Electronic Hematology Consultations at Veterans Affairs (VA) Connecticut: Analysis of Effects on Patient Care, and Provider and Patient Satisfaction

Introduction:

Electronic consultation (e-consult) is a healthcare delivery method in which a consultant provides input on the management of a patient by reviewing the medical chart without a face to face visit. This method is especially suited to systems that use a comprehensive electronic medical record (EMR). E-consults have the potential to improve efficiency and timeliness of care, save costs, prevent unnecessary patient visits, and address shortage of specialists. They may be especially valuable in rural areas, and for patients who have difficulty traveling. Published data regarding the utility and efficacy of remote hematology consultations are limited.

At the VA Connecticut Healthcare System (VACT) electronic hematology consultations were initiated in July of 2011 as part of a national program. Providers are allowed to choose between referring their patient to a face to face visit or an e-consult, based on their clinical judgment and their patients’ preferences. The purpose of this study is to evaluate the impact of electronic hematology consultation on patient care, to measure its effect on the face-to-face encounters at the VACT hematology clinics, and to assess provider and patient satisfaction.

Methods:

We conducted a retrospective review of 300 patients who had a hematology e-consult between the years 2011 to 2013 at VACT. Data abstracted included demographics, diagnoses, timeliness of care, and need for face to face visits. In addition patient and provider satisfaction were evaluated by anonymous surveys. Hematology e-consults were performed by board eligible/certified hematologists based on review of the EMR and peripheral blood smears as appropriate. When necessary, recommendations were made to refer a patient for a face to face evaluation in the hematology clinic. Our study was approved by our local IRB.

Results:

The most common reason for a hematology e-consult was anemia (25%), followed by anticoagulation in patients with venous thromboembolism (14%), thrombocytopenia (8%), erythrocytosis (7%), leukocytosis (6%), paraproteinemia (6%), neutropenia (6%), pancytopenia (2%), abnormal iron indices (2.5%) and abnormal coagulation profiles (2%). Additional reasons included thrombocytosis, macrocytosis, lymphocytosis, eosinophilia, thalassemia, splenomegaly, lymphadenopathy, and hemoglobinopathies. The vast majority of patients were male (95%) with an average age of 63 +16 years. Average distance between the patients’ homes to our medical center was 36.6+22 miles. Electronic hematology consultations were completed on average within 16 days. We observed that implementation of hematology e-consults was accompanied by a 15% decrease in the annual number of face to face hematology visits (from 377 in 2011 to 319 in 2013), while the number of Veterans enrolled at VACT during that period did not change significantly. Only in 42 patients (14%) a face to face hematology consultation was recommended after completion of the e-consult. Of the 50 patients that were sent satisfaction surveys, completion rate was 34% and 65% replied that they preferred an e-consult over a face to face visit. Among 61 providers that received surveys, 15 (25%) responded and 100% indicated that they were “satisfied” or “very satisfied” with the process.

Conclusions:

Our study suggests that electronic hematology consultation can address many common hematology diagnoses and can prevent the need for a face to face visit in the majority of patients selected for an e-consult by their referring providers. These consultations can be provided without compromising patient and provider satisfaction and may decrease the need for face to face visits. This could have important implications for the delivery of hematology care, especially in healthcare systems that utilize an EMR.