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      Electronic consultations (e-consults) to improve access to specialty care: A systematic review and narrative synthesis


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          We define electronic consultations (“e-consults”) as asynchronous, consultative, provider-to-provider communications within a shared electronic health record (EHR) or web-based platform. E-consults are intended to improve access to specialty expertise for patients and providers without the need for a face-to-face visit. Our goal was to systematically review and summarize the literature describing the use and effects of e-consults.


          We searched PubMed, EMBASE, the Cochrane Library, and CINAHL for studies related to e-consults published between 1990 through December 2014. Three reviewers identified empirical studies and system descriptions, including articles on systems that used a shared EHR or web-based platform, connected providers in the same health system, were used for two-way provider communication, and were text-based.


          Our final review included 27 articles. Twenty-two were research studies and five were system descriptions. Eighteen originated from one of three sites with well-developed e-consult programs. Most studies reported on workflow impact, timeliness of specialty input, and/or provider perceptions of e-consults. E-consultations are used in a variety of ways within and across medical centers. They provide timely access to specialty care and are well-received by primary care providers.


          E-consults are feasible in a variety of settings, flexible in their application, and facilitate timely specialty advice. More extensive and rigorous studies are needed to inform the e-consult process and describe its effect on access to specialty visits, cost and clinical outcomes.

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          Utilization, benefits, and impact of an e-consultation service across diverse specialties and primary care providers.

          Access to specialist advice remains a barrier for primary care providers (PCPs) and their patients. Virtual consultations have been used to expedite access. There are few studies demonstrating the utilization and impact of such services. We established a regional e-consultation service that was used across a wide range of specialty services and PCPs. We prospectively collected all e-consultations submitted from April 1, 2011 to June 30, 2012. Utilization data collected included number of e-consultations submitted, specialist response, and time required for the specialist to complete the e-consultation. Perceived benefit to the PCPs and their patients and the impact on care delivery were determined from a close-out survey. Fifty-nine PCPs submitted 406 e-consultations to 16 specialty services. The specialist provided an answer without requesting further information in 89% of cases, with >90% of cases taking 90% of cases. In 43% of submitted cases a traditional referral was originally contemplated but was now avoided. We successfully implemented an e-consultation service across diverse PCPs and specialty services that was highly valued. Almost half of referrals submitted would have required a face-to-face consultation if the service had not been available. Thus e-consultation has tremendous potential for improving access to specialist advice in a much more timely manner than the traditional referral-consultation process.
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            eReferral--a new model for integrated care.

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              Not Perfect, but Better: Primary Care Providers’ Experiences with Electronic Referrals in a Safety Net Health System

              Background Electronic referrals can improve access to subspecialty care in safety net settings. In January 2007, San Francisco General Hospital (SFGH) launched an electronic referral portal that incorporated subspecialist triage, iterative communication with referring providers, and existing electronic health record data to improve access to subspecialty care. Objective We surveyed primary care providers (PCPs) to assess the impact of electronic referrals on workflow and clinical care. Design We administered an 18-item, web-based questionnaire to all 368 PCPs who had the option of referring to SFGH. Measurements We asked participants to rate time spent submitting a referral, guidance of workup, wait times, and change in overall clinical care compared to prior referral methods using 5-point Likert scales. We used multivariate logistic regression to identify variables associated with perceived improvement in overall clinical care. Results Two hundred ninety-eight PCPs (81.0%) from 24 clinics participated. Over half (55.4%) worked at hospital-based clinics, 27.9% at county-funded community clinics, and 17.1% at non-county-funded community clinics. Most (71.9%) reported that electronic referrals had improved overall clinical care. Providers from non-county-funded clinics (AOR 0.40, 95% CI 0.14-0.79) and those who spent ≥6 min submitting an electronic referral (AOR 0.33, 95%CI 0.18-0.61) were significantly less likely than other participants to report that electronic referrals had improved clinical care. Conclusions PCPs felt electronic referrals improved health-care access and quality; those who reported a negative impact on workflow were less likely to agree. While electronic referrals hold promise as a tool to improve clinical care, their impact on workflow should be considered.

                Author and article information

                J Telemed Telecare
                J Telemed Telecare
                Journal of Telemedicine and Telecare
                SAGE Publications (Sage UK: London, England )
                September 2015
                September 2015
                : 21
                : 6
                : 323-330
                [1 ]Center for Healthcare Organization and Implementation Research (CHOIR), US Department of Veterans Affairs, Bedford, Massachusetts, USA
                [2 ]Section of Endocrinology, Diabetes, and Nutrition, Boston University School of Medicine, Boston, Massachusetts, USA
                [3 ]Department of Health Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
                [4 ]VA Boston Healthcare System, Boston, Massachusetts, USA
                [5 ]Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
                [6 ]Division of General Internal Medicine, Brigham and Women’s Hospital, Boston Massachusetts, USA
                [7 ]Harvard Medical School, Massachusetts, USA
                Author notes
                [*]Varsha G Vimalananda, MD, MPH Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial VA Medical Center (152), 200 Springs Road, Bedford, Massachusetts 01730, USA. Email: varsha.vimalananda@ 123456va.gov
                © The Author(s) 2015

                This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 3.0 License ( http://www.creativecommons.org/licenses/by-nc/3.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access page( https://us.sagepub.com/en-us/nam/open-access-at-sage).

                : 26 January 2015
                : 22 March 2015
                RESEARCH/Systematic Review

                remote consultation,teleconsulting,telehealth,telemedicine,e-consults
                remote consultation, teleconsulting, telehealth, telemedicine, e-consults


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