Electronic Consultations (“eConsults”) – Improving the Quality, Efficiency, and Value of Ambulatory Specialist Care
Partners Population Health Perspectives blog aims to share the opinions and ideas of our leadership team on health care topics related to population health management. In this post, Jason Wasfy, MD, Medical Director for Population Health Management at the Massachusetts General Physicians Organization (MGPO), shares his thoughts on the use of electronic consultations, or “eConsults,” and how they help both providers and patients in a myriad of ways.
As a cardiologist, I have a lot of consultations with new patients, just like other specialists. But sometimes, a patient is referred to the office with a clinical question such as lipid management or interpretation of cardiac imaging when I can answer the question even without an office visit. Today, many primary care providers don’t always feel properly equipped to make complex interpretations or decisions related to specialty care. Similarly, I’ve heard from my colleagues in primary care that they dislike having to curbside their specialty colleagues with one-off questions. Furthermore, curbsides do not have any documentation, so the thinking of the curbside can get lost with time in the medical record.
The sheer volume of clinical care and other administrative expectations of physicians—both in primary care and specialty—often leaves little time for meaningful knowledge sharing and discussion among peers as it relates to potential specialty needs.
It begs the question – does the primary care/specialty relationship present an opportunity to leverage technology to support both the patients and the providers on both sides of the care equation?
Over the past 5+ years, I‘ve had the privilege of advancing the use of technology across the Partners HealthCare network to streamline the communication process between providers. Our electronic consultations program, known as “eConsults,” is showing dramatic results. eConsults offer ambulatory providers an electronic, asynchronous alternative for specialist input (peer-to-peer “advice”) – to free up clinic time for more complex/urgent care needs. eConsults are intended for non-urgent questions about a patient without established care, and not medically complicated such that a visit is required to provide input.
How it Works
Today, any provider within the Partners Healthcare network, including Brigham Health, Massachusetts General, Newton-Wellesley, and other affiliated sites, who use the Partners electronic health record (EHR) can order an eConsult in Epic. An eConsult is a non-urgent request to an ambulatory specialist for input on a specific patient care question. The aim is to avoid a potentially unnecessary in-person clinic consult and to get specialist input on the care plan in a way that would be much faster than waiting for an ambulatory specialty clinic visit. The eConsult request is routed to a pool, then assigned to an available specialist in the group for review. The specialist response, offered as “advice for consideration,” is documented in the chart – typically within 3 business days. An internal survey of primary care providers across the Partners system ranked “eConsults” as the highest recommended for new interventions and one of the highest value interventions for these providers. Ambulatory specialists may also use eConsults to request input from other ambulatory specialists when appropriate.
Our Experience at MGH
As of July 2019, 230 MGH specialists have completed more than 27,000 eConsults across 47 specialty service areas, including cardiology, endocrinology, and infectious disease, among many others. With high satisfaction and efficacy, eConsults have become standard work for MGH care providers and appear to be a key population health management intervention – offering those in health care an opportunity to reimagine the way care should be.
One thing we’ve been careful to avoid is a wave of unnecessary eConsults. At some other organizations, specialists have been bombarded with electronic consultations used to screen inbound ambulatory referral requests—many of which will need a specialty appointment anyway. This flow of unnecessary consults creates a massive burden on the specialists to review and reply to each request in a timely manner. To address this problem at MGH, we encourage the reviewing specialists to be selective about the requests accepted for review. There were ~8% of eConsults declined per month (overall) in 2018.
While primary care providers were the only requesting providers for eConsults initially, we are starting to see a growing proportion of eConsult requests from ambulatory specialists seeking input on care from peers in other specialty areas. In each case, an eConsult order should be used only for an appropriate request: a specific, non-urgent question about an ambulatory patient in their care. An eConsult is typically declined (not accepted) for a patient with established care in the eConsult service area—a question about this type of patient is best handled by the established specialty care provider.
We have found eConsults to be extremely useful for clarification or interpretation of guidelines, for advice on possible diagnoses to consider or rule out, need for high cost imaging or labs, testing, alternative approaches to consider for medications/dosing/tapering, procedure eligibility and/or next steps in the care plan (e.g. surveillance vs. need for clinic consult and management). An eConsult can also provide needed reassurance to the treating provider or patient that nothing was missed. We’ve also heard that an eConsult can equip the treating provider with guidance on why a non-compliant patient needs to take action. With our program, eConsults are not appropriate to address urgent or medically complicated questions that require an in-person clinical evaluation to determine next steps; In these cases, the eConsult team might decline a formal review, and suggest the patient be referred to see a sub-specialist.
Enabling Efficiency and Effectiveness
We continue to see the impact of eConsults to streamline care and are excited when thinking about how to leverage our experience and lessons learned to further improve our care delivery. While the program’s aim is to reduce potentially unnecessary consults to a clinic to improve access for other, more medically complex patients, we see so many other aspects of value— one of which is peer training and education.
As a health care system with two world-class academic medical centers, education is baked into our DNA. It makes Partners well positioned to amplify the impact of the peer to peer educational contribution. I’ve heard numerous times from requesting and reviewing providers that they see very high value in peer education via eConsults. We’re currently building use cases to capture valuable lessons learned through eConsults (e.g. identifying topics for frequently asked questions and those that need to be declined). We hope to include this new material within primary care educational sessions, and, if possible, eventually build out the eConsult content to qualify for continuing medical education credits (CME’s).
In a paper our team recently published, we found that implementation of an eConsult program in Allergy/Immunology resulted in decreased in-person wait times despite an increase in overall consult volume during the study period, supporting this model’s ability to provide expedited, problem-focused care. Program contributions include publications on the effectiveness of eConsults for cardiology, endocrinology, and gastroenterology, among others. The evidence shows that this program is good for patients. But as we think about scaling this program and how it will transform over the long-term, I believe we must look to how it impacts physicians. The fact that these show high-value as an educational tool is as important as our original goal of reducing unnecessary in-person referrals. We believe that eConsults have improved care for patients and improved workflow for providers. Furthermore, we publish our results so that we can help our colleagues across the country improve quality and value in care delivery.
Jason H. Wasfy, MD, is an Assistant Professor at Harvard Medical School and Director of Quality and Outcomes Research at the Massachusetts General Hospital Heart Center. He is also a Medical Director of the Mass General Physicians Organization, where he directs all activities in population health management. As a clinical cardiologist, he sees a broad range of patients with heart disease and cares for patients in the Cardiac Intensive Care Unit. Dr. Wasfy’s research interests include evaluation of the patient impact of changes in health policy, variation analyses, novel forms of care delivery, and population health management. Dr. Wasfy completed his cardiology fellowship and residency at the MGH, where he was the Roman DeSanctis clinical scholar in cardiology. He received his undergraduate degree in chemical engineering from the Massachusetts Institute of Technology, holds his MPhil from Oxford University, and both the SM and MD degrees from Harvard.