Abstract
Objective
To assess whether transferring knowledge from specialists at centres of excellence to referring doctors through online consultations can improve the management of patients requiring specialised care.
Design
Retrospective case review of the first year of internet based patient initiated consultations between referring doctors and consulting specialists.
Setting
US teaching hospitals affiliated with an organisation providing internet based consultations.
Participants
Doctors in various settings around the world engaging in internet based consultations with specialists.
Main outcome measures
New recommendations for treatment, change in diagnosis, and turnaround time for consultation compared with time to see a specialist.
Results
79 consultations took place. 90% (n=71) of consultations were for services related to oncology. 90% of consultations involved new recommendations for treatment. The most common recommendation was a new chemotherapeutic regimen (68%, n=54). Diagnosis changed in 5% (n=4) of cases. The average turnaround time was 6.8 working days compared with an average of 19 working days to see a comparable specialist.
Conclusions
Internet based consultations between specialists at centres of excellence and referring doctors contribute to patient care through recommendations for new treatment and timely access to specialist knowledge. Although change in diagnosis occurred in only a few cases, the prognostic and therapeutic implications for these patients may be profound.
What is already known on this topic
Telemedicine could improve health care by transferring knowledge from centres of excellence to patients' doctors
Few studies have systematically assessed the value of such internet based specialty consultations
What this study adds
Patients can benefit from internet based consultations between their doctor and consulting specialists
New recommendations for treatment were discussed in 90% of cases, and change in diagnosis occurred in 5% of cases
Patients can access a specialist's opinion more quickly than waiting to see a specialist
Introduction
Health care in the United States varies widely by geography.1–3 A key factor in this variability is the doctor's preference for practice.4 In many cases research to guide clinical decision making exists but is not put into practice.5,6
We hypothesised that transferring knowledge through online consultations from specialists at academic medical centres to referring doctors could improve patient care by delivering the most current information. To test this we launched Partners Online Specialty Consultations. This service allows patients around the world to initiate consultations with specialists at centres of excellence. Consultations are conducted through the patient's doctor to maximise the quality of information exchanged. Partners HealthCare is a non-profit making service located in Boston, MA. It was founded by Massachusetts General Hospital and Brigham and Women's Hospital, both affiliated with Harvard Medical School. Partners also has affiliations with other organisations, including the Dana-Farber Cancer Institute. The service was established to extend the knowledge of over 4000 specialists to doctors and patients around the world. We chose the internet to deliver the consultations because of its widespread and growing use by patients and their relatives.7
We believe that our model is unique among telemedicine applications. Although telemedicine is used for both clinical and educational purposes, traditionally programs comprise models that are based on geography, population, or specialty.8–12 One barrier to the development and implementation of telemedicine programs is the limited dissemination of quantitative outcomes.12 We review the first year of Partners Online Specialty Consultations.
Methods
Before a consultation can take place the patient must register on the Partners Online Specialty Consultations website (econsults.partners.org) and confirm that his or her doctor practices in a state or country that is serviced by Partners Online Specialty Consultations. Some states are excluded because of statutory limitations, and certain countries are excluded because of restrictions on commerce imposed by the US government.
A menu shows the costs of services offered (table 1). The price of consultations is comparable to similar services in a hospital or clinic setting. Patients may enter details of their credit card when they initiate a consultation or when their record is complete and ready for review. Patients are made aware that the service is unlikely to be reimbursed by insurance.
Table 1.
Costs of services
| Service
|
Fee ($)
|
|---|---|
| Specialist opinion | 350 |
| Assessment of imaging studies | 225 |
| Assessment of pathological images | 225 |
| Specialist opinion, assessment of pathological images and imaging studies | 600 |
| Special staining of tissue samples, additional services | Individual assessment |
$1 (£0.61; €0.93).
A letter is generated by the website for the patient to give to his or her doctor. The letter asks the referring doctor to provide relevant medical information. Before entering information on a patient, the referring doctor must agree to certain terms and conditions. The website contains a sample patient consent form, outlining security measures and privacy.
