Background/Purpose: Recent publications have suggested that implementation of an electronic consultation (E-Consult) system can improve communication between primary care clinicians and subspecialists, reduce wait times, and improve access to care, particularly in safety net hospital systems. Provider-consultant-provider communication through the E-Consult system before any face-to-face interaction is termed a preconsult exchange. Preconsult exchanges can help reduce unnecessary face to face visits, but often require a substantial, potentially uncompensated, time commitment on the part of the reviewer, and have not yet been found to affect the outcome of patients who have been accepted for face-to-face consultation. As a measure of the utility of the preconsult exchange, we conducted a retrospective study to determine whether changes in diagnosis were more likely among those who had electronic exchange compared to those who did not.

Methods: Harbor UCLA is one of the safety-net hospitals of Los Angeles County, serving primarily minority uninsured and Medicaid patients. The hospitals and their community partner clinics provide integrated services for patients, and in order to facilitate subspecialty access, the Department of Health Services adopted an E-Consult system similar to one used at San Francisco General Hospital since 2007. We identified new patients to our clinic who were referred to us via the E-Consult system, then identified those for whom there was preconsult exchange and those for whom there was not. We then conducted a retrospective cohort study of patients accepted for face-to-face evaluation using available data from the E-Consult system and from our electronic medical record. The primary outcome was the odds of diagnosis change after face to face evaluation based on whether a patient had a preconsult exchange or not. Secondary outcomes examined whether a change in diagnosis was associated with a prior diagnosis of a rheumatic condition. Because E-Consult exchanges are asynchronous, obtaining sufficient information to close a consult can often take days to weeks. As an additional measure of this time cost, we compared mean times between consult initiation and face-to-face evaluation.

Results: Between November 2014 and March 2016, 230 patients were seen for face-to-face evaluation for which an E-Consult had been submitted. 68 of these E-Consults were identified as having had an exchange and 162 had not. Odds of a change in diagnosis after face to face consultation were higher for the group who received preconsult exchange but were not statistically significant (Figure 1). Odds of change in diagnosis were no different among those who had a prior rheumatologic diagnosis and also preconsult exchange versus those who did not. Patients for which there was a preconsult exchange were seen a mean 15.5 days later (mean 119.5 days between consult initiation and visit for patients with a preconsult exchange versus 104.1 days for those who did not; se = 11.6 days, p = 0.18).

Conclusion: As E-Consult systems become more widely adopted, particularly among resource limited safety net systems, providers and payers will need clarification on the benefits of preconsult exchange beyond currently available data, which primarily emphasizes improved access but does not address quality or cost (in dollars or in time). Although this study did not meet statistical significance for its endpoints, the results do suggest a trend towards utility of preconsult exchange in sorting patients who need a rheumatologist evaluation, but at a cost of delayed face to face consultation.

« Back to 2016 ACR/ARHP Annual Meeting

ACR Meeting Abstracts - https://acrabstracts.org/abstract/does-preconsult-electronic-exchange-affect-postconsult-diagnosis/