Econsultation to Hematologists from Primary Care: An Assessment of Content and Patient Impact

Introduction: National referral rates and wait times to see specialists continue to increase, contributing to the continued rise of health care cost in the United States. Electronic consultations (eConsults) are text-based inquiry responses between providers and consultants that represent a potential means of ameliorating this trend. eConsults have been shown to improve access to specialist care while increasing patient satisfaction and decreasing unnecessary specialist visits. However, there is little research about the impact and content of eConsults within hematology at U.S. academic medical centers. The available research demonstrates that eConsults to hematology can resolve issues without requiring a face-to-face visit, while hematologists report short response times (Khamisa et al, Blood 2015) and satisfaction with eConsult programs (Cecchini et al, Blood 2016). We aim to study the most common topics queried by primary care providers (PCPs) to hematologists via eConsult, and to evaluate the impact of eConsults on patients.

Methods: This retrospective study included eConsults made to benign hematology at a single US based tertiary care academic medical center from December 1, 2015 to June 1, 2018. The patient population included patients established with primary care physicians within the hospital network. For data collection, we modified a template used to analyze eConsultations to gastroenterology developed by the authors (JW, SP) within the same academic medical center. Data review included patient demographics, type of question asked, clinical content, specialist response time, and eConsult outcome.

Results:

Content of eConsults: Overall, 82 different topics were addressed in a total of 350 eConsults. eConsults to hematology were most often placed by attending physicians (54.8%), followed by nurse practitioners (26.3%) and residents (18.9%). Questions asked were most likely concerning diagnosis or further workup of disease (56%), followed by patient management (38.5%) and lab interpretation (7.5%). Question content fell into one of eight general categories, including anticoagulation (22%), anemia (22%) and abnormal lab result (21%) (Figure 1). Specific topics with a high rate of resolution via eConsult included: macrocytic anemia (93%), microcytic anemia (83%), pulmonary embolism anticoagulation (83%), atrial fibrillation anticoagulation (80%), iron deficiency anemia (75%), and Factor V Leiden mutation anticoagulation (73.3%) (Table 2). Topics requiring a face-to-face hematology visit included: abnormal bleeding (100%), polycythemia (75%) and other venous thrombosis (57%).

Patient Impact: The average response time to eConsult was 12 hours, compared to average time between eConsult and in-person hematology visit of 50.21 days. The majority of queries, 63%, were resolved via eConsult alone, avoiding a visit to hematology. The total round trip mileage saved by these eConsults was 18,933.6 miles, with an average of 75.7 miles per person (Table 1, Figure 2).

Discussion: Despite lack of in-person evaluation, eConsultants were able to resolve the majority of cases encountered during the study period. In those cases that resulted in a hematology visit, the eConsultant often recommended the appropriate pre-visit workup by the PCP, improving the initial hematology visit. Further, our results demonstrate that eConsults increase patient access to timely specialty input while reducing unnecessary face-to-face visits. These findings elucidate potential topics for further provider education, as well as support the continued development and refinement of eConsult programs in health systems across the country.

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