E-Consultations: What Is the Value in Hematologic Care?

Electronic consultation (e-Consult), in which a consultant provides medical recommendations by reviewing a patient’s electronic medical record (EMR), offers an alternative to face-to-face health care – potentially improving the timeliness of care, decreasing costs, preventing unnecessary medical visits, and addressing a shortage of specialists. Though e-Consult has been implemented in the radiology and pathology settings and is being used more broadly in internal medicine, no data have been published regarding the effectiveness of e-Consults in hematology.

In a recent letter to the editor published in Blood, Michael Cecchini, MD, from the Department of Medical Oncology at Yale School of Medicine, and colleagues reported on the use of a hematology e-Consult program in the Veterans Affairs (VA) Connecticut Healthcare System (VACT).

The VACT initiated hematology e-Consults in 2011 as part of a national initiative to improve access to care; in the program, referring providers are given the choice between an e-Consult and a face-to-face clinic visit.

Dr. Cecchini and colleagues analyzed data from patient EMRs collected from 2009 through 2013.

“The majority of referrals to our service come from primary-care clinicians, and guidelines called ‘service agreements’ were developed with the primary-care leadership to help referring clinicians determine which clinical issues were appropriate for each type of consult,” Dr. Cecchini and co-authors wrote.

After referrals were made, hematologists reviewed the EMR, peripheral blood smear, and imaging (when appropriate), and then recommended medical care in the patient’s EMR. The hematologist was able to recommend additional testing and/or a face-to-face visit referral, which the referring clinician would then communicate back to the patient.

The authors noted that VA EMRs are especially comprehensive, including data on problem lists, pharmacy records, laboratory data imaging, and all provider visits, which helped to enhance the results of this study.

The researchers randomly selected 302 e-Consults, 305 face-to-face consults prior to e-Consult implementation, and 302 face-to-face consults after the implementation of e-Consult. The most common reason for consultation was anemia, and the majority of these cases were benign disease or presumed early myelodysplastic syndromes. See TABLE for more on patient characteristics.

E-Consults were converted to face-to-face consults in 17 percent of study cases. Patients who received e-Consults had more timely evaluations and lived further from the clinic than patients who had face-to-face consults (TABLE).

The majority of coagulation-related e-Consults were related to the management of venous thromboembolism, with a few cases attributed to atrial fibrillation and von Willebrand disease.

Dr. Cecchini and co-authors also measured patient and provider satisfaction with e-Consults via anonymous surveys delivered to 50 patients who received e-Consult. Seventeen of those patients responded, with 65 percent noting that they preferred the e-Consult to a face-to-face visit. Sixty-one providers were also sent the survey, and of the 15 who responded, 100 percent reported they were “satisfied” or “very satisfied” with the outcomes of the e-Consult.

“We observed an 18 percent drop in face-to-face consults within two years after the implementation of e-Consult,” Dr. Cecchini and colleagues wrote, dropping from 391 annual face-to-face visits prior to e-Consult implementation to 319 after e-consult implementation. Importantly, the researchers “did not observe any delays in care, missed diagnosis, or other negative clinical outcomes as a result of the e-Consult mechanism.”

However, the number of hematology consults, both face-to-face and e-Consult, increased from 391 in 2010 to 704 in 2013, suggesting that referring providers were more likely to request a hematology consult if it did not require a face-to-face visit. So, while e-Consults are convenient for patients and referring clinicians, the impact of this mechanism on the overall workload of the hematologists in the VACT system is currently unknown, the authors noted.

One limitation of this study is that, in the United States, Medicare, Medicaid, and commercial payers lack reimbursement guidelines for this form of health-care delivery, so it may be difficult to generalize this format to other U.S. health-care systems. In addition, the study was not randomized, making it difficult to determine if patient characteristics contributed to the likelihood of e-Consult referral or recommendations. However, “with the widespread adoption of EMRs and increasing interest in payment reform and cost containment, the e-Consult mechanism may gain traction,” Dr. Cecchini and co-authors wrote.


Reference

Cecchini M, Rose MG, Wong EY, Neparidze N. The implementation of electronic hematology consults at a VA hospital. Blood. 2016. [Epub ahead of print]

TABLE. Clinical Characteristics of Study Participants Based on Trial Implementation
  e-Consults

(n=302)

Face-to-face consults Prior to e-Consult Implementation

(n=305)

Face-to-face consults after e-Consult Implementation

(n=302)

p Value
Median age (years) 64 69.3 65.92 <0.001
Diagnosis
   Anemia 64 (21%) 103 (34%) 63 (21%) <0.001
   Thrombocytopenia 28 (9%) 34 (11%) 38 (13%) 0.419
   Leukocytosis 31 (10%) 19 (6%) 28 (9%) 0.183
   Neutropenia 18 (6%) 11 (4%) 14 (5%) 0.397
   Paraprotein 23 (8%) 26 (9%) 15 (5%) 0.231
   VTE 38 (13%) 17 (6%) 36 (12%) 0.005
Time to completion (days) 13.25 29.36 31.39 <0.001
Distance from clinic (miles) 37.56 33.04 33.77 0.017
VTE = venous thromboembolism

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