By Annette M. Boyle
BOSTON—VA physicians in facilities across New England increasingly turn to infectious disease specialists at the VA Boston Healthcare System (VABHS) with questions about antibiotic resistance, Lyme disease and other issues, but the rise in demand has not led to more travel or meetings. Instead, the infectious disease (ID) specialists use electronic consultations to respond to questions, a system that has seen rapid adoption in the region.
The e-consults allow providers to tap into the ID department’s expertise without the hassle of coordinating schedules for face-to-face meetings over video or in person—or even arranging a convenient time for a phone call.
The asynchronous consultations permit a provider to ask for a specialist’s input through the integrated electronic health record and receive an answer much more quickly than a patient appointment could be arranged. In many cases, e-consults can occur more quickly and with more complete patient information than possible through even informal conversations or phone calls, particularly for off-site physicians.
According to research published in Clinical Infectious Diseases, the addition of e-consults contributed to a nearly 150% increase in overall consultations between 2011 and 2014 without any drop in face-to-face consults. Before the introduction of e-consults in 2012, the section handled 193 consultations annually. Two years later, there were 195 face-to-face consults and 285 e-consults. The study numbers did not include in-patient consults.1
The “ease of access to a specialist and an answer to a clinical question in a more timely manner than face-to-face visit” drove the sharp increase in consultations, according to lead author Judith Strymish, MD, an infectious disease specialist at the VABHS. In the study, face-to-face (FTF) consults took 16.5 days to arrange, while providers received responses via the e-consult system in a matter of hours (0.6 days).
The number of infectious disease e-consults has continued to rise since 2014, Strymish told U.S. Medicine. “The most-recent data in infectious diseases for the last 12 months, July 2016 through June 2017, showed that we have done 531 e-consults,” she said.
The VABHS infectious disease section responds to consult requests from the health system’s three primary campuses and five community-based outpatient clinics as well as other regional facilities and two adjacent VA healthcare systems. Providers ask for consults for patients in acute inpatient, rehabilitation, skilled nursing, palliative, hospice and specialty care units. All requests come through the VA’s nationwide EHR.
Providers at subacute and long-term care facilities turned to e-consults at four times the rate that they requested in-person consultations and non-VABHS facilities used the consults through the EHR at three times the frequency of FTF consultations.
The e-consults covered different and much a much broader range of issues than FTF consults, too. A third of e-consults addressed antimicrobial use, of which about one-quarter pertained to urinary tract infections. Questions about management of positive urine cultures had not been topics addressed previously in face-to-face consults. Perioperative prophylaxis and nontravel-related immunizations also were new issues for consultation following introduction of e-consults.
The ID section had 50% more consults concerning treatment and prophylaxis of bacterial infection, once e-consults were offered. The requests for consultations about Lyme disease more than quadrupled, as well, with e-consults accounting for nearly all the increase. Strymish said she continues to see significant differences in the kinds of requests she handles via e-consults rather than in a face-to-face setting.
“The need for a clinical decision or action in a timely manner” likely led to the request for e-consults for these topics, Strymish noted. The study’s discussion cited the over two week delay for face-to-face consultations as a reason ID specialists may not have been previously involved in some cases that could have benefitted from their expertise. “This is an important finding to note considering recent research on the increased costs associated with failure to address ID concerns in a timely manner,” the authors said.
The authors also noted that e-consults were preferentially used when patients had mobility issues or faced other barriers to travel. E-consults tapped more frequently into an ID specialist’s specific knowledge rather than evaluation of a patient, as with immunization information.
Some patients had face-to-face consultations, as well as e-consults. In a review of 40% of the 2014 e-consults, the researchers identified only 19 patients (16%) seen in the ID clinic who were also subjects of e-consults. Of those, ID physicians saw two prior to the e-consult. Five were seen both before and after the e-consult, which addressed questions that needed answers between scheduled visits. Twelve patients came to the ID clinic after an e-consults, six at the recommendation of the ID specialist, four at the request of the referring physician and two because the patient wanted to discuss their issue directly with the ID specialist.
Overall, e-consults have emerged as an “efficient clinical tool for accessing specialty care when used in certain conditions, questions or situations,” Strymish said. “In the area of infectious diseases, I see a potential role in appropriate use of antibiotics prescribing and management of some subacute infectious diseases.”
- Strymish J, Gupte G, Afable MK, Gupta K, Kim EJ, Vimalananda V, Simon SR, Orlander JD. Electronic Consultations (E-consults): Advancing Infectious Disease Care in a Large Veterans Affairs Healthcare System. Clin Infect Dis. 2017 Apr 15;64(8):1123-1125. doi: 10.1093/cid/cix058.