Declare the Past, Diagnose the Present, Foretell the Future: Electronic Consultations in Infectious Disease Practice

(See the Brief Report by Strymish et al on pages 1123–5.)

The field of infectious diseases (ID) is ever changing. New challenges arise continually in the form of new pathogens, antimicrobial resistance, and immunocompromising treatments. At the same time, medical delivery systems are undergoing a sea change. Although ID specialists excel at in-person diagnosis and treatment of individuals, the triple aim approach of better health, better care, and lower per capita cost is shining a light on our role in population management as part of healthcare system reform [1]. Informal consultation, whether face to face, by telephone, or by e-mail, has always been a near-daily part of that effort for ID specialists. Such interactions permit the ID specialist to triage whether the question can be simply answered or whether a formal consultation is required to provide the best care, but these interactions tend to be both undocumented and uncompensated despite professional work effort.

Increasingly, ID specialists are being asked to manage both individual patients and population health through the interface of the electronic health record (EHR). The implementation of this tool offers the opportunity to enhance and improve informal ID consultation. In the inpatient setting, telephone consultation has been shown to be inferior to bedside consultation, in the management of Staphylococcus aureus bacteremia, presumably owing to incomplete or incorrect information transfer [2]. Electronic consultations (e-consults), defined as asynchronous, consultative, provider-to-provider communications that occur within the EHR [3], are inherently more patient specific, allowing the specialist access to the data needed to make more informed recommendations that presumably would lead to improved outcomes.

The study by Strymish et al [4] in this issue of Clinical Infectious Diseases examines the impact of e-consults on total outpatient ID consultative services within the Veterans Affairs Boston Healthcare system since their implementation in 2012 as a way to improve access sto specialist care. The Veterans Health Administration is the largest integrated healthcare delivery system in the United States. More than 800 community-based outpatient clinics (CBOCs) facilitate local primary care for the 41% of veterans living in rural communities, yet specialty care is largely located in urban medical centers, creating difficulties with access.

To improve access, the Veterans Health Administration began a national specialty e-consult project in 2011. An observational cohort study found that for primary care patients at one of the CBOCs, e-consults may decrease travel burden and direct travel costs, but this study did not assess patient outcomes [5]. The percentage of patients with CBOC-based primary care receiving e-consults increased from 28.5% to 45.6% during the 3-year study period [5]. Although the current study [4] does not quantify the percentage of e-consults originating from primary care, a larger study encompassing all e-consults in the Veterans Affairs Boston Healthcare system in 2012 and 2013 noted that 37.4% of e-consults originated in primary care [6]. In Ottawa, Canada, an e-consult service was introduced in 2009 to improve access to specialty care; waiting times improved from up to 12 months to <3 days in 75% of cases [7].

In Northern Ireland, wait times for neurology consultations improved from up to 72 weeks to 4 weeks [8]. Similarly, excessive wait times for specialty care at San Francisco General Hospital were improved with introduction of an electronic referral system, decreasing the mean (standard deviation) time to initial consult from 112 (74) days to 49 (27) days (P = .02) within 1 year [9]. The Mayo Clinic instituted e-consults in 2008 with primary care–to–specialist and specialist-to-specialist consultations comprising 74% of the e-consults within clinic walls [10]. They noted that 11.5% of patients had a face-to-face visit within 30 days, and 17.7% within 90 days; fewer conversions were seen for gastroenterology and ID than for other specialties [11]; and conversions to face-to-face consultation occurred primarily at the request of the specialist [12].

Two reviews in recent years have explored the efficacy, population impact, and costs associated with implementation of e-consult services. Liddy et al [13] reviewed 36 studies through August 2014 and found that most were single-specialty services (primarily dermatology) and located in the United States. Although most of the studies cited timely advice from specialists, good medical care, confirmation of diagnoses and educational benefits, no clinical outcomes were reported. Patient experience was generally positive, with specialist response times ranging from 4.6 hours to 3.9 days, 12%–84% avoided specialty referrals, and 78%–93% reported being satisfied [13]. Only 7 studies reported system costs, but outcome measures and settings were too diverse to allow comparability.

Vimalananda et al [3] reviewed 27 studies from 1990 through December 2014, finding that most studies reported on workflow impact, timeliness of specialty input, and/or provider perceptions of e-consults. The literature to date, though providing evidence demonstrating earlier access to specialty expertise and feasibility of establishing programs within systems that have a single EHR, offers sparse data regarding patient outcomes, system cost, and quality of care. This question has been most comprehensively addressed by the group in Canada [14], who showed that their multispecialty e-consult service generated cost savings from the societal perspective; total estimated societal costs were estimated at $207 787, with estimated savings at $246 516, leading to a net societal savings of $38 729 ($11 per e-consult) over a 1-year period (1 April 2014 through 31 March 2015) [14].

To our knowledge the current study [4] is the first in the literature to offer details about ID-specific experience, showing that e-consults increased the volume of outpatient consultations, primarily related to antimicrobial use in bacterial infections and diagnosis and management of latent tuberculosis. In that regard, a 12-month observational prospective analysis of an antimicrobial stewardship “tele-expertise” system in a single hospital in France reported 1386 tele-expertise actions, 87% adherence without clinical bedside evaluation, with 79% prescriber agreement with diagnosis and 87% to therapeutic advice [15]. Recently, an antimicrobial stewardship program using remote EHR access in a long-term acute care hospital led to a significant decrease in antibacterial usage and Clostridium difficile rates, suggesting a potential for expansion into settings with limited local ID resources [16].

“Declare the past, diagnose the present, foretell the future,” a motto attributed to Hippocrates, is an apt description for where ID stands today in the midst of healthcare reform. Although the informal advice offered in the past as “curbside consultation” will surely remain as part of the fabric of day-to-day ID practice, more widespread implementation of EHRs within medical systems provides ID specialists with the opportunity to expand access to our clinical expertise, both by rapid response to simple clinical issues and by opening access for more complex problems in busy clinics, and to establish telehealth-based antimicrobial stewardship programs across those systems. EHRs offer the ability to track e-consults in order to quantify contributions of the ID specialist in a bundled-payment world.

Credit and reimbursement are likely to be more of an issue outside integrated healthcare systems than within them, and the contribution of e-consults to scheduling, workflow and productivity remains to be determined. As hospitals add additional synchronous and asynchronous connectivity technology and EHR communication functionality continues to evolve, physicians will have increasing opportunities to interact, participate in, and document patient care outside conventional bedside and office encounters. Such interactions and technologies will help define the hospitals and healthcare systems of the future, increasing access to expert ID care. The final piece of the puzzle that remains to be determined relates to outcomes: studies are needed that quantify the effects of ID specialty e-consults toward the triple aim goals of better health, better care, and lower per capita cost.

Notes

Potential conflicts of interest. Both authors: No reported conflicts. Both authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.

References

Author notes