Speed, Spectrum, and Satisfaction: Assessment of an Infectious Diseases eConsult Program

Abstract

This report examines the implementation and early functioning of a new infectious diseases (ID) eConsult program. We recorded the reasons for placing ID eConsults, time to eConsult completion, in-person clinic wait times, and referring provider satisfaction following implementation of our outpatient eConsult program. Our data suggest that this ambulatory eConsult program led to improved access to ID subspecialty care, both via eConsults directly, and by reducing clinic wait times for patients who required an in-person evaluation.

At both the healthcare system level, and for many individual patients, timely access to infectious diseases (ID) experts improves outcomes and lowers healthcare costs [1–3]. However, 80% of US counties, where two-thirds of the population resides, do not have a single ID physician [4]. The lack of access to ID expertise disadvantages the rural population and potentially burdens community providers, many of whom may not feel comfortable managing patients with complex infectious diseases [5]. This shortage is likely to worsen, as 44% of all ID fellowship training programs did not fill their available positions for July 2023. While ID physicians are in increasing demand, fewer trainees are choosing our subspecialty, increasing the divide between demand and access.

One potential solution is to expand telehealth technologies to provide ID subspecialty care. Synchronous video visits can be utilized, but have the disadvantage of needing to be scheduled and reliant on the patient's availability, as well as the need for video hardware and encrypted software technology. Indeed, lack of access to, or knowledge of, the required technology can be a major barrier to video visits. However, electronic consultations (eConsults) can be completed asynchronously, do not require secure communication software, and offer lower-cost subspecialist access compared to in-person or synchronous telemedicine visits.

Essentially, an eConsult is when a referring provider requests the opinion of a subspecialist but there is no face-to-face visit with the patient. Rather, the subspecialist reviews the consult asynchronously, evaluating the consult question and data in the electronic medical record (EMR), including previous provider notes, laboratory values, microbiology results, imaging, pathology, vaccinations, and other pertinent history, then renders an assessment and recommendations in the patient's medical record. The purpose of an eConsult is to answer relatively straightforward questions that can likely be answered only utilizing information provided in the EMR. This strategy is directly provider-to-provider rather than provider-to-patient, and a goal is to eliminate the need for the consultant to perform a full, synchronous history and physical. Some refer to an eConsult as a “written curbside,” as it is not meant to be utilized for complex questions or for patients who would benefit from a more thorough, in-person evaluation. By definition, these should essentially be nonurgent ambulatory issues. There are inpatient eConsult programs, including within our ID division and medical center, but those more urgent and time-dependent consults are not analyzed in this manuscript.

Theoretically, utilization of the eConsult method of subspecialty care can (1) reduce the time to evaluation, (2) reduce travel and inconvenience for the patient, (3) reduce low-yield in-person referrals for simple questions, (4) reduce cost, and (5) reduce “no show” visits that were scheduled in-person. So, eConsults should benefit the patient, the referring provider, and the ID subspecialists and improve access to in-person clinic visits for more complex cases. Previous published eConsult data have shown benefits for management of a myriad of infections, including tuberculosis, Lyme disease, and parasitic infections [6, 7]. This method of subspecialty care could be particularly useful in answering straightforward clinical questions in both rural centers without ID providers and larger centers with more demand for subspecialty opinions than available ambulatory visits.

The Ohio State University Wexner Medical Center is a large academic medical center located in Columbus, Ohio, one of America's fastest-growing cities. The health system manages >62 000 inpatients with >1.86 million ambulatory visits annually. To improve access to our ID subspecialty clinic, our Division of Infectious Diseases began an ambulatory eConsult program in January 2020. The timing of implementation was motivated in part by an increasing lag in time to first visit in the ambulatory ID clinic and requests for improved access to ID expertise.

In this implementation science study, we examined the time to eConsult completion and explored the reasons for which our eConsult service was being utilized. We also assessed satisfaction of referring practitioners with the service provided by conducting an anonymous survey. We hypothesized that an eConsult program would reduce time to subspecialty evaluation compared to traditional in-person evaluation. Furthermore, we hypothesized that referring providers would be satisfied with the timely opinions offered. This program took about 3 months to design, build, and implement, with the main task being the establishment of orders in the EMR and workflow. Subspecialist physicians responding to eConsult requests received work relative value units (RVUs) for the clinical care provided, but other details of the business model are beyond the scope of this article.

