e-consult is a mechanism developed by the

Department of Veterans Affairs The United States Department of Veterans Affairs (VA) is a Cabinet-level executive branch department of the federal government charged with providing life-long healthcare services to eligible military veterans at the 170 VA medical centers and ...

that enables

primary care Primary care is the day-to-day healthcare given by a health care provider. Typically this provider acts as the first contact and principal point of continuing care for patients within a healthcare system, and coordinates other specialist care t ...

providers to obtain specialists' inputs into a patient's care treatment without requiring the patient to go to a face-to-face visit. Not to be confused with

eConsult eConsult is a medical app developed by the Hurley Group. In June 2018, the practice announced that it planned to use the eConsult online system for most consultations. This enables patients to submit their symptoms to a GP electronically, an ...

, a medical app used in England.

Overview

E-consult is a web-enabled system and process, where primary care clinicians and specialists are able to communicate, share clinical information and consult electronically to manage patient care. It reduces the specialty referral and appointment process to just a few days, which increases the speed delivery for patient care services.

Process

* Step 1 – PCP asks patient to agree to an e-consult * Step 2 – PCP enters an e-consult request with a defined clinical question * Step 3 – Specialist reviews chart and answers the clinical question * Step 4 – The PCP communicates the specialist's recommendations to the patient and formulates a care plan with the patient

Implementation

Closed health systems with existing

electronic health record An electronic health record (EHR) is the systematized collection of patient and population electronically stored health information in a digital format. These records can be shared across different health care settings. Records are shared throu ...

(EHR) can incorporate e-consult services into the system, making start-up cost minimal. Open health systems must create a secured website portal to utilize e-consult service due to discrepancy in their respective EHR systems.

Cost and benefit analysis

Mayo Clinic The Mayo Clinic () is a nonprofit American academic medical center focused on integrated health care, education, and research. It employs over 4,500 physicians and scientists, along with another 58,400 administrative and allied health staff, ...

researchers estimated that their system could avoid 1,800 specialty consultations and subsequently reduce direct costs by $450,000 annually, if each provider orders e-consultations two to three times every month. Patient benefits: * Increased satisfaction * Improved continuity of care * Improved access to specialty care * Improved patient care * Timeliness of results Additionally, Mayo Clinic's e-consult resulted in a shorter time frame of 1 day and 6 hours, compared to 7 days and 20 hours for traditional consultation. In a study at San Francisco General Hospital, 60% of PCPs reported better access for non-urgent issues, and 54% reported shorter wait times for arranging a new appointment with a specialist.

Provider benefits

* Exchange medical skills * Less interrupted workflow * Pre-screen potential in-person visit * Improved track of referrals Due to better transfer of skills from specialists to PCPs, general practitioners for chronic kidney disease in the UK reported more confidence in managing the condition. Also, clinicians reported less interrupted workflow due to asynchronous communication. A specialist survey at Mayo Clinic agreed that e-consult was less disruptive than consultations by telephone or pager by 67%. And at the San Francisco General Hospital there was a reduction of 2.1% in inappropriate specialty referrals by the surgical specialty clinicians compared to 9.8% of paper-based referrals. PCPs also saw improvements in their ability to track referrals by 89%.

Disadvantage

Disadvantage of e-consult is workload shift from specialist or administrative staff to PCPs. Tasks, usually performed by administrative staff such as tracking referral process and correcting errors, are PCP's responsibility in the e-consultation system. Moreover, PCPs are responsible for completing the prior work-up that the specialist requests, whereas such work was done by specialist as necessary in the paper referral system.

Policy implications

Under the

Balanced Budget Act of 1997 The Balanced Budget Act of 1997 () was an omnibus legislative package enacted by the United States Congress, using the budget Reconciliation (U.S. Congress), reconciliation process, and designed to balance the federal budget by 2002. This act wa ...

(BBA), only services provided to rural Health Professional Shortage Areas were eligible for reimbursement. With the changing Medicare requirements, hospitals are beginning to utilize technology to meet Accountable Care Organization (ACO) requirements. The

American Recovery and Reinvestment Act of 2009 The American Recovery and Reinvestment Act of 2009 (ARRA) (), nicknamed the Recovery Act, was a stimulus package enacted by the 111th U.S. Congress and signed into law by President Barack Obama in February 2009. Developed in response to the Gr ...

