It all just clicks: Development of an inpatient e-consult program
Although the use of electronic consultations (e-consults) in the outpatient setting is commonplace, there is little evidence of their use in the inpatient setting. Often, the only choice hospitalists have is between requesting a time-consuming in-person consultation or requesting an informal, undocumented “curbside” consultation. For a new, remote hospital in our healthcare system, we developed an e-consult protocol that can be used to address simple consultation questions. In the first year of the program, 143 e-consults occurred; the top 5 consultants were infectious disease, hematology, endocrinology, nephrology, and cardiology. Over the first 4 months, no safety issues were identified in chart review audits; to date, no safety issues have been identified through the hospital’s incident reporting system. In surveys, hospitalists were universally pleased with the quality of e-consult recommendations, though only 43% of consultants agreed. With appropriate care for patient selection, e-consults can be used to safely and efficiently provide subspecialty expertise to a remote inpatient site. Journal of Hospital Medicine 2017;12:332-334. © 2017 Society of Hospital Medicine
© 2017 Society of Hospital Medicine
Electronic consultation (e-consult) in the outpatient setting allows subspecialists to provide assessment and recommendations for patients without in-person visits.1 An e-consult is an asynchronous communication that uses the electronic medical record (EMR) and typically involves an electronic order from a requesting provider and an electronic note from a consulting provider. The initial motivation for developing this consultation modality was to improve access to subspecialty care for patients in the primary care setting, and findings of studies at several sites support this claim.1-4 In addition, e-consult may also reduce cost because converting unnecessary face-to-face encounters into e-consults reduces patients’ travel costs and healthcare organizations’ expensive subspecialty clinic time.3,5 Moreover, instead of addressing less complex clinical questions in informal, undocumented face-to-face or telephone “curbside” consultations with specialists, providers can instead ask for e-consults and thereby ensure thorough chart review and proper documentation.6
Use of e-consults in the inpatient setting is relatively novel.7 In addition to having the advantages already mentioned, e-consults are faster than in-person bedside consultations and may be beneficial in the fast-moving inpatient care setting. Finally, healthcare systems with multiple hospital sites may not have the capacity to physically locate subspecialists at each site, which makes e-consults attractive for avoiding unnecessary travel time.
In this article, we describe how we developed an inpatient e-consult protocol for a new, remote hospital within our healthcare system and explore data on safety and physician attitudes after e-consult implementation.
METHODS
The Institutional Review Board of the University of California San Francisco (UCSF) approved this study.
Setting
In February 2015, UCSF opened a new hospital in the Mission Bay neighborhood of San Francisco, 4 miles from the existing hospital. The new hospital is home to several adult inpatient services: urology, otolaryngology, colorectal surgery, obstetrics, and gynecologic surgery. A hospitalist is on-site 24 hours a day to provide consultation for these services around issues that relate to internal medicine. A hospitalist who requires subspecialty expertise to answer a clinical question can request a consultation by in-person visit, video telemedicine, or e-consult, each of which is available 24/7. Almost all of the medicine subspecialists work on the existing campus, not in Mission Bay.
Protocol Development and Implementation
The protocol for the e-consult program was developed over several months by an interdisciplinary group that included 3 hospitalists, 1 obstetrician, 1 project manager, and 1 informaticist. The group outlined the process for requesting and completing an e-consult (Figure), designed a note template for consultants to use for EMR documentation, conducted outreach with subspecialty groups to discuss the protocol, and developed an EMR report to track e-consult use and content over time. As our medical center does not bill payers for inpatient e-consults, e-consult note tracking is used to provide reimbursement internally, from the medical center to the respective departments of the consultants. Reimbursement is made at a set rate per e-consult note, with the rate set to approximate the reimbursement of a low-acuity in-person consult on the main campus.
The workflow of an e-consult is as follows: (1) Whe
