E-Consults: Increasing the Efficiency and Efficacy of the Referral Process

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One useful piece of innovation that can more effectively enhance a clinical setting is the use of E-consults, which has shown an increase in satisfaction by both patients and clinicians alike.

As clinicians continue to strive for more innovative ways to “take back their practices,” one method that proved remarkably successful in the San Francisco Health Network was the advent of E-consulting.

In “How E-Consults Can Improve Care and Reduce Unnecessary Referrals,” Elizabeth J. Murphy, MD, DPhil. of the UCSF- SF General Hospital, San Francisco, Calif., explains how and why e-consulting makes such good sense. “For a cognitive specialty like endocrinology, e-consulting provides a lot of advantages,” she says. “It’s much more efficient for certain cases and questions because you do not necessarily have to see the patient in person.”

First, this saves the patient a visit to see the clinician, which in itself can be extremely burdensome for some patients, who may not have readily available transportation, for example, or who may not feel up to going out, or who may not be able to miss work, or for any number of other reasons. Second, this saves the endocrinologist’s practice all the work and expense that goes along with having a full visit. “Instead, you can provide advice directly to the practitioner taking care of the patient,” Murphy says, “and, often you can avoid unnecessary testing by giving the referring provider some quick advice.”

Another clear advantage is that e-consulting, as opposed to on-the-fly advising, formalizes the process, so everything that takes place is documented in the patient’s medical record.

Although e-consulting cannot preclude all in-person visits, it has already provided advantages even if a visit should become necessary. “If the patient does eventually come to you, they’ll have had a better workup at that point, so the visits with you are much more effective, useful, and high-yield—they’re just much more efficient,” Murphy explains. “You have the data you need, so you can talk to the patient and do the parts of the exam you need.”

To show how these benefits work in practice, Murphy provided some examples. Say a patient has a thyroid-stimulating hormone level of 7, which is borderline elevated. This is something that might typically stay in primary care, but an inexperienced provider could reach out to an endocrinologist to get some initial guidance. “I look at the labs and see that this is subclinical hyperthyroidism,” Murphy says, “and I tell the provider, ‘this is what I would recommend, and this is what I would ask the patient. Then get back to me when you have that information.’ They see the patient and follow-up with me, and I say, ‘start this treatment. Let me know later if you have questions or if this, this, or this happens’.”

Virtual Co-Management

Sometimes the e-consult is just a quick question, like, “I got this weird lab result, does it mean anything?” Or, “My patient has hyperthyroidism, so I ordered these 10 tests.” Murphy says that she can intervene and save time and money by striking unnecessary testing from the list.

“If the patient does eventually come to you, they’ll have had a better workup at that point, so the visits with you are much more effective, useful, and high-yield—they’re just much more efficient. You have the data you need, so you can talk to the patient and do the parts of the exam you need.” – Elizabeth J. Murphy, MD, DPhil. of the UCSF- SF General Hospital, San Francisco, Calif.

In these scenarios, the specialist does not see the patient, and, in this way, it is different from co-management. “The specialist does this, the primary care provider can do that, and you keep going back and forth,” Murphy says, “but everything is in the primary care provider’s hands. It’s more like virtual co-management.”

But, again, if the patient ultimately does need the visit to the endocrinologist, they have already had the workup and possibly even tried an initial therapy, so the endocrinologist already has loads of information to work with. “We’ve skipped several visits and have an informed starting point,” Murphy says. “As opposed to, in the older days, you’d get a referral and the patient wouldn’t even know why they’re there. And, in the record, the referring provider has written only, ‘referred to endocrine’, which is not very helpful.” In this way, e-consulting eliminates a lot of the guesswork.

Sharing the Success

E-consulting began for Murphy in 2007 within the San Francisco Health Network that was then directed by Mitchell H. Katz. “We were one of the first systems to do e-consulting in a widespread way,” she says. “We’re all UCSF faculty, but we operate through the Department of Public Health in San Francisco.” On the success of San Francisco’s e-consulting program, Katz went on to implement similar systems in Los Angeles County and currently in the New York State Department of Public Health.

Although each system will have its own particular functionality, the key to its usefulness is making sure that the referring provider and the specialist have access to the same electronic medical record data, and the e-consult is very well integrated into the platform. Third-party vendors like RubiconMD also make e-consulting possible, although this is a more limited means.

In the San Francisco Health Network, referrals can only happen through e-consulting, which makes it different from some other systems. According to Murphy, this prevents a lot of mistakes. Patients might get referred to the wrong specialty, for example, and, without e-consulting, a wasted visit would have transpired. With e-consulting, on the other hand, a physician screens the referral and can redirect as necessary. Or, a patient might come to a primary care provider with a disease they read about online that turns out to be made up, like “adrenal fatigue.” “You can give them a link, such as from the Endocrine Society that has documents for providers about what is and what isn’t an accepted medical diagnosis.”

“I also discourage endocrinologists from taking the ‘here’s $10 to help your colleagues out’ bait. There should be no endocrine consult that is so easy that it’s only valued at $10. If you do it for $10, that becomes the norm. Advocate for yourself.” – Elizabeth J. Murphy, MD, DPhil. of the UCSF- SF General Hospital, San Francisco, Calif.

There’s an incidental advantage here as well — reduced traffic in specialty clinics means faster care for those who need it. “Of the patients referred to us,” said Murphy, “we do not see half of them in clinic. The patients are happier, because it saves them unnecessary visits. The primary care providers are happier because they have quick access to specialists that otherwise would mean a two- to three-month wait. This way, in three days, you have at least an initial answer to your question because the clinics are less clogged up. The patients who are sick and need to see you get in sooner.”

Despite being in the public health system, Murphy says wait times in their clinics are better than what they can be in the private insurance sector. “Almost all of our clinics have wait times of less than two weeks for a new patient appointment. We’ve screened out the inappropriate referrals, and we’ve dealt with straightforward things that we can do by the e-consult. When the patients come to the clinic, they’ve had the appropriate workup, so I don’t need two or three visits to get the workup done — they come with the workup done.”

Getting Remunerated

E-consulting sounds like a no-brainer, because it is. One aspect, though, that is critical to its success is getting adequately compensated for doing it. Some systems expect clinicians to do email consulting for free or for an inadequate sum, and this is a dangerous precedent, according to Murphy. “Endocrinologists have to say no to that because if you do things for free, people will expect you to continue to do them for free. I also discourage endocrinologists from taking the ‘here’s $10 to help your colleagues out’ bait. There should be no endocrine consult that is so easy that it’s only valued at $10. If you do it for $10, that becomes the norm. Advocate for yourself.”

Murphy says this was a key message she hoped to convey in her talk, that is, teaching people how to advocate for adequate compensation for e-consulting. “Cognitive specialties in particular are undercompensated because there’s no special relative value unit for thinking, which is what cognitive specialties do — we think about numbers, but we don’t do anything to anyone.”

Because the healthcare system as a whole stands to reap huge savings from e-consulting, reimbursement codes are now available. As e-consulting continues to demonstrate value, reimbursement will only increase.

Horvath is a freelance writer based in Baltimore, Md. She wrote about new obesity research from ENDO 2019 in the October issue.

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