Chelsea Leonard, PhDa; Rachael R. Kenney, MAa; Marcie Lee, MA, MPHa; Preston Greene, PhDb; Melanie Whittington, PhDa,c; Susan Kirsh, MD, MPAd; P. Michael Ho, MD, PhDa; George Sayre, PsyDb; and Joseph Simonetti, MD, MPHe Correspondence: Chelsea.Leonard (chelsea.leonard@va.gov)
Author affiliations
aDenver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Aurora, Colorado bDenver/Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington cDepartment of Clinical Pharmacy at the University of Colorado Anschutz Medical Campus, Aurora dCase Western Reserve University School of Medicine, Cleveland, Ohio; Veteran Affairs Central Office, Washington, DC eDivision of Hospital Medicine, University of Colorado School of Medicine, Aurora
Author disclosures
Dr. Ho is supported by research grants from NHLBI, VA HSR&D, and University of Colorado School of Medicine. He has a research agreement with Bristol-Myers Squibb administered by the University of Colorado. The authors report no other actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.
Ethics and consent
The activities were undertaken in support of a Veterans Health Administration (VHA) operational project and did not constitute research, in whole or in part, in compliance with VHA Handbook 1058.05. Therefore, institutional review board approval was not required.
Funding
This work was funded by the VHA Office of Rural Health and sponsored by the VHA Office of Veterans Access to Care, Department of Veterans Affairs, Washington, DC through a MyVA Access Improvement Project Grant: “VISN 19 VA Denver Developing best practices for subspecialty e‐consultation procedures.”
We conducted 34 interviews with clinicians (Table 1) from 13 VISNs. Four best-practice themes emerged among both PCPs and specialists, including that e-consults (1) are best suited for certain clinical questions and patients; (2) require relevant background information from requesting clinicians and clear recommendations from responding clinicians; (3) are a novel opportunity to provide efficient, transparent care; and (4) may not be fully adopted due to low awareness. Supporting quotations for the following findings are provided in Table 2.
Specific Clinical Questions and Patients
PCPs described specific patients and questions for which they most frequently used e-consults, such as for medication changes (Q1), determining treatment steps (Q2,3), and or clarifying laboratory or imaging findings. PCPs frequently used e-consults for patients who did not require a physical examination or when specialists could make recommendations without seeing patients face-to-face (Q3). An important use of e-consults described by PCPs was for treating conditions they could manage within primary care if additional guidance were available (Q4). Several PCPs and specialists also noted that e-consults were particularly useful for patients who were unable to travel or did not want face-to-face appointments (Q5). Notably, PCPs and specialists mentioned situations for which e-consults were inappropriate, including when a detailed history or physical examination was needed, or if a complex condition was suspected (Q6).
Background Data and Clear Recommendations
Participants described necessary data that should be included in high-quality e-consults. Specialists voiced frustration in time-consuming chart reviews that were often necessary when these data were not provided by the requestor. In some cases, specialists were unable to access necessary EHR data, which delayed responses (Q7). PCPs noted that the most useful responses carefully considered the question, used current patient information to determine treatments, provided clear recommendations, and defined who was responsible for next steps (Q8). PCPs and specialists stated that e-consult templates that required relevant information facilitated high-quality e-consults. Neither wanted to waste the other clinician's time (Q8).
A Novel Opportunity
Many PCPs felt that e-consults improved communication (eg, efficiency, response time), established new communication between clinicians, and reduced patients’ appointment burden (Q10, Q11). Many specialists felt that e-consults improved documentation of communication between clinicians and increased transparency of clinical decisions (Q12). Additionally, many specialists mentioned that e-consults capture previously informal curbside consults, enabling them to receive workload credit (Q13).
Lack of Awareness
Some noted that the biggest barrier to e-consults was not being aware of them generally, or which specialties offer e-consults (Q14). One PCP described e-consults as the best kept secret and found value in sharing the utility of e-consults with colleagues (Q15). All participants, including those who did not frequently use e-consults, felt that e-consults improved the quality of care by providing more timely care or better answers to clinical questions (Q16). Several practitioners also felt that e-consults increased access to specialty care. For example, specialists reported that e-consults enabled them to better manage patient load by using e-consults to answer relatively simple questions, reserving face-to-face consults for more complex patients (Q17).
Discussion
The objective of this study was to identify potential best practices for e-consults that may help increase their quality and use within the VA. We built on prior studies that offered insights on PCP and specialists’ overall satisfaction with e-consult by identifying several themes relevant to the further adoption of e-consults in the VA and elsewhere without a face-to-face visit.8,13,14,16–18 Future work may be beneficial in identifying whether the study themes identified can explain variation in e-consult use or whether addressing these factors might lead to increased or higher quality e-consult use. We are unaware of any qualitative study of comparable scale in a different health care system. Further, this is the first study to assess perspectives on e-consults among those who initiate and respond to them within the same health care system. Perhaps the most important finding from this study is that e-consults are generally viewed favorably, which is a necessary leverage point to increase their adoption within the system.
