The Rapid Rise of e-Consults Across Specialty Care

Electronic consultations (e-consults) are consults wherein a specialist provides guidance in the care of a patient through review and interpretation of available data without the requirement to interact with the patient directly. The VHA is for many reasons an ideal system in which to use this approach. The VHA has a well-developed, integrated electronic health record, which allows a clinician at one site to review care received by the veteran in any VA facility across the country. The patients we serve often live long distances from specialist locations. For frailer patients who may live geographically close, trips into the facility may still be difficult. The VHA can institute e-consults without the need to be concerned with billing or payment issues, which would impact private sector and fee-for-service systems.

In the past 6 months, 3 reports on the use of e-consults within the VHA have been published in Federal Practitioner, including “A Medical Specialty e-Consult Program in a VA Health Care System,” published in May 2014 by Matthew McAdams, MA; Lynne Cannavo, RN, MSN; and myself.^1-3 At the recent Society of General Internal Medicine 37th Annual Meeting (April 2014), VA leadership noted that over half a million e-consults have been completed in the VHA nationally in the past few years. In our own facility, the number of specialties and subspecialties that now provide e-consults has extended beyond medical specialties to include all surgical specialties, anesthesia, neurology, psychiatry, pharmacy, and more. Currently, there are 45 individual e-consult options at the VA Boston Healthcare System.

E-consults can improve the timeliness of care because of relatively rapid specialist responses to consult questions. By providing e-consults for patients who do not require a face-to-face visit, we can improve access to specialty clinics for those who do. Costs may also go down, for even if the time commitment of the specialist completing an e-consult is identical to that which would be expended during a live visit, use of the facility, support staff, and travel would all be reduced. Perhaps rapid specialty input could even avoid emergent visits and hospitalization.

We seem to be in a rapid growth phase and exponential use of e-consults. Our task now is to be sure that we use this option in meaningful ways. We need to identify those circumstances where e-consults are optimal and those in which they may not provide benefit. We can explore new applications, such as that proposed by Vasudevan and colleagues, who have suggested that proactive chart advice for high-risk patients with diabetes may be helpful, even after the initial consult is completed.² Because “roads make traffic,” we want to be sure that the ease of e-consults does not result in large numbers of unnecessary or trivial consults that usurp specialist time and result in a net decrease in access.

All signs suggest that e-consults are here to stay within the VHA. E-consults are also gaining traction outside the VHA, with colleagues at the University of California, San Francisco, and Mayo Clinic in Rochester, Minnesota, publishing their experiences. There are many more questions that can be asked. New processes of care always raise new and challenging problems. I am sure that collectively, we will be up for the challenge of diffusing this promising technology in appropriate ways.