Overview

An academic medical center demonstrated that eConsults for infectious disease (ID) can more efficiently provide primary care doctors with counsel on antimicrobials, recommended clinical evaluation, and treatment indications, while also reducing call volume to an internal telephone consultation service.

Organization Name

University of Washington

Organization Type

• Academic Medical Center

National/Policy Context

• Specialist consultation in the U.S. faces many challenges, including geographic isolation, overwhelmed referral systems, and in the case of “curbside consults,” medicolegal risks. 
  • Other challenges include scheduling issues, logistical barriers for patients (i.e., travel time), and back-ups in busy specialist clinics. 
  • To mitigate, primary care providers (PCPs) might informally contact specialists by phone or email (i.e., “curbside consult”) for advice. However, this practice is problematic because: 
    • Specialist counsel is based on limited clinical information
    • Often the patient is unaware of this consultation and the consult isn’t documented in the electronic medical record (EMR)
    • Patients, specialists, and PCPs are not billed accordingly
• Previous research demonstrates the benefit of Electronic Consults (eConsults) in the EMR via:
  • Reduced referral wait times
  • Increased care capacity
  • Decreased care costs
  • Enhanced professional satisfaction amongst PCPs
    • Strengthened relationships with specialists
    • Increased clinical knowledge 
• In 2014, national medical organizations including the Association of American Medical Colleges (AAMC) and Center for Medicare and Medicaid Innovation (CMMI), created the Coordinating Optimal Referral Experiences (CORE) program,  which enables asynchronous communication between PCPs and specialists via the EMR. Academic medical centers opted into the CORE program. 

Local/Organizational Context

• Due to their involvement in the CORE program, UW established eConsult programs in many specialties. 
  • Infectious Disease (ID) was not the first specialty for which eConsults were launched at UW, but it was the first eConsult program at UW to undergo a quality improvement  (QI) analysis.

Patient Population Served and Payor Information

• The ID eConsult program was offered at comprehensive medical centers within the UW system as well as at local neighborhood clinics, which serve patients of all insurance status.

Leadership

• The leadership was composed of clinical and technical project managers, who focused on recruiting specialists, leading template design, and educating PCPs about the eConsult process (including onboarding and expectations).

Funding

• CMMI grant supported implementation of eConsults.

Research + Planning

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Tools or Products Developed

• The UW team modeled their eConsult program on a UCSF program. Key elements of the program included:
  • PCPs opt to use eConsults
  • PCPs and specialists are compensated by relative value units (RVUs)
    • All payors reimburse for eConsults
  • Continuous quality assurance via review of PCP questions and specialist responses to improve use of eConsults and clinical education

Training

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Tech Involved

• Electronic medical record

Team Members Involved

• Physicians
• Quality Improvement Director
• Support Staff

Workflow Steps

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Budget Details

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Where We Are

• The other specialties that previously implemented eConsults are now determining ways to further refine their processes via QI.
• The ID team is looking qualitatively at the perspectives of PCPs and specialists on eConsult utility, barriers to use, suggestions for improvement.

Outcomes

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Future Outcomes

• The innovators suggest that further research consider changes to referral wait times and care costs.
• The team is developing ways to offer the ID eConsult program to PCPs outside the UW system (users do not need to be EPIC users to benefit from this service).

Benefits

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Unique Challenges

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Sources

• Wood BR, Bender JA, Jackson S, et al. Electronic consults for infectious diseases in a United States multisite academic health system. Open Forum Infect Dis. 2020;7(4). doi: 10.1093/ofid/ofaa101
• Deeds SA, Dowdell KJ, Chew LD, Ackerman SL. Implementing an Opt-in eConsult Program at Seven Academic Medical Centers: a Qualitative Analysis of Primary Care Provider Experiences. J Gen Intern Med. 2019;34(8):1427-1433. doi:10.1007/s11606-019-05067-7
• Brian Wood, personal communication, June 23, 2020.