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Electronic consultations (e-consults), also called e-referrals, are an alternative method of obtaining general patient information through the electronic health record (EHR) shared by primary care providers (PCPs) and specialists in the VHA. In the e-consult system, test results, medication lists, and other pertinent data are available.1 Many PCPs are willing to use new technologies to maximize practice efficiency and patient convenience.2 In the VHA’s hub-and-spoke model of care, e-consults have the potential to make delivery of specialty care more efficient by prearranging or completing necessary diagnostic testing and redirecting inappropriate referrals to the correct specialists.1
Some early studies of e-consults report better communication, improved referral appropriateness, and greater access to specialty care as well as better continuity of care and information transfer between patients and PCPs.3-5 Researchers at the VA Boston Healthcare System in Massachusetts found that 61% of specialists surveyed agreed that e-consults improve quality of care and found the approach beneficial to help initiate diagnostic testing prior to a face-to-face visit.6 However, researchers at the Michael E. DeBakey VAMC in Houston, Texas, found no improvement in care coordination.7 To date, there have been no large-scale evaluations of e-consult programs or assessments of implementation of e-consult programs.
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In early 2011, the VHA Office of Specialty Care Services (OSCS), Office of Specialty Care Transformation launched a national e-consult pilot as part of a broader effort to improve the delivery of patient-centered specialty care. This initiative was based on core concepts advanced by the American College of Physicians, which highlighted the importance of specialty care within a patient- centered medical home and provided a framework for collaboration.8,9 The goals of the e-consult program were to improve access to specialty care for veterans and their PCPs, to enhance the collaborative relationship between PCPs and specialists, and to augment PCP education.
The OSCS created an Electronic Consultation Implementation Guide to help sites develop and implement each of their e-consult programs.10 The Implementation Guide established operating rules, strategies for engaging key stakeholders, and recommendations for provider education and training.
As with face-to-face referrals, e-consults are organized in a hub-and-spoke model, where community-based outpatient clinics (CBOCs) are linked to a central VAMC. An e-consult can be accessed by any CBOC, VAMC, medical center-based primary care clinic or specialist, and between medical centers that share the same EHR. There were 217,014 completed e-consults between May 2011 and December 2013 across VHA.11
Some programs created an e-consult template to aid in the transition to electronic referrals (Figure). Although not mandatory, the template helped organize needed information to expedite the e-consult.
The objective of this evaluation is to describe the implementation of e-consults from the perspectives of PCPs, specialists, and other key staff involved in the pilot. Key findings were related to: (1) how the e-consult pilot was implemented; (2) how implementation of the e-consult pilot affected providers; and (3) to what extent the e-consult pilot achieved programmatic objectives from the provider’s perspective.
Methods
The authors conducted a key informant analysis with 2 waves of interviews at 8 e-consult pilot sites across the U.S., selected for variation on early progress in implementation. The sites cannot be identified based on an agreement with the VA Office of Labor-Management Relations.
Setting
The e-consult pilot involved 15 VAMCs in 2 cohorts: alpha sites, which began using e-consults in May 2011, and beta sites, which began using e-consults in July 2011. The alpha sites included 10 VAMCs in 12 medical specialties, with a total of 21 facility-specialty combinations. For the evaluation, sites were defined based on specialty, regardless of location within the same medical center (eg, cardiology and diabetes at the same VAMC would be 2 sites). Beta sites included 5 VAMCs with 6 medical specialties for a total of 6 sites. For 1 year, alpha sites received $175,000 and beta sites received $150,000 to support start-up activities.
Initial specialties included diabetes, hepatitis C, geriatrics, cardiology, liver transplant, dementia, gastrointestinal disease, pulmonary medicine, rheumatology, pain management, neurosurgery, infectious diseases, hematology/oncology, and vascular surgery. Facilities could add additional e-consult specialties but did not receive further funding.
Sample
Study participants were selected from 8 of the 15 pilot sites (geographic site/specialty combinations). Site selection was based on 2 measures of baseline e-consult implementation: (1) overall e-consult implementation rates, measured as the ratio of e-consults to all consults for the specialties of interest; and (2) CBOC participation, measured as the ratio of e-consults for patients from CBOCs vs e-consults for patients from primary care clinics located within the 152 VAMCs. Participation with CBOCs was important for ensuring that implementation factors that influenced uptake of e-consults within tertiary medical centers and between VAMCs and CBOCs could be identified. Two e-consult sites were randomly selected from each of the 4 resulting categories (VAMC high volume, VAMC low volume, CBOC high volume, and CBOC low volume). Volume data of e-consults were obtained from the VA Corporate Data Warehouse and assessed from the beginning of the pilot period to initial site selection, May 2011 to February 2012.