The use of electronic (e-) consultation in nephrology has the potential to have a positive impact on patient care. This benefit can come in a variety of forms. First, the nephrologist will be able to make recommendations for a greater number of patients in a much larger geographic area. Second, the use of e-consultation could encourage more efficient patient triage to allow sicker (or more urgent) patients to be seen more quickly. What do primary care physicians (PCPs) think about e-consultation? Do they think it adds value? Do nephrologists value e-consultation? These are the questions asked in a recent AJKD Research Letter by Mendu et al.
Mendu and colleagues recently implemented e-consultation in nephrology at Brigham and Women’s Hospital in Boston, Massachussetts. They conducted a pilot study to examine the impact of e-consultation over the course of 15 months (September 2014 – December 2015). During this time, two nephrologists provided e-consultation for 74 patients, most of whom had chronic kidney disease stages 1 or 2 (see Table 1 from original article, reproduced below). The goal of the study was to try to identify which condition is most suited for e-consultation and whether the referring physicians and nephrologists where satisfied with this type of encounter.
What did they find?
- Turnaround time was fast (~3 hours from consultation to completion)
- Nephrologists requested in-person visit in ~20% of cases
- Most common e-consults involved chronic kidney disease stage 3, medication questions, and abnormal imaging
Did PCPs like e-consults? (66% survey completion)
- 96% stated that the clinical question was answered
- 96% felt that the use of e-consultation was efficient
- 59% would have sought informal advice if e-consult did not exist
- 69% thought patient could be managed without in-person referral
What about the nephrologists? (96% survey completion)
- Thought that 85% of the e-consults reviewed were appropriate for this type of encounter
- Thought that 83% of time, PCPs would have sought informal advice or in-person consult if e-consult did not exist
- 65% thought that patient could be managed without in-person referral.
Overall, Mendu et al. found that e-consults were efficient and well-received by both the PCP and nephrologist. However, the relatively small sample size of 74 patients must be noted. Nonetheless, the use of e-consult could help allow groups to triage patients more efficiently while providing valuable recommendations for those that don’t necessarily need an in-person visit. While the scope of this study was quite limited, it does provide important information as to the initial impression of this type of patient care encounter from the viewpoint of the referring physician and the specialist. I wonder in many instances if the patient is even aware of this behind-the-scenes activity. What does the patient think about e-consultation? This is another question for future investigation. It is clear that with the widespread use of electronic medical records, the use of e-consultation will continue to increase. In a recent systematic review, the largest adopters of e-consultation are the San Francisco General Hospital, the Mayo Clinic, and the Department of Veterans Affairs.
Another unanswered question is “how do we bill for an e consult?” From a quick review of this topic by the Centers for Medicare and Medicaid Services, it is not immediately clear how this will be handled. How will the time and input given to this endeavor be reimbursed by insurance companies? Another unanswered question is about the potential increased risk of malpractice, particularly if the health care professional has never really seen the patient in person. A recent Medscape post discuss this very issue and states that the incidence of such claims are quite low.
The use of e-consultation will likely continue to grow and the data provided here help shed some light on the perceived value of this approach from the viewpoint of both the nephrologist and the PCP. From my position, the use of e-consultation looks promising. But will e-consultation become mainstream?
Matt Sparks, MD
AJKD Blog Advisory Board Member