METHODS

Our outpatient eConsult service described here was designed to evaluate internal referrals for patients ≥18 years of age. Once an eConsult was ordered via electronic medical record by the referring provider, the request was routed to the ID eConsult Medical Director. As eConsults were reviewed, the “reason for consult” specified by the referring provider as well as the name and specialty of the referring provider were recorded. A fixed list of consult categories was provided and could be checked in the order set for clarity; however, we also allow for an “other” category for unusual conditions that do not fit into the common reasons for consult. For the purposes of this study, each category was recorded, and those in the “other” category were classified according to the free-text background history provided. In designing the program, the goal was to complete every eConsult within 3 business days. Once the eConsult was completed, the time from requisition to completion was recorded in hours. Data were de-identified and recorded in a password-encrypted document for statistical analysis.

All eConsult requests were included consecutively beginning at program inception 1 January 2020 through 31 July 2022. The response to an eConsult could be any of the following: completed, converted, or declined. The completed eConsults are included in the data below. Converted eConsults are considered reasonable questions that are too complex, or in other ways inappropriate, for the asynchronous method and should be seen in-person. Any converted or declined eConsult requests were not included in this data analysis. At the completion of the prespecified inclusion period, all referring providers who requested at least 1 eConsult were invited to partake in an anonymous online satisfaction survey. This survey was designed utilizing a 5-level Likert scale utilizing Research Electronic Data Capture (REDCap) software. The survey and 2 reminders were distributed by email to all referring providers as a function of this software. Descriptive statistics were employed. Approval of the enterprise institutional review board was obtained and all measures were employed to assure patient and provider confidentiality.

RESULTS

In total, the eConsult service completed 488 eConsult requests during the study period. The median time to completion was 20 hours (interquartile range, 3.25–40 hours). Among all eConsults, 24.7% were completed within 3 hours, 60.6% within 24 hours, 83.8% within 48 hours, and 100% within 72 hours. This timing compares quite favorably with the time to first available appointment with an ID physician in our ambulatory clinic, both pre-program and after the implementation of eConsults (see Discussion). While we did not record how much time each eConsult took to complete, our ID consultants did record time spent in review and medical decision-making in their notes, most of which were 10–15 minutes.

Overall, there were 117 separate reasons for eConsult placement (Figure 1). The most common reason was latent tuberculosis infection with 88 consults (18%). This was followed by 48 (10%) for coronavirus disease 2019 (COVID-19) management, 45 (9%) for complicated urinary tract infection, 39 (7%) for syphilis, 23 (5%) for Clostridioides difficile infection, 21 (4%) for hepatitis C, 16 (3%) for cellulitis, 13 (3%) each for human immunodeficiency virus and Lyme disease, 10 (2%) for cytomegalovirus DNAemia, and 9 (2%) each for hepatitis B and osteomyelitis. There were 105 (32%) other reasons for consult, which varied widely in complexity, acuity, and scope.

Figure 1.

Percentage of eConsults received, stratified by reason for eConsult. Abbreviations: CMV, cytomegalovirus; COVID-19, coronavirus disease 2019; HCV, hepatitis C virus; HIV, human immunodeficiency virus; TB, tuberculosis.

Ambulatory eConsults were requested by 300 individual providers representing 24 medical or surgical specialties. Of all 488 eConsults, 270 (55%) were requested by primary care internal medicine/family medicine. Dermatology and rheumatology each requested 29 (6%) and 28 (6%), respectively, while 9 other medical subspecialties requested a combined 52 (11%). Obstetrics and gynecology requested 27 (6%), while 9 other surgical subspecialties requested a combined 44 (9%). Psychiatry and neurology together requested 12 (2%). The referring provider's specialty could not be definitively ascertained for the remaining 26 (5%).

Of the 300 referring providers, there were 58 who either graduated, retired, took leave, changed employers, or had other reasons they were not able to be reached via email to complete the survey. This left 242 providers with whom the anonymous survey was shared. Among these, there were 64 responses (26.4%). Referring providers were only contacted once to complete the survey.

Of the referring providers who completed the survey, 90.6% were satisfied with the process of requesting an eConsult (62.5% strongly agreed, 28.1% agreed), while 3.1% disagreed and 6.3% were undecided. Timeliness of return of eConsult report was satisfactory to 71.4% (47.6% strongly agreed, 23.8% agreed), while 12.7% disagreed, 7.9% strongly disagreed, and 7.9% were undecided. Some 67.2% felt the eConsult process was more efficient than an in-person ID clinic visit (46.9% strongly agreed, 20.3% agreed) while 3.1% disagreed and 26.6% were undecided. The content of the eConsult report was satisfactory to 80.6% (43.5% strongly agreed, 37.1% agreed) while 8.1% disagreed, 1.6% strongly disagreed, and 9.7% were undecided. Overall, 73.4% rated ID eConsults positively, either “very good” (53.1%) or “good” (20.3%), while 10.9% rated eConsults negatively, as “poor” (9.4%) or “very poor” (1.6%). The remaining 15.6% gave ID eConsults a neutral rating.

