Utility, Appropriateness, and Content of Electronic Consultations Across Medical Subspecialties.

BACKGROUND: Electronic consultations (e-consults) can facilitate patient access to specialists, minimize travel, and reduce unnecessary in-person visits. However, metrics to enable study of e-consults and their effect on processes and patient care are lacking. OBJECTIVE: To assess novel metrics of e-consult appropriateness and utility. DESIGN: Retrospective cohort study. SETTING: Primary and specialty care practices at 2 large academic and 2 community hospitals of an integrated health system. PARTICIPANTS: Patients with e-consult requests to 5 specialties-hematology, infectious disease, dermatology, rheumatology, and psychiatry-between October 2017 and November 2018. MEASUREMENTS: The appropriateness of e-consult inquiries was assessed by review of medical records and defined as meeting the following 4 criteria: not answerable by reviewing evidence-based summary sources ("point-of-care resource test"), not merely requesting logistic information, having appropriate clinical urgency, and having appropriate patient complexity. Interrater agreement in assessments of e-consult appropriateness was assessed by the κ statistic. Utility of e-consults was assessed by the rate of avoided visits (AVs), defined by the absence of an in-person visit to the same specialty within 120 days. RESULTS: Overall, 6512 eligible e-consults were made by 1096 referring providers to 121 specialist consultants. Inquiries were characterized as diagnostic, therapeutic, for provider education, or at the request of the patient. Most consultations were answered within 1 day, with variation across specialties (73.1% for psychiatry to 87.8% for infectious disease). Overall, 70.2% of e-consults met all 4 criteria for appropriateness; the frequency of unmet criteria varied among specialties. Raters agreed on the appropriateness of 94% of e-consults (κ = 0.57 [95% CI, 0.36 to 0.79]), indicating moderate agreement. The overall rate of AVs across the 5 specialties was 81.2%; the highest rate was in psychiatry (92.6%) and the lowest in dermatology (61.9%). LIMITATION: Generalizability is unknown outside a single integrated health system, where requesting and consulting providers share a common electronic health record. CONCLUSION: Novel metrics to assess the appropriateness and utility of e-consults provide meaningful insight into practice, provide a rubric for comparison in future studies in additional settings, and suggest areas to improve resource use and patient care. PRIMARY FUNDING SOURCE: None.

A Pooled Electronic Consultation Program to Improve Access to Genetics Specialists.

Innovative service delivery models are needed to increase access to genetics specialists. Electronic consultation (e-Consult) programs can connect clinicians with specialists. At Massachusetts General Hospital, an e-Consult service was created to address genomics-related questions. In its first year, the e-Consult service triaged 153 requests and completed 122 in an average of 3.2 days. Of the 95 e-Consults with actionable recommendations, there was documentation that most ordering clinicians followed through (82%). A variety of providers used the service, although the majority (77%) were generalists. E-Consult models should be considered as one way to increase access to genetics care.

Asynchronous telehealth visits for the treatment of overactive bladder.

OBJECTIVE: Overactive bladder affects 17% of women, and adherence to treatment is notoriously low. The objective of this pilot study is to investigate the efficacy and feasibility of the use of asynchronous telehealth visits for the treatment of women with overactive bladder. METHODS: This is a pilot study of women who participated in the asynchronous telehealth program with a new diagnosis of overactive bladder presenting to the Massachusetts General Hospital from January of 2020 to March of 2021. Pre-post differences in Urogenital Distress Inventory score-6, and Incontinence Severity Index Scores were compared with paired t tests as coprimary endpoints. To assess potential mechanisms of association between asynchronous visits and patient-reported outcomes, total fluid intake, caffeinated beverage consumption, urinary frequency, episodes of urinary leakage were also compared as secondary endpoints. RESULTS: A total of 23 women participated, with 50 e-visits completed. The first asynchronous visit was completed after a median of 42days (IQR 36, 51.5) from the initial visit. There was a decrease in the Urogenital Distress Inventory-6 score between the first asynchronous visit and the last (29 points, IQR 16, 37 vs 12 points, IQR 12, 25), respectively (P = 0.014). Similar findings were seen with the Incontinence Severity Index questionnaire, from three (IQR 2, 4) to three (IQR 1, 3) after the asynchronous visit (P = 0.002). CONCLUSION: We demonstrate the feasibility of asynchronous visits for the treatment of overactive bladder. Although our results suggest efficacy, given the prepost change in overactive bladder-related questionnaire scores following asynchronous visits, the comparative effectiveness of asynchronous visits versus regular care needs to be confirmed in a randomized trial.

Video Summary:http://links.lww.com/MENO/A917 .

Electronic Consultations in Allergy/Immunology.

BACKGROUND: Allergic condition management more often requires allergist guidance than allergy testing; necessary testing may be unavailable at initial drug allergy consultations. Electronic consultations (e-consults) provide expedited, problem-focused, potentially cost-saving care in other medical specialties, but have not yet been studied in Allergy/Immunology. OBJECTIVE: To describe e-consult use at an academic allergy/immunology practice. METHODS: E-consult data (August 10, 2016 through July 31, 2018) and in-person consult data (August 1, 2014 through July 31, 2018) were reviewed to determine consult volume, outcomes, indications, and timing. Referral reasons and wait times were compared with chi-square tests. RESULTS: E-consults grew from 1% to 10% of all new consults, with concurrent growth in in-person consults. Of 306 completed e-consults, 41 (13.4%) made diagnostic, therapeutic, or alternative referral recommendations, with 30 (73%) recommendations followed; 183 (59.8%) patients required an in-person Allergy/Immunology consult, and only 5 (<2%) patients saw an allergist without an e-consult recommendation to do so. E-consults were used more often than in-person consults for adverse drug reactions (66% vs 9%; P < .001), especially penicillin allergy (132, 61% of all e-consults) and immunodeficiency (15% vs 2%; P < .001). Allergists completed e-consults in a median of 11 minutes, with a median turnaround time of 22 hours. E-consult implementation was associated with a decreased median in-person consult wait time (1.5 fewer calendar days; P < .05). CONCLUSIONS: E-consults were increasingly used, particularly for historical adverse drug reactions and immunodeficiency. Implementation of an e-consult program resulted in decreased in-person wait times despite an increase in overall consult volume, supporting this model's ability to provide expedited, problem-focused care.