Doctors too busy to talk are now using email
Q: What are eConsults, and how do they affect patient care?
A: The kind of thing we have done instinctively in our workplaces for two decades — sending a quick email instead of setting up a meeting — has until recently eluded many doctors.
Electronic consultations, or eConsults (sometimes called eReferrals), are a growing way for primary care doctors and specialists to communicate with each other securely. They can help patients avoid additional visits to specialists and free up capacity in crowded health systems, reducing waiting times for others.
Studies have found that a large proportion of referrals to specialists — upward of 40 percent in some cases — are not needed.
Here is how eConsults work: When a question arises that your primary care doctor cannot answer without advice from a specialist — whether an MRI for knee pain is warranted, for example, or how to interpret a test result — she messages a specialist reviewer for help. That reviewer engages in an electronic dialogue with your doctor to gather information and decide if the issue can be addressed without a separate visit. Often it can be.
Some of the early eConsults adopters were the larger public health systems in the United States, including the Veterans Health Administration.
The first U.S. system to adopt one, in 2005, was the San Francisco Department of Public Health. Wait times fell and a large majority of primary care doctors said it improved care.
"A safety net system can't afford to hire enough specialists to meet demand — eConsults get around that problem by increasing access through enhancing efficiency," said Mitchell Katz, who was director of the San Francisco Department of Public Health when eConsults began there.
The Los Angeles County Department of Health Services, the second-largest public health care system in the nation, began using eConsults in 2012. By 2015, according to a study in Health Affairs, waiting times for specialists had fallen by an average of 17 percent, to 52 days from 63 days. The proportion of appointments scheduled within 30 days rose to 30 percent from 24 percent. A quarter of eConsult engagements between primary care and specialist physicians were resolved with no visit at all.
"Because they're so busy, doctors have a hard time talking to one another," said Michael Barnett, a co-author of the study and an assistant professor of health policy and management at the Harvard T.H. Chan School of Public Health. "EConsults resolve a lot of problems that can be addressed with simple communication."
A systematic review of eConsult systems in the United States — including at Kaiser Permanente and the Mayo Clinic — and abroad yielded similar results, but little evidence so far on improved outcomes.
Electronic consultations are less expensive than in-person visits, but they are not without cost. Someone has to do the work of figuring out how to respond to each inquiry. Some insurers and public programs — though not Medicare — reimburse physicians for eConsults. But patients do not pay for eConsults, whereas in-person visits would typically cost them something, depending on insurance coverage.
That sounds like a great deal. But to the extent eConsults increase the volume of patients seen by the system — as has been found in some studies — they could contribute to rising health care spending. That may be money well spent if they contribute to better health, something that has not yet been documented.
— Austin Frakt, The New York Times