The referring doctor enters the patient's history, physical examination details, and any specific questions. He or she may upload pathology images and imaging studies relevant to the patient. Hard copies, slides, or tissue blocks may be posted. A coordinator for Partners Online Specialty Consultations collects the materials and credit card details before triaging the case. The referring doctor may request a specific consulting specialist, or the coordinator will work with a team of doctors to triage the case. When the consultation is complete the referring doctor is notified by email that the details are available on the website. The referring doctor may telephone the consulting specialist to discuss the case.
Review of case record
The first year of internet based consultations (30 June 2001 to 1 July 2002) were reviewed to identify treatment recommendations made by the consulting specialist that either were not mentioned by the referring doctor or were mentioned as an uncertain approach. Recommendations contingent on the results of further testing, disease progression, or patient preference were included. Drugs were included if a specific name was given or if the drug could be readily identified.
Consultations were also reviewed to identify changes in diagnosis, as determined by the consulting specialist. IK and HBB independently reviewed the cases. Discrepancies were resolved by JCK. Reviewers were blinded to each other's decision.
Turnaround time, follow up, and storage of data
The turnaround time for a consultation was the time between collection of relevant materials, including payment, and completion of the consultation. The number of working days was averaged to determine the turnaround time.
In 2002 we conducted a telephone survey of a total of 12 specialists and outpatient specialty clinics affiliated with the Dana-Farber Cancer Institute, as well as the practice manager of the cancer centre at the Massachusetts General Hospital, to determine the average lead time to see a specialist. Practices were asked when the next non-urgent appointment was available. We specifically selected oncologists because 90% of consultations had been for services related to this specialty.
We searched our databases to see if any patients had registered at a Partners institution after their online consultation. If a patient was identified, we contacted the consulting specialist to determine if the patient had been seen.
All electronic correspondence is stamped according to time and stored in a relational database. A relational database stores data in tables that have common values, allowing the tables to relate to one another. Electronic images are maintained in the format and size they are sent and stored on a storage device (Data Mover; EMC; Hopkinton, MA). Hard copies of imaging studies that are not requested back by patients or referring doctors are kept in long term storage.
Results
During the first year of service there were 21 243 unique visitors to the Partners Online Specialty Consultations' website. By 1 July 2002, 954 patients, 376 referring doctors, and 427 consulting specialists had registered. Overall, 79 consultations were conducted online. A variety of services were provided in these consultations (table 2). Change in diagnosis occurred in 5% (n=4) of cases. These changes resulted from a review of the pathology images (see table A on bmj.com). New treatment was recommended in 90% (n=71) of cases, the most common being a new chemotherapeutic regimen (68%, n=54; table 3) The mean time from collection of materials to completion of the consultation was 6.8 (SD 7.2) working days whereas the mean time to see a Partners's oncologist for a non-urgent appointment was 19.0 (SD 10.4) working days (P=0.001 by unpaired two tailed t test).
Table 2.
Service provided
| Service
|
No (%)
|
|---|---|
| Specialist opinion | 37 (47) |
| Specialist opinion, assessment of imaging studies, assessment of pathological images | 16 (20) |
| Specialist opinion, assessment of imaging studies | 14 (18) |
| Specialist opinion, assessment of pathological images | 11 (14) |
| Assessment of pathological images | 1 (1) |
Table 3.
Recommendations for new treatment in 79 online consultations
| Recommendation
|
No (%)
|
|---|---|
| New chemotherapeutic regimen | 54 (68) |
| New medical regimen (non-chemotherapeutic) | 19 (24) |
| Surgery | 13 (16) |
| Radiation | 11 (14) |
| Stop drug | 3 (4) |
| Change dose | 2 (3) |
| Other* | 5 (6) |
Several recommendations may have been made for one patient.
