the PCP, whereas specialist responses often provided additional recommendations pertaining to more than one category (Figure 2). Among the 80 eConsults that pertained to “diagnosis only,” 26 specialist responses pertained to “diagnosis plus treatment,” and 10 responses pertained to “diagnosis plus monitoring” recommendations. Specialists provided additional recommendations in 43% of all eConsult responses.

Figure 2.

Content of primary care provider (PCP) questions vs specialist responses (n = 200).

PCP implementation of specialist responses

PCPs ordered 79% of all recommended laboratory tests, and an additional 10% ordered some of the recommended laboratory tests. PCPs ordered 86% of recommended imaging tests or procedures, 65% of recommended new medications, and 73% of recommended medication changes (Table 5).

Table 5.

Percentage of specialist recommendations ordered by primary care providers (PCPs) in the six months following completion of the electronic consultations (eConsults) (n = 200 eConsults).

	n	Percentage
Laboratory testing recommended (n = 79)
All recommended lab tests ordered	62	78.5%
Some recommended lab tests ordered	8	10.1%
No recommended lab tests ordered	9	11.4%
Imaging studies and procedures recommended (n = 81)
Imaging study or procedure ordered	70	86.4%
Imaging study not ordered	11	13.6%
Medication recommendations (n = 57)
Recommended new medications (n = 31)
All recommended new medications ordered	20	64.5%
Some recommended new medications ordered	1	3.2%
Recommended new medications not ordered	10	32.3%
Recommended changes in medication (n = 26)
All recommended changes in medication ordered
Some recommended changes in medication ordered	19	73.1%
Recommended changes in medication not ordered	1	3.8%

Specialist visits following eConsults

Based on medical record review, 14% of eConsult patients (n = 27) had a visit with the specialist in the same speciality as the eConsult during the six-month period following the eConsult. By specialty, 13% of Cardiology referrals (n = 5), 15% of Endocrine referrals (n = 9), 15% of Gastroenterology/hepatology referrals (n = 7), 19% of Nephrology referrals (n = 4), and 15% of Pulmonary medicine referrals (n = 2) had a subsequent in-person visit. No Hematology, Infectious disease, or Rheumatology eConsult patients had a visit during this period.

Among the 27 patients who had a subsequent visit with the specialist, 24 had a visit addressing the condition discussed in the eConsult (89%). In 59% of cases (n = 16), the PCP referred the patient for an in-person visit based on conditional recommendations provided by the specialist in the initial eConsult response.

ED visits and hospital admissions following eConsults

Based on chart review, 11% of eConsult patients (n = 22) had an ED visit at UCSF in the six-month period following the eConsult. Only 1.5% (3/196) had an ED visit related to the condition discussed in the eConsult. By specialty, 15% of Cardiology referrals (n = 6) and 10% of Endocrine referrals (n = 6) had an ED visit. No Hematology, Infectious disease, or Pulmonary medicine eConsult patients had an ED visit during this period, and few Gastroenterology/hepatology referrals (n = 3), Nephrology referrals (n = 5), and Sleep medicine referrals (n = 1) had visits.

Of the patients, 11% (n = 22) had a hospital admission at UCSF within the six months following completion of the eConsult. Of these 22 patients, 16 were also patients noted to have an ED visit. Only one patient had an admission related to the condition discussed in the eConsult (0.05% of all eConsults in this analysis). This patient had hyperparathyroidism and was admitted for an elective parathyroidectomy.

Discussion

We found that eConsults from primary care to medical subspecialties include clinical questions across the spectrum of patient care: diagnosis, treatment, and monitoring of multiple different medical conditions. PCPs most frequently asked diagnosis-related questions, with the majority of these related to recommendations about pursuing diagnostic work-up. With the number and complexity of clinical laboratory tests rapidly expanding, PCPs often experience uncertainty and challenges in ordering and interpreting diagnostic tests,²² and our findings suggest that eConsults may serve as one form of support to help address this problem. Just under half of PCP eConsult questions related to treatment, and a smaller percentage related to monitoring. Other studies have described reasons providers request eConsults, but these findings have been based on PCP survey responses or review of an electronic consultation order set.^15,18 Our study extends upon these findings, providing additional details about specific types of questions and responses, as we performed a detailed review of the text of each eConsult.

While eConsults from PCPs often contained a clinical question within a single dimension of care (diagnosis, treatment, or monitoring), specialist responses often included additional recommendations pertaining to more than one dimension. In doing so, specialists may be intending to provide PCPs with the additional guidance needed for them to continue managing that patient’s condition within the realm of primary care. In support of this, we found that only a small minority of patients with eConsults (14%) went on to have a specialist visit within the six-month period following the eConsult.