(ARRA) allocated $417 billion to the

Federal Communications Commission The Federal Communications Commission (FCC) is an independent agency of the United States federal government that regulates communications by radio, television, wire, satellite, and cable across the United States. The FCC maintains jurisdiction ...

(FCC) to implement national broadband networks. Additional grants are available and can be found at the

Health Resources and Services Administration The Health Resources and Services Administration (HRSA) is an agency of the U.S. Department of Health and Human Services located in North Bethesda, Maryland. It is the primary federal agency for improving access to health care services for peop ...

(HRSA). The

Affordable Care Act The Affordable Care Act (ACA), formally known as the Patient Protection and Affordable Care Act and colloquially known as Obamacare, is a landmark U.S. federal statute enacted by the 111th United States Congress and signed into law by Presid ...

(ACA) emphasizes integrated care that provides a value-driven and patient-centered health care. According to Section 3022, an ACO is required to define a process that promotes

evidence-based medicine Evidence-based medicine (EBM) is "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients". The aim of EBM is to integrate the experience of the clinician, the values of t ...

and coordinated care through the use of telehealth and other enabling technologies. Telehealth, such as e-consultation, can facilitate communications between providers and patients, while making ACOs viable.

Department of Veterans Affairs

E-consult was developed by the Office of Specialty Care Transformation, under the

to improve access to specialty care. In the Department of Veterans Affairs system, e-consult requires a multi-departmental collaboration. There is an e-consult lead who coordinates between departments to ensure that e-consult service is implemented correctly and adheres to both facility and national policies. In order for an e-consult program to be active in a specialty clinic, a location name and note title must be created in the VA's EHR system called Computerized Patient Record System (CPRS). The Clinic Maintenance Department creates a location name to ensure that non-billing and workload codes are attached to the location name. Once created, the Clinical Informatics Department takes the newly created clinic name and links it to a newly created Note Title in CPRS. This allows for PCPs to go into the CPRS system and have the ability to select the desired specialty e-consult (location clinic) to send an e-consult request. When a specialist answers the PCPs e-consult request, he or she responds using the Note Title specifically for that specialty clinic. E-consult must be completed or forwarded to an in-person visit within three business days of it being requested.

L.A. Care

L.A. Care, a publicly operated health plan, has increased efforts for the adoption of virtual care to improve patient access to specialty care. Beginning in 2009, L.A. Care engaged SynerMed and Partners in Care Foundation to launch an 18-month e-consult pilot program. It included 1,300 PCPs in 108 community clinics and health centers across

Los Angeles County, California Los Angeles County, officially the County of Los Angeles, and sometimes abbreviated as L.A. County, is the List of the most populous counties in the United States, most populous county in the United States and in the U.S. state of California, ...

. L.A. Care plans to expand the program to an additional 76 sites throughout 2013 to serve close to one million low-income individuals and families. Preliminary results indicated that about half of the e-consults generated a reduction of 24% to 48% of face-to-face visits based on specialty.

Los Angeles Department of Health Services (DHS)

The

Los Angeles County Department of Health Services Los Angeles County Department of Health Services (abbreviated DHS and LADHS) operates the public hospitals and clinics in Los Angeles County, and is the United States' second largest municipal health system, after NYC Health + Hospitals. DHS op ...

is the second largest public health system in the nation and the largest provider of uncompensated care in the county. With the goal of improving the health of county residents through innovation and research, it implemented e-consult across more than 40 ambulatory and primary care clinic sites in June 2012. Currently, e-consult serves safety net patients with the goal of increasing the access to specialty care for

Medi-Cal The California Medical Assistance Program (Medi-Cal or MediCal) is California's Medicaid program serving low-income individuals, including families, seniors, persons with disabilities, children in foster care, pregnant women, and childless adults wi ...

recipients.Katz, M. H. (2012). Fast Facts. Los Angeles County Department of Health Services Outcomes to date * On average, specialists responded to e-consults within 2.6 days (includes non-business days). * 35% of patients on e-consult were managed without face-to-face specialist visits. * In some specialties, there was more than a 50% reduction in wait time for face-to-face visits. * 1,500 + PCPs using the system at 162 sites (43 DHS, 119 community partners).

References

{{reflist Telemedicine