Includes chemoembolisation, cyroablation, radiofrequency ablation, bone marrow transplant, and physiotherapy.
Overall, 53% (n=42) of patients were men and 47% (37) were women. The mean age of patients was 51 (SD 17; range 9 to 80) years. Patients were from several continents, with over half from North America (see table B on bmj.com). There was no predominance of consultations from any one state in the United States. Most consultations were for oncology related services (table 4). One patient registered at a Partners institution after the date of consultation. This patient was seen in clinic by the specialist who consulted on his case through Partners Online Specialty Consultations.
Table 4.
Specialty mix of 79 online consultations
| Specialty
|
No (%) of cases
|
|---|---|
| Oncology | 71 (90) |
| Neurology | 2 (3) |
| Orthopaedics | 1 (1) |
| Ophthalmology | 1 (1) |
| Surgery | 1 (1) |
| Cardiology | 1 (1) |
| Neurosurgery | 1 (1) |
| Nephrology | 1 (1) |
Discussion
Internet based specialist consultations contribute to patient care through change in diagnosis, new recommendations for treatment, and timely access to specialist knowledge. Follow up of patients using the Partners Online Specialty Consultations website for consultations remained local, with only one patient registering with a Partners's institution after the consultation.
A previous study of internet based specialist consultations found that new recommendations for treatment were made in 71% of cases, similar to our findings. The study evaluated 150 randomly selected online consultations through WorldCare International, a profit making organisation that has contracts with several academic medical centres, including Partners (N Lugn, personal communication, 2002). Another study reported the benefits of a second opinion on pathology review provided by a large referral hospital.13 Change in diagnosis occurred in 1.4% (86 of 6 171) of cases. The criteria for change in diagnosis included a major change in prognosis or therapy. The authors noted that although the number of cases was not high, the potential implications for patients and cost of care were profound.
Most of the consultations with Partners Online Specialty Consultations were for oncology related services. Patients with cancer may represent early adopters of the service who, faced with a life threatening illness, are most willing to embrace an unconventional approach to seeking medical knowledge.
The number of consultations was small compared with the number of visitors. The website and its service were not heavily publicised. Factors that may have contributed to non-submission of a consultation include severity of illness, cost of the consultation, and openness to the internet as a vehicle to obtain a consultation with a physician.
Limitations
Our study had several limitations. The consulting specialist's recommendations were assumed to reflect the most current medical knowledge but were not evaluated for this. Also, some recommendations may be attributable to the consulting specialists feeling compelled to add something to the patient's care because of their role as consultants. Moreover, the definition of new recommendations for treatment was broad, inclusive of recommendations contingent on various factors. We did not measure the implementation of the recommendations and their effect on clinical outcomes, steps important for assessing improvements in quality of care. Another limitation of our study was the relatively small sample size.
Although we compared the waiting time for an office visit with the turnaround time for an online consultation, the comparison is inexact as services rendered and the patient experience will be different in these encounters. The comparison illustrates that Partners Online Specialty Consultations provides patients with an alternative way to navigate the healthcare system. As a result, patients may get the opinion of a specialist quicker than if they waited to see a specialist.
Implications
Online consultations between consulting specialists and referring doctors are one approach to decreasing the geographical variability of care, by transferring up to date clinical knowledge from centres of excellence to doctors around the world. Partners Online Specialty Consultations does, however, have several hurdles to overcome before its service can be more widely adopted. Most consumers are still not aware that they may access specialist knowledge online. Moreover, many may be unable to pay directly for a consultation. Insurance coverage for telemedicine is minimal in the United States at present, but growing.14,15 The receptivity of physicians to online consultations is another challenge, but seems to be growing as electronic imaging systems and electronic medical records increasingly become part of routine patient care.
Supplementary Material
Acknowledgments
We thank John Glaser for his continued support of the program and Eric Menn for his editorial support.
Footnotes
Funding: Partners HealthCare's information system's research and development budget.