In the eConsult program at UCSF, as with other eConsult programs, specialists provide PCPs with recommendations, and the PCP is responsible for their implementation. Prior studies have shown that PCPs report using information from eConsults in their patient care,¹⁸ and that PCP follow-up visits after eConsults increased compared with in-person consultations.²³ These findings might suggest that the PCP is actively managing the patient’s condition, yet we found a paucity of data in the literature about whether PCPs are actually implementing the specialists’ recommendations. In our study, we found that in the majority of cases (79%), PCPs ordered all recommended laboratory tests, and in an additional 10% of cases, PCPs ordered at least some of the recommended laboratory tests. PCPs ordered new medications in 65% of cases, and medication changes in 73% of cases. These findings confirm that PCPs are indeed following specialists’ recommendations, with this data supported by formal medical record review, and not just survey data of PCPs’ reported practices.

With only 14% of eConsult patients going on to have an in-person specialist visit in the same specialty as the eConsult within the six-month period following completion of the eConsult, eConsults appear to be decreasing office-based visits to specialists, if we assume that many of the eConsults would have otherwise resulted in an office-based referral. In the majority of cases (59%; n = 16), the PCP referred the patient to the specialist for an in-person visit based on conditional recommendations provided in the initial eConsult response. Thus, while these eConsults did not ultimately eliminate the need for office-based consultation, they may have resulted in timely diagnostic work-up and treatment trials being completed in the primary care setting before an office-based visit. Previous analysis has shown that in the first eight months of the eConsult program at UCSF, eConsults were used for approximately 8% of total specialty contacts, with referral rates of 9.9 standard office referrals and 0.9 eConsults per 100 primary care visits per month.²⁰

A common concern with eConsults is whether they pose a safety risk for patients by not having an in-person evaluation. In our program, few patients went on to have an ED visit (11%; 22 out of 196) or hospital admission (11%; 22 out of 196) in the six months following the eConsult, with only 3 out of 22 ED visits and 1 out of 22 hospital admissions related to the eConsult condition. The related hospital admission was an elective admission for a scheduled parathyroidectomy.

The “curbside” consult is one informal mechanism that many physicians have used to help interpret clinical data, diagnose specific conditions, select appropriate diagnostic tests and treatment plans, and determine the need for formal consultation.²⁴ However, “curbside” consults tend to take place by phone or email, and specialists have reported that information communicated by PCPs is often insufficient.²⁴ In this program, specialists have full access to the patient's medical record, and thus can access additional important clinical information that might not be specifically documented in the PCP's consultation request. Having this information may help prevent misdiagnosis or inappropriate treatment.

There are several limitations to this study. First, this was a single centre study, conducted at a large, urban, academic medical centre, and therefore the results may not be generalizable to other practice settings. However, the eConsult program at UCSF has been implemented across multiple different primary care practice sites within our institution, including general internal medicine, family and community medicine, geriatric, and HIV primary care practices, perhaps expanding its generalizability. Second, for the first two months of the eConsult program, a single lead eConsultant responded to the majority of eConsults sent to each specialty, and thus it is possible that if we extended our analysis of eConsult responses, we may see more variation in response types. Our analysis of post-eConsult healthcare utilization only captured subsequent specialist visits, ED visits, and hospital admissions within the UCSF system, and it is possible that patients went on to receive further care at other institutions. Also of note, eConsults to Infectious disease, Hematology, and Sleep medicine were not available in the first several months of the eConsult program, and thus there are only a small number of eConsults to these specialties in our study sample. Therefore, we may not have sufficient numbers to detect if the types of referral questions and responses differ for consults to these specialties. Finally, the DSRIP Medicaid Waiver program supports funding for the UCSF eConsult program, but a similar eConsult program might be difficult to implement at other institutions that would require payment from health insurance companies and co-pays from patients.

At UCSF, the eConsult program continues to expand into additional specialties, particularly those with long wait-times for new-patient visits. Multiple payers now reimburse UCSF for this clinical service. With dissemination grants from the University of California Center for Health Quality and Innovation and from the Center for Medicare and Medicaid Innovations (to Association of American Medical Colleges), the UCSF eConsult model is currently being implemented in several additional academic health centres.

In summary, we found that eConsults provide guidance to PCPs across the spectrum of patient care, and PCPs implement specialist recommendations in the large majority of cases. Few patients subsequently require specialty care, ED visits, or hospital admissions related to eConsults. Our findings support the use of eConsults as a viable strategy to help PCPs continue to manage issues of lower clinical complexity within the realm of primary care, thus reducing demand for office-based specialty care and reducing inconvenience and cost to patients. More research is needed to assess patients’ perspectives, long-term clinical outcomes, cost savings, and the sustainability of such programs under more traditional financial models.

Footnotes

Acknowledgements

The authors wish to acknowledge the contributions of Don Collado and Michael Wang. Preliminary findings from this study were presented at the Society of General Internal Medicine Annual Meeting in San Diego, California, USA in April 2014.

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: R Gonzales serves as medical advisor to Phreesia, Inc. To the best of our knowledge, the authors do not have any additional conflicts of interest, financial or otherwise.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The UCSF Medical Center Delivery Systems Reform Incentive Program provided support for development of the eConsult program.

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