Massachusetts General Hospital (MGH), part of the Harvard School of Medicine and the Partners Health System, is piloting an e-consult system that allows primary care physicians to essentially request a “curbside” within the electronic health record (EHR).
When it comes to those “unnecessary consults” that specialists tend to complain about, it’s often not that the question being posed was inappropriate. Rather, it’s that the question could have been answered without imposing the cost and time burden on the patient of having to physically see the specialist. In cardiology, that’s often the case with things like abnormal EKGs or uncertainty about appropriate stress test modalities.
In those circumstances, a simple “curbside” can be enough. That only works though in settings where specialists and generalists interact relatively frequently, like in the hospital. And then there’s the risks associated with applying recommendations that are not documented anywhere, even when the curbside was done with good intention.
To that end, MGH piloted a system that lets primary care physicians request cardiology e-consults. Basically, the referring physician would pose a patient-specific question to the cardiologist who would answer after reviewing the electronic record. The recommendations could include scheduling a clinic visit, diagnostic testing, or medication adjustments.
In their pilot 6-month period, a total of 78 e-consults were requested. Of these, 48% recommended a noninvasive test like echocardiogram or Holter monitor. In 12% of e-consults, a medication adjustment was recommended. And in 14%, an in-person visit was advised.
Surveys of the referring physicians were particularly striking. Twenty seven of the 62 referring physicians were surveyed – all of them said the system was helpful and they would use it again. Of the 30 patients who were surveyed, nearly all were somewhat or very satisfied with the convenience, experience, and plans formulated through these e-consults.
Importantly, consulting cardiologists were also reimbursed for this service. The amount they were reimbursed isn’t specified but generally described as the estimated cost of their time based on traditional fee-for-service consult reimbursements.
It’s important to recognize, as the authors do, that this pilot represents preliminary data to encourage further development and evaluation. While I can certainly think of anecdotes of patients I’ve seen that would have been well served by an e-consult, I can also think of others for whom that would be a disaster. And there are also some questions about liability worth addressing – if a patient has a bad outcome after an e-consult, will that e-consult at least be considered comparable to the standard of care in a courtroom? For that latter point in particular, more rigorous evaluation is particularly needed.
The safety and efficacy of a platform like this really comes down to applying it to the right population and the right set of clinical questions. And that’s precisely what further studies using the e-consult system can help guide.