Competing interests: All authors are either employed by or have a consulting arrangement with Partners HealthCare. Partners gains revenue from online consultations.
Details of the website's properties, change in diagnosis, and geographical source of referral appear on bmj.com
References
- 1.O'Connor GT, Quinton HB, Traven ND, Ramunno LD, Dodds AT, Marciniak TA, et al. Geographic variation in the treatment of acute myocardial infarction: the cooperative cardiovascular project. JAMA. 1999;281:627–633. doi: 10.1001/jama.281.7.627. [DOI] [PubMed] [Google Scholar]
- 2.Birkmeyer JD, Sharp SM, Finlayson SR, Fisher ES, Wennberg JE. Variation profiles of common surgical procedures. Surgery. 1998;124:917–923. [PubMed] [Google Scholar]
- 3.Wrobel JS, Mayfield JA, Reiber GE. Geographic variation of lower-extremity major amputation in individuals with and without diabetes in the medicare population. Diabetes Care. 2001;24:860–864. doi: 10.2337/diacare.24.5.860. [DOI] [PubMed] [Google Scholar]
- 4.Wennberg JE, Cooper MM, editors. The Dartmouth atlas of health care 1998. Chicago: American Hospital Publishing; 1998. [PubMed] [Google Scholar]
- 5. California HealthCare Foundation. Variations in medical practice. The quality initiative. Jan 2000. www.chcf.org/documents/quality/variations.pdf (accessed 1 Sept, 2002.)
- 6.Hunt DL. Overcoming the evidence-to-application gap in clinical practice [editorial] Evidence-based Cardiovasc Med. 2001;5:34–35. doi: 10.1054/ebcm.2001.0364. [DOI] [PubMed] [Google Scholar]
- 7. Fox S, Rainie L. Vital decisions: how internet users decide what information to trust when they or their loved ones are sick. Pew Internet & American Life Project. 22 Mar 2002. www.pewinternet.org/reports/toc.asp?Report=59 (accessed 1 Sept, 2002.)
- 8.McNeill KM, Weinstein RS, Holcomb MJ. Arizona telemedicine program: implementing a statewide health care network. J Am Med Inform Assoc. 1998;5:441–447. doi: 10.1136/jamia.1998.0050441. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Krupinski EA, McNeill K, Ovitt TW, Alden S, Holcomb M. Patterns of use and satisfaction with a university-based teleradiology system. J Digit Imaging. 1999;12:166–167. doi: 10.1007/BF03168790. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Vassallo DJ, Hoque F, Farquharson Roberts M, Patterson V, Swinfen P, Swinfen R. An evaluation of the first year's experience with a low-cost telemedicine link in Bangladesh. J Telemed Telecare. 2001;7:125–138. doi: 10.1258/1357633011936273. [DOI] [PubMed] [Google Scholar]
- 11.Person DA. Pacific Island Health Care Project: early experiences with a web-based consultation and referral network. Pacific Health Dialog. 2000;7:29–35. [PubMed] [Google Scholar]
- 12.Shannon G, Nesbitt T, Bakalar R, Kratochwill E, Kvedar J, Vargas L. Organizational models of telemedicine and regional telemedicine networks. Telemed J e-Health. 2002;8:61–70. doi: 10.1089/15305620252933400. [DOI] [PubMed] [Google Scholar]
- 13.Kronz JD. Mandatory second opinion surgical pathology at a large referral hospital. Cancer. 1999;86:2426–2435. [PubMed] [Google Scholar]
- 14. US Department of Health and Human Services, Health Resources and Services Administration, Office of the Advancement of Telehealth. 2001 Telemedicine Report to Congress. Jan 2001. telehealth.hrsa.gov/pubs/report2001/main.htm (accessed 1 Sept, 2002.)
- 15.Simon V. Insurance coverage of telemedicine grows, but payments subject to limits. Physician Compensation Rep. 2002;3:1–3. [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.