DISCUSSION

Evaluating the time to completion of eConsults confirms our belief that eConsults reduce time to subspecialty evaluation compared to in-person evaluation. Here we show that majority of eConsults are able to be completed within 24 hours, with one-quarter completed within 3 hours of request—comparable to an inpatient consult. Comparing eConsults to separately collected institutional quality data, the lag time from referral to new outpatient initial visit went from a pre-pandemic 84 days in September 2019 to 12 days in September 2020. The cause of this improvement was certainly multifactorial and was not solely due to the implementation of our eConsult program, but it seems likely to be a significant contributor as those patients with lower-complexity diagnoses and more straightforward questions were no longer being referred for in-person ambulatory visits.

Regarding reasons for consult, we observed similar rates of utilization for such diagnosis as latent tuberculosis and syphilis as in other studies [7, 8]. As opined by Wood et al, these conditions require specialized ID knowledge but generally do not require a physical examination, and would be the optimal scenario for eConsult [9]. Besides these, the 105 other reasons for consult that could not be categorized reflects the broad array of clinical issues for which an ID specialist can be useful. Perhaps reflective of our patient population, we observed several eConsults for chronic viral hepatitis, particularly from obstetricians. Probably reflective of the epidemiology of parasitic infections and the geography of being located in Ohio, we observed few eConsults for parasitic infections and more eConsults for histoplasmosis compared to other studies [7].

A substantial portion (10%) of eConsults were for management of COVID-19, as our program's inception coincided with the onset of the pandemic. This eConsult program was distinct from several other institutional initiatives which delivered testing, vaccination, and antibody infusions. Even with these other initiatives, one-tenth of our eConsult program's utilization involved COVID-19. Unsurprisingly, the frequency of consults for COVID-19 varied as the pandemic waxed and waned. With the advent of effective immunization, the impact of COVID-19 on our eConsult service in the coming months to years will warrant further examination.

Furthermore, we observe satisfaction with the process of requesting an eConsult, timeliness and content of eConsult report, and efficiency compared to in-person ID clinic visit.

Regarding limitations, we recognize our study describes a single-center experience at a tertiary public academic medical center, and our experience may not be generalizable to neither extremes of geography nor community. Second, our generally positive survey results are based on a response rate of 26.4%. It is plausible to think dissatisfied providers may be more likely to ignore an email survey and satisfied providers more likely to participate, thus introducing selection bias. Of note, it will be interesting to see what role, if any, artificial intelligence may play in eConsults in the future. It is difficult to predict, but this mechanism does currently only function well with human expertise involved. Finally, we do not yet have outcomes data to support the clinical efficacy of such a program. While some survey responses were not entirely positive, we suspect this reflects some cases that were more complex and perhaps inappropriate for the eConsult mechanism, leading to less helpful advice than anticipated. In addition, there was seemingly an expectation from some referring providers that completion of consults would take far less than 3 business days.

A strength of this study is the inclusion of referrals from medical and surgical subspecialties in addition to primary care. Other studies describe the types of ID eConsult received from primary care physicians only [7, 9]; however, 40% of our cohort was referred from medical or surgical subspecialties. Our study would seem to be an accurate reflection of what an outpatient ID eConsult program would likely resemble at large, academic, tertiary care centers, although primary care providers were well-represented.

Regarding lessons learned and advice from the authors, there are certainly some helpful aspects of the program to consider prior to implementation. First, having a sustainable business model is key. This will likely look different for every institution, with some variables being more important than others. For example, Medicaid does not reimburse for eConsults, so a medical center's payor mix can be influential. Also, establishing expectations, such as turnaround time and the appropriateness of follow-up questions, is vital to maximize referring provider satisfaction. Finally, we advise that the ID consultant responding to the request not be reluctant to either convert or decline an eConsult. There are many specific patients and conditions that are best managed with an in-person evaluation and are too complex for the eConsult mechanism. Evaluating patients asynchronously via eConsult is not meant for every condition, particularly when taking further history and performing a physical examination can shed light on the appropriate diagnosis and treatment recommendations.

CONCLUSIONS

Implementing an ambulatory eConsult program led to improved access to ID subspecialty care, both via eConsults directly and likely by reducing clinic wait times. This program was well received by referring providers. If care and consideration are given to potential volumes and staffing needs, as well as compensation via direct billing of patients or RVU credits, an eConsult program is both feasible and potentially beneficial.

Notes

Acknowledgments. J. D. Y. conceived and designed the study and collected the data. K. C. performed statistical analysis. J. H. wrote the initial draft of the manuscript, with revisions performed by J. H. and J. D. Y. All authors have seen and approved the manuscript and contributed significantly to it.

Patient consent. This study was approved by the Institutional Review Board and Office of Responsible Research Practices of The Ohio State University. Written consent was obtained from subjects when appropriate.