Original Research
A Medical Specialty e-Consult Program in a VA Health Care System
Utilization, satisfaction, and perceived benefits differed among primary care providers and specialists in this study of e-Consults across the VA...
Although the VA has the largest health care system in the U.S., not every VA facility offers medical subspecialty care. As a result, patients are often separated by long distances from services they need.
At the VA Pittsburgh Healthcare System (VAPHS) in Pennsylvania, about 15,700 veterans received care in 2011. The Gastroenterology Department (GD) served many of these patients: 5,800 patients were seen in clinic appointments, 2,500 underwent colonoscopy, and 1,700 underwent esophagogastroduodenoscopy (EGD). Patients traveled up to 150 miles from 3 states for appointments and procedures. Prior to each procedure, a face-to-face appointment was standard practice for most patients to plan procedures and ensure medical stability. Patients expressed dissatisfaction with transportation, cost, time, and inconvenience, particularly when they were required to attend both the preprocedure and procedure appointments.
Patient satisfaction, timely care, and appropriate use of resources are important VA goals of care, so the VAPHS developed an electronic consultation (e-consult) program as a component of its long-term strategic plan. The goal was to increase access to care through the use of an e-consult in lieu of a face-to-face appointment for select patients. The e-consult program established guidelines and benchmark goals (Table). The program also established a database to track the benchmarks.
The purpose of this quality improvement (QI) project was to evaluate e-consults in the GD over a 6-month period from January 2012, when e-consults were implemented in the GD, to July 2012. Based on the outcomes, recommendations for program continuation, change, and sustainability were made.
Background
Telemedicine using information technologies has been reported as a viable solution to support health care delivery when distance limits patients’ access to care.1,2 Telemedicine has also been shown to improve efficacy in clinical decision making and reduce costs. It also can increase patient satisfaction by reducing travel and time, minimize duplication of diagnostic testing, and integrate services effectively across multiple sites when an electronic medical record (EMR) is in place.1-5
A randomized controlled trial in 2004 compared a standard outpatient referral appointment with a joint teleconsultation between provider, specialist, and patient.3 In the teleconsultation arm, there was higher patient satisfaction, fewer diagnostic tests (particularly in gastroenterology), and lower patient costs.
A study published in 2009 examined the impact of cardiac, dermatologic, and diabetes teleconsultations on organization and patient outcomes in 950 patients in 30 rural communities.2 Rapid access to care was provided for 85% of the patients. Organizational benefits included resource savings and efficacy improvement measured by a provider opinion Likert scale. Patient benefits included reductions in wait times, transportation savings, avoidance of unnecessary office visits, and ease of use.
A large systematic review of telemedicine services across all medical specialties in 2006 included 106 published studies.4 Clinical outcomes (decision making, diagnosis, and management) were similar between conventional care and telemedicine in specialty care, particularly in neurology and psychiatry. Virtual consults provided equal care to traditional specialty visits.6
Communication and coordination of care via an e-consult instead of a face-to-face clinic visit was evaluated by Horner and colleagues.5 The authors identified e-consult benefits for patients and specialists and that e-consults can reduce unnecessary referrals and appointments by 30%. They concluded that reserved time to complete e-consults must be built into workflow systems and that an advanced EMR was necessary for successful use of e-consults.
Two studies have evaluated satisfaction with e-consults. A preliminary analysis of satisfaction with e-consults was conducted in 2009 by K. L. Rodriguez, PhD, and colleagues (unpublished data). Patients, primary care providers (PCPs), and medical specialists reported overall satisfaction in 8 satisfaction domains. A pilot study of 34 patients in 2011 with inflammatory bowel disease compared a standard patient-GD physician encounter with a video encounter.7 The authors reported patient satisfaction, appointment time, wait times, and quality of care were similar for the 2 groups.
Methods
The GD where this QI project was completed consisted of a clinic staffed by nurse practitioners (NPs) and a procedure lab staffed by gastroenterology physicians. Before e-consult implementation, a NP reviewed and triaged new referrals daily. During the project period, an average of 25 to 35 new referrals were received daily via the EMR. Referrals came mostly from PCPs requesting an evaluation of their patients’ gastroenterology problem. Patients were triaged either to an appointment for evaluation or directly to the GD procedure lab for EGD or colonoscopy.
When e-consults were implemented, several changes occurred. Two providers were assigned to new referral triage, and they were expected to process 20% as e-consults. In the EMR, e-consult note titles, templates, and an e-consult encounter form were created, and staff was given access to the e-consult tracking database. The EMR referral template was amended so the entering provider could say whether a face-to-face appointment was desired or whether an e-consult was acceptable. The patient was to be included in decision making about this choice. Department staff had permission to triage according to judgment and expertise; thus, appointment requests could be triaged to e-consults, and e-consult requests could be triaged to appointments.