Abstract: With the onset of the COVID pandemic, computer-assisted clinic visits and telemedicine have become a critical aspect of patient care. As a rural National Cancer Institute-designated cancer center, the Dartmouth Hitchcock Medical Center has been utilizing electronic consultations (eConsult) for hematology patients even prior to the onset of the pandemic. To verify the usefulness of eConsults, we performed a retrospective analysis of all hematology eConsults completed over a 23-month period to determine the utilization rate, patient outcomes, and the time required by the consulting hematologists. Two hundred eighty-eight eConsults were generated. Seventy-seven percent of eConsults (n = 222) did not require an in-person consultative appointment. Of the 66 patients requiring a consultation, 10% of patients (n = 28) required ongoing hematology specialty care. Sixty-seven percent of all eConsults required ≤20 minutes for a hematologist to complete. With the onset of COVID, we have instituted this process within the new hematology patient referrals clinical pathway, since this process greatly expedites patient referrals and a specialists’ evaluation.
Key Words: electronic consultation, eConsult, virtual visit, telemedicine, specialist
An electronic consultation (eConsult) is a rapid, user-friendly electronic communication between a patient care provider and a specialist. This process allows the treating clinician to refer a patient to a specialist and to receive the specialist’s assessment in a timely manner. Current research indicates that eConsults improve access to a specialist, increase the referring physician’s satisfaction while enhancing patient convenience, and reducing unnecessary referrals.1-4 The most common mode of electronic consultation utilizes a secure and password-controlled Health Insurance Portability and Accountability Act (HIPAA)-compliant document within the electronic medical record (EMR).5
Dartmouth-Hitchcock Medical Center (DHMC) is a 390-bed tertiary care academic medical center located in rural New Hampshire. The hospital includes a National Cancer Institute (NCI)-designated Comprehensive Cancer Center. The institution serves as a referral center for patients throughout rural, northern New England, including New Hampshire, Vermont, Maine, Northern Massachusetts, and Eastern New York. The medical center is part of a large health care alliance, called the Dartmouth-Hitchcock Health (D-HH) system, which includes 1618 physicians and associate providers located throughout New Hampshire and Vermont.
Utilizing a Center for Medicare & Medicaid Innovations grant, DHMC implemented a hematology eConsult program to expedite rapid assessment of new referrals prior to the COVID pandemic. To better understand the impact of eConsults on the delivery of oncology care, we examined the practical use and perception of the eConsult program. We performed a retrospective analysis of all hematology eConsults in a 23-month period and examined the number of eConsults requested, the types of patients who were referred, the need for a formal in-person consultation, the time commitment of the hematologist performing the patient assessment, and the referring provider’s satisfaction with the process.
Submission and Completion of an eConsult
Clinical care providers (physician or nurse practitioner) within the D-HH system can request an electronic hematology consultation utilizing the patient’s EMR. To initiate an eConsult, a provider employed the patient’s encounter within the EMR and selected a hematology template note, from one of six categories, including anemia, thrombocytopenia, monoclonal gammopathy of undetermined significance, leukopenia, leukocytosis, or unspecified (Box 1). Using the short template note, the referring clinician provides relevant patient data, laboratory results, and a specific clinical question(s), using a process that requires 5 minutes or less to complete.
Once submitted, the eConsult is immediately available to a hematologist within the hematologist’s EMR “inbox.” Each of the 10 hematologists at DHMC selected 1-week blocks when he/she would be responsible to address each incoming hematology eConsult. Once the hematologist received the eConsult, a chart review of pertinent clinical history and laboratory results was performed. The
hematologist then provided recommendations addressing the provider’s question(s) or, if appropriate, a referral to the hematology clinic was recommended.
The time required by the hematologist to complete the eConsult varied, depending on the complexity of the patient’s clinical course and the question(s) being asked. Once completed, the hematologist checked a “billing box” that identified the time required to complete the eConsult. The eConsult note was then automatically routed back to the inbox of the referring care provider.
