Can a Virtual Benign Hematology Consult Improve Access to and Quality of Care?

A multidisciplinary team of researchers developed a virtual benign hematology consultative service that can potentially reduce the time it takes a specialist to examine patient charts and improve access to care for individuals in remote areas. The researchers published the findings of their pilot program in Blood.

“The idea for this program came from the belief that there was a better way to practice benign hematology,” lead author Ashok Pai, MD, from Kaiser Permanente Oakland Medical Center in California, told ASH Clinical News. “Our goal was to provide high-quality care for patients, more timely service for our colleagues, and develop expertise and capacity within this aspect of hematology.”

The program was designed to leverage a small number of physicians to provide expert consults to a large patient population, the authors explained. In October 2017, a pilot project was initiated at two participating medical centers after receiving buy-in from the departments of adult and family medicine. By March 2018, the program expanded to a total of five medical centers.

Under the project’s protocol, practitioners electronically submitted all non-urgent benign hematology consultation requests through an e-consult portal. The portal’s landing page included evidence-based work-ups for discrete common hematologic conditions that were developed by members of 15 hematology departments.

Evidence-based workups assessed consultation requests for common causes, while urgent health questions and in-patient consults were called in directly to an on-call physician. Through the e-consult service, hematologists reviewed the patient’s chart and provided advice to the primary-care physician or conducted an in-person visit with the patient when deemed appropriate.

One hematology physician from each medical center rotated weekly in triaging consults for other hematologists at his or her respective center. The e-consult program also included other factors to increase efficiency and streamline care, such as prepopulated templates that answered frequently asked questions and use of established order sets for the workup of common hematologic issues. Also, the authors wrote, “this allowed the referring providers to choose the tests they ordered more wisely.”

During the first seven months of the program, practitioners at the participating medical centers submitted a total of 2,013 requests through the e-consult portal. These fell under the categories of “Ask the Specialist” (n=1,107) or a specific diagnosis code (n=906).

Eighty-five percent of the requests submitted under the generic “Ask the Specialist” code were handled electronically, and the remaining were triaged to an in-person consult. Most of the requests resulted in advice, rather than in-person appointments (FIGURE). The most common triaged diagnoses for in-person appointments were thrombocytosis (60.8%), leukopenia (50.0%), and thrombocytopenia (47.6%).

Of those with a designated diagnosis code, the most frequently submitted queries included:

  • abnormal serum protein electrophoresis test results (10.3%)
  • anemia (11.9%)
  • anticoagulation (7.1%)
  • thrombocytopenia (5.1%)
  • leukocytosis (3.6%)
  • thrombocytosis (2.8%)
  • erythrocytosis (2.2%)

Approximately 90 percent of the consultation requests were addressed within 24 hours. Data on the time to completion of an e-consult was available from seven of the participating hematologists; the average time necessary to complete a consult was 14.47 minutes (range = 14.02-14.91 minutes).

“The time needed for hematology expert virtual electronic medical record (EMR) case review and clinical recommendation is likely one-quarter of the time needed for a traditional in-person consultation,” Dr. Pai explained. “With the virtual consultation service, experts’ time can be used more efficiently, and the service can be made available anytime and anywhere.

The authors also surveyed hematologists about their perceptions of the program, with most reporting that the workup algorithms were concise, relevant, and helpful.

Based on the experiences with this pilot program (which still allowed for in-person consultations when desired), Dr. Pai said, “The future of hematology is in virtual, expert-based consultative services available to support patients and frontline physicians everywhere.”

However, he cited limitations of the program, including the single-center experience and the program’s reliance on EMR data accuracy and accessibility. “Work will need to be done so the future EMR are mostly focused on clinical needs,” he concluded.

The authors report no relevant conflicts of interest.

Reference

Pai A, Kotak D, Facher N, et al. Development of a virtual benign hematology consultation service: results of a pilot project involving 5 medical centers. Blood. 2019;133:993-5.

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