Clinician-to-clinician electronic consultation in cardiology is also a digital health technology for cardiovascular care

We read with great interest the manuscript by Whitelaw et al. assessing the barriers and facilitators of the uptake of digital health technology (DHT) in cardiovascular care: a systematic review.¹ They conclude that there are a multitude of barriers and facilitators to the uptake of DHT in cardiovascular care; internet access, user-friendliness, organizational support, workflow efficiency, and data integration with the electronic medical records were reported as important factors for the uptake of DHT by patients and clinicians. We congratulate the authors for their work and agree that the study findings can be used to inform and guide clinicians and stakeholders who develop and implement DHTs that meet the needs of clinicians and patients.

All the experiences included in the analysis describe the results of DHT programmes for communication between patients and health professionals including tele-visits/virtual visits, remote monitoring and management, patient engagement with care activities, and consumer/patient access to clinical data. DHTs tools, which facilitate the share of clinical information between patients and clinicians, improve the patient accessibility to care, enhance the characterization of patients’ health status, improve the personalization of clinical follow-up, and clinical outcomes.^2,3

The Whitelaw manuscript was not included any reference to DHTs aimed to improve the communication between health providers. Clinician-to-clinician electronic consultation programmes (e-Consult) are an emerging health care innovation developed to address excess wait times for specialist care by enabling primary care physicians (PCPs) to obtain a specialist consultant’s expert opinion in a timely manner.⁴ E-consultation is defined by three characteristics: (i) asynchronous communication between two health care professionals, (ii) performance of both the consultation and the response in a secure electronic system and their documentation in the patients’ official medical records, and (iii) the management of a specific clinical problem in the entire medical act.^2,3Figure 1 summarizes a proposal for the implementation of an e-consultation program as the first step for outpatient cardiology care. Our e-Consult activity is made via our integrated electronic health record, which comprises all the patient information from all the levels of care (primary care and hospitals). The e-Consult must contain all the clinically relevant information, and the cardiologist, who sees the e-consultation a few days later, can also check all the additional tests performed in the primary care setting (mainly electrocardiogram, chest x-ray, and blood tests), as well as all the previous relevant information about the patient’s disease. Despite have been described other alternatives for health professional interchange of patient’s clinical information, we think that the models using institutional clinical health records is the more efficient and secure model for perform this type of ambulatory care.

Figure 1.

E-consultation programme in the cardiology department of clinic university hospital of Santiago de compostela, Spain, as the first step for outpatient cardiology care. e-Consult, electronic-consultation; PC-CD: primary care-cardiology department.

Many countries face challenges in accessing specialist advise after a PCPs referral. A recent wait time report in England showed that in the first 7 months of 2017, 89.4% of patients waited up to 18 weeks to see a specialist. This result failed to meet their standard of 92% of patients waiting no more than 18 weeks for their consult.⁵

e-Consult services were shown to be effective in terms of providing faster access to specialist’s advice, with short response times of the participating specialists and resulting in substantial avoidance of face-to-face referral visits. The average/median time for specialists to respond to e-Consult requests sent by PCPs ranged from 1 to 6 days.⁶ Comparing these wait times to those typically experienced with a traditional referral pathway for face-to-face visits with a specialist, e-Consults provide a promising alternative.

Beyond a reduction in the elapsed time to care described in e-Consultation programmes, the implementation of an outpatient care programme that includes e-Consultation has been associated with an improved access to healthcare for all patients and mainly for those furthest from the referral centre.⁷ This model of care is safe since is associated with better outcomes, lower rates of emergency department visits, hospital admissions, and mortality in the first year compared with a face-to-face consultation for all the referrals.⁸ Those patients who quickly needed specialist care were identified much sooner than under the traditional model, and they may have been able to schedule and go to their first cardiology visit sooner.⁹ This may have also improved outcomes, as patients with more critical needs were not only identified sooner, but they may also have actually been treated significantly sooner.

These published results with e-consultation programmes indicate that the implementation of a model with these characteristics would improve the efficiency of the outpatient care process in cardiology. The e-Consult also has utility in the outpatient management after a hospitalization, in selected patients who need to be followed-up because their clinical situation is fragility, or their physicians want to ensure the good evolution or to look out the complications in the first days after hospitalisation.¹⁰

Finally, we recognize some barriers and limitations to the uptake of e-consultation programme in the outpatient cardiology care. Whitelaw et al.¹ summarize some recommendations to increase the uptake of DHTs in cardiovascular care which apply to e-Consult programmes, been the need of the integration with an electronic medical record the most relevant issue for the success of these digital health programmes.