Using the EMR, each hematology eConsult that was performed over a 23-month period (April 2015-March 2017) was audited. The results of each eConsult were tracked to identify three major patient outcomes: (1) the number of eConsults that required no additional hematology evaluation or care; (2) the number of eConsults that required additional testing or treatment for hematologic issues that could be managed by the referring provider; or (3) the number of eConsults that required a referral to the hematology clinic. Additionally, the amount of time the hematologist needed to complete the eConsult (based on self-reporting), the referring provider’s location, and the time required from submission to completion of the eConsult were identified.
To examine referring provider satisfaction with the hematologist’s recommendations and the timeliness of the response, electronic satisfaction surveys were emailed to each referring provider who had submitted an eConsult (Box 2).
Defining the Number of eConsults
Between April 2015 and March 2017, 288 hematology eConsults were generated by referring care providers (Figure 1). Reasons for the eConsults included anemia (n=60), leukocytosis (n=28), leukopenia (n=32), thrombocytopenia (n = 23), or monoclonal gammapathy (n=16). “Unspecified” hematologic issues comprised the majority of the eConsults (n=129) and included conditions such as polycythemia, macrocytosis, iron overload, and thrombocytosis (Table 1).
Of the 288 eConsults submitted, 222 eConsults (77%) did not require a consultative appointment with a hematologist. Of the 66 eConsult patients who required a formal hematology consultation (23%), 24 patients required no further hematology follow up, 14 patients needed hematology follow-up care by their referring provider, and 28 patients necessitated continued ongoing hematology care.
Of the 28 patients who required ongoing follow-up and treatment by a hematologist, 17 patients presented with abnormal blood counts and 6 of these patients were found to have a malignancy. Of the 24 patients who required a hematology consultation with no subsequent hematology follow-up, 16 patients were referred due to abnormal blood counts, 5 patients were referred for anemia, and 3 patients were referred for iron deficiency. For the 14 patients who required a hematology clinic visit without further hematology care, the hematology assessment and testing answered a medical issue that could be managed by the referring care provider.
Time Commitment of the Hematologist
Each hematologist spent approximately 1.9 hours per week completing the eConsults (median: range 0-3.1 hours/week). For the hematologists performing the eConsults, 4% of eConsults (n=13) required 10 minutes or less, 63% of eConsults (n = 169) required 11 to 20 minutes, and 30% of eConsults (n = 79) required 21 to 30 minutes (Figure 2). Only 3% of eConsults (n=8) required 31 minutes or more to complete. In addition, 78% of all hematology eConsults were completed within two business days of submission.
Relative Value Units Associated With eConsults
Following the completion of each eConsult, the hematologist self-reported the time required to complete the eConsult within the EMR. Due to the time commitment of the hematologist to complete an eConsult, work relative value units (wRVUs) were provided to each hematologist who performed eConsults. These wRVUs were based on the time required by the hematologist to complete the eConsult (Table 2).
Favorable Elements of the eConsult
A random survey of referring providers who submitted an eConsult was conducted. Seventy-one surveys were emailed to referring providers, and 21 responses (29.6%) were received. Each of the 21 responders noted extreme satisfaction of the process, highlighting the ease of use, and said they were “very likely” to use the process again.
This retrospective review revealed many favorable elements of the eConsult system. Face-to-face specialist visits were obviated for the majority of eConsults, and the satisfaction of the referring provider was maintained. Our results indicate that 77% of eConsults did not require an office visit, and only 10% of eConsult patients (n=28) required a hematology consultation with ongoing specialty care. Each eConsult was completed quickly, with 78% of all eConsults completed within 48 hours. eConsults may reduce the number of in-person consultations for low-complexity patients, thereby allowing access to higher acuity and more complex patients.
Without the need for a clinic consultation visit, these results suggest possible increased efficiency and cost savings, to both patients and to insurance companies. By providing wRVUs to the hematologists, the eConsult process is not only sustainable, but it is also growing and expanding into other specialties at our institution. There is an associated high level of satisfaction and acceptance from referring providers. The eConsult process is now the first step in our clinical pathway of referring hematology patents.
