Enhancing the e-Consult: Empowering Efficient and Collaborative Care

Am J Manag Care. 2023;29(12):648-649. https://doi.org/10.37765/ajmc.2023.89465

In this issue of The American Journal of Managed Care, authors report on the results of a qualitative study describing the perspectives of both primary and specialty care clinicians on the quality of e-consults. Not surprisingly, both parties had common and divergent opinions on what makes a well-constructed e-consult. In the opening narrative, the authors describe the characteristics of e-consults upon which both primary care and specialty providers agree, at least in spirit; both primary and specialty care clinicians agree that focused questions accompanied by sufficient information within the electronic health record represented the basis for a well-crafted e-consult. However, how best this is practically applied across thousands of clinicians is likely the crux of the issue. In exploratory probes, the authors highlight 3 major subthemes to explain the difference between optimal and actual e-consult requests. The first highlights structural issues with the e-consult interface. The lack of structure was noted as a source of frustration for common reasons. Primary care providers noted that the open-ended nature did not help facilitate provider understanding of whether the question is appropriate, and specialists could thus lack sufficient information or not understand the essence of the question when responding. This lack of structure may also contribute to the second perception that e-consults do not provide sufficient productivity credit. Additionally, there was general concern from both primary care and specialist clinicians about the transfer of responsibilities and workload to each other. Finally, the range of knowledge across primary care clinicians was noted to be an issue for specialists. Specialty providers felt that some primary care providers may not know relatively basic information about a condition, whereas primary care providers noted that specialists may take their knowledge for granted.

What this study did not provide was the prevalence of suboptimal e-consults or whether the referenced concepts were suboptimal from the patient perspective. In addition, although the study was based within the US Department of Veterans Affairs (VA), given the breadth of the use of e-consults, the lessons likely extend to many health care systems. Nonetheless, the article highlights areas for additional study and optimization.

The origins of the e-consult were codified from the informal “curbside” consult, during which colleagues would chat directly with each other about issues that could use clarification but may not rise to the need for referral. At that time, many primary care practitioners and specialists were colocated with high potential for interaction. As health systems have pushed primary and specialty care outside hospital settings, clinicians have lost this communication avenue. Within large VA facilities, for example, it is common for community-based outpatient clinics to cover hundreds of square miles. At the same time, few efforts have recognized that informal communication and relationships are equally, if not more, important as structured communication. The focus on access and productivity without attention to human interaction may contribute to untoward effects on workforce interaction that directly affect patient care delivery.

That notwithstanding, the manuscript highlights some of the complexity of improving the e-consult process. To address demand, both primary and specialty care have expanded their workforce with more heterogeneity in training experience. Creating templates that include symptom description and necessary testing for common e-consults may optimize and improve the results on both sides, particularly if they are easy to use in the electronic health record. At the same time, as illustrated in the article, adding structure could have unintended effects of limiting ease of use and creating access barriers, which may be mitigated through national-level agreements with user-centered design. These agreements could include a reasonable expectation for primary care knowledge and actions prior to referral and for specialists to understand their scope in response. This effort would require dedicated effort and represent a “living” engagement that is embodied by high reliability and learning health systems.

There are additional opportunities for this next generation of e-consults. For example, the article continues to highlight that e-consults are provided in the context of recognition and desire for referral. This approach is rooted in historical approaches to specialty care engagement and does not leverage the opportunity for health systems to act on behalf of a population. The use of population health approaches to measure quality and proactively close quality gaps has been demonstrated to be feasible but would require changes in specialty care perspectives on responsibilities. Moreover, current approaches do not fully employ the modern understanding of human behavior and efficiency well. Modern behavioral economics principles could be used by having specialists set up orders on behalf of primary care to approve, modify, or decline. This would conserve the relationship between primary care clinicians and their patients while supporting care delivery by reducing errors that occur when ambiguous recommendations are incorrectly translated into clinical care. This approach could support primary care providers, as they would need only to agree if the suggestions of specialists are viewed as reasonable. Setting up care delivery for primary care’s final approval would also be more acceptable if agreements could be reached on acceptable constraints on e-consult content. Finally, there is an opportunity to leverage integrated health records that include notations, laboratory values, and imaging and apply artificial intelligence to help narrow the ever-expanding amount of information and facilitate decision-making.

In conclusion, the article highlights need for improvement and, in this editorial, we provide some suggestions for this modality of care, as e-consults have been shown to improve care delivery and access to specialty services. We should use this information to iterate the next series of improvement on the process that services the broad needs of patients. 

Author Affiliations: Veterans Health Administration, Department of Veterans Affairs (SRK, DHA), Washington, DC.

Source of Funding: None.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (SRK, DHA); analysis and interpretation of data (DHA); drafting of the manuscript (SRK, DHA); critical revision of the manuscript for important intellectual content (SRK).

Address Correspondence to: Susan R. Kirsh, MD, MPH, Veterans Health Administration, Department of Veterans Affairs, 810 Vermont Ave, Washington, DC 20420. Email: Susan.Kirsh@VA.gov.

REFERENCE

Anderson E, Krones A, Vimalananda VG, et al. Understanding suboptimal e-consult requests: lessons from the VA. Am J Manag Care. 2023;29(12):e378-e385. doi:10.37765/ajmc.2023.89472