The eConsultation service provides numerous benefits including rapid access to specialty care, while promoting communication between referring providers and specialists. If eConsults are available, referring providers are more likely to utilize an eConsult, rather than referring their patient to a specialty clinic.6 Referring providers believe the eConsult process addresses patient care in a timely fashion.6-10 Research demonstrates that eConsults reduce the incidence of marginal referrals to specialty clinics and decrease wait times for access to specialists.1-8 As noted, our results indicate that the far majority of eConsults (77%) did not require an in-person referral to the specialist. Similar results are noted within the literature, with published data demonstrating that 44% to 69% of eConsults did not require meeting with the specialist.9-15
The location and patient catchment areas of a medical center utilizing eConsults is critical. For example, we previously demonstrated that the majority of our patients travel 2 hours or more for a hematology evaluation, due to our institution’s rural patient catchment areas.16 eConsults reduce financial burdens to patients and insurance companies by minimizing unnecessary specialty clinic visits while also reducing patients’ time away from work.10,13-15,17
In addition, the geographical location our rural medical center and the medical center’s involvement with a large referral base increased our sample size, as the hospital system provides referrals from 5 states. Due to the rural location of our institution and the large referral area, the hematology eConsult process could improve access to a hematologist for patients who do not live in the immediate vicinity of the medical center.
Potential limitations to our study exist. Because this was a retrospective analysis, the incidence of “curbside” consults was not enumerated during the study period. As a result, we cannot conclude if eConsults took the place of these informal discussions. Although this is a single-center trial with inherent shortcomings as in any single-center trial, our sample size (n=288) is comparable to recently published results.10,14,17 In addition, we did not determine the impact of eConsults on the patient referral numbers to the hematology clinic. Based on the number of patients not requiring a formal in-person hematology consultation, we assume that fewer patients were referred to hematology clinic. However, we did not quantify this variable, and studies addressing the eConsult process and its effect on in-person referrals are lacking.18,19 In addition, we did not examine outcomes, such as the timeliness of a patient’s evaluation or the overall survival of patients. Previous studies addressing these issues provided mixed results. For example, one study demonstrated a more rapid evaluation of patient medical issues when using the eConsult process, but the perception of improved quality of patient care was mixed among referring providers.20,21 Finally, since eConsults were a novel concept at our institution when instituted in 2015—and were not fully implemented until 2019—the number of eConsults was initially low at 1 to 3 per week. This number has now increased substantially to 7 to 9 eConsults each week, especially in the midst of the COVID pandemic. Unfortunately, we do not have data addressing why a formal consult was not recommended. As two of the hematologists that routinely performed eConsults (CHL, KRM), we noted that the far majority of consultations asked straightforward questions about a patient evaluation (ie, “What is the recommended laboratory evaluation of a macrocytic anemia?”) or treatment recommendations (ie, “What are the indications to switch from oral iron to intravenous iron, when treating a patient with iron deficiency?”).
With this initial successful implementation, and now in the midst of a pandemic, DHMC is expanding eConsults into other specialties and into other community practices. We continue to educate our providers about the benefits of utilizing eConsults to access specialists. With ongoing education of referring providers, as well as providing work RVUs to the hematologists, we have observed a steady rise in the number of hematology eConsults with a process that is well accepted. We continue to track the clinical metrics of patients participating in this process, including outcomes and survival, as well as the overall impact that eConsults has on our clinical programs during the COVID pandemic.
The hematology eConsult process can improve access to a hematologist for patients in rural areas who do not live near a medical center. Higher utilization of eConsults may reduce the number of in-person consultations for low-complexity patients, allowing access to higher acuity and more complex patients and may contribute to increased efficiency and cost savings for both patients and insurance companies.
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2. Davis A, Gilchrist V, Grumbach K, James P, Kallenberg R, Shipman SA. Advancing the primary/specialty care interface through econsults and enhanced referrals. Ann Fam Med. 2015;13(4):387-388. doi:10.1370/afm.1829
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7. Kohlert S, Murphy P, Tse D, Liddy C, Afkham A, Keely E. Improving access to otolaryngology-head and neck surgery expert advice through e consultations. Laryngoscope. 2018;128(2):350-355. doi:10.1002/lary.26677
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12. Mckellips F, Keely E, Afkham A, Liddy C. Improving access to allied health professionals through the Champlain BASE ™ eConsult service: a cross-sectional study in Canada. Br J Gen Pract. 2017;67(664):e757-e763. doi:10.3399/bjgp17X693125
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