Understanding Suboptimal e-Consult Requests: Lessons From the VA

ABSTRACT

Objectives: Electronic consultations, or e-consults, which are requests for specialist advice without direct patient interaction, are becoming increasingly common across health systems. We sought to identify clinicians’ perspectives on the quality of e-consult requests that they send and receive.

Study Design: A qualitative research study at the US Department of Veterans Affairs (VA) New England Healthcare System.

Methods: We interviewed a total of 73 clinicians, including 38 specialists across 3 specialties (cardiology, neurology, pulmonology) and 35 primary care clinicians (PCCs), between March and June 2019. The interviews were analyzed using thematic analysis.

Results: VA specialists and PCCs generally agreed that e-consult requests should be focused and precise, not require lengthy chart review, and include adequate preliminary workup results. At the same time, specialists expressed frustration with what they perceived as suboptimal e-consult requests. Interviewees attributed this gap to 3 factors: limitations of the electronic health record user interface, divergence between PCCs and specialists in the areas of expertise, and organizational pressures on the 2 groups.

Conclusions: VA clinicians’ perspectives on suboptimal requests contain lessons that are broadly applicable to other health systems that seek to maximize the potential of e-consults to facilitate clinician collaboration and care coordination.

Am J Manag Care. 2023;29(12):e378-e385. https://doi.org/10.37765/ajmc.2023.89472

Takeaway Points

Electronic consultations, or e-consults, provide speedy access to specialist input through direct clinician-clinician interaction without a patient visit. The quality (appropriateness, clarity, and completeness) of the initial e-consult request has implications for the specialist’s ability to provide a useful answer within a reasonable amount of time.

• We found that US Department of Veterans Affairs (VA) primary and specialty care clinicians agreed on features of optimal e-consult requests, yet specialists expressed frustration with the abundance of suboptimal ones.
• We discuss how other health systems can draw on lessons from the VA’s experience in their efforts to address the issue of suboptimal e-consult requests.

Electronic consultations, or e-consults, are a technology for asynchronous clinician-to-clinician communication via an electronic health record (EHR) or stand-alone platform.¹ Typically, a primary care clinician (PCC) initiates an e-consult request, and a specialist clinician provides a written response. e-Consults can ensure timely access to specialist advice and decrease unnecessary face-to-face encounters, thus increasing patient and clinician satisfaction, decreasing costs, and improving quality outcomes.^2-5 Numerous health systems in the United States and abroad have moved to implement e-consults,^1,6 and the use of e-consults expanded during the COVID-19 pandemic^.7

Research shows that an effective consultation is contingent on the clarity and completeness of the request.⁸ The nature and framing of the initial question can affect the direction of the consultation, as determined in one study of traditional referrals in a tertiary care center.⁹ In application to e-consults, Tran et al found that diagnostic questions were more likely to be answered entirely as an e-consult compared with questions about the utility of a face-to-face referral.¹⁰ Bergus et al reported that well-formulated e-consult questions specifying the proposed intervention and the desired outcome were more likely to be answered via e-consult alone than those that did not contain such details.¹¹ However, fewer than 40% of questions were deemed well formulated. Similarly, Ahmed et al found that nearly one-third of the reviewed e-consults did not meet 4 criteria for appropriateness formulated by the study team—namely, they were potentially answerable by reviewing evidence-based summary sources, requested logistic information, had inappropriate clinical urgency, and/or had inappropriate patient complexity.⁵

What is missing from this literature is an empirically grounded yet conceptually rich understanding of the potential reasons for suboptimal e-consult requests. The US Department of Veterans Affairs (VA), the largest integrated health system in the United States and an early adopter of e-consults, offers a unique opportunity to explore issues surrounding e-consults.¹² In this article, we present diverse perspectives from VA clinicians on the quality of e-consult requests they send and receive. We then discuss the implications of our findings for health systems that may want to tackle the issue of suboptimal e-consult requests.

METHODS

Study Design

This article draws on the larger qualitative research study of e-consult implementation in the Veterans Integrated Service Network 1 (VISN 1).^13,14 VISN 1 comprises 8 VA medical centers and more than 40 affiliated community-based outpatient clinics (CBOCs) across New England. We selected 6 VA medical centers with associated CBOCs with different rates of e-consult use. Our team included clinician and nonclinician researchers with backgrounds in health services research, informatics, anthropology, and medicine. The study was approved by the VA Bedford Healthcare System Institutional Review Board.

Participants

E.A. (health services researcher with doctoral-level training in anthropology) conducted semistructured phone interviews from March to June 2019 with 73 clinicians, including 35 frontline PCCs across disciplines and 38 specialists from 3 specialties with a high e-consult volume (cardiology, neurology, and pulmonology). To represent a broad range of practice patterns, we recruited 53 participants from VA medical centers, where specialists and PCCs are generally colocated, and 18 participants from CBOCs, where PCCs practice in relative isolation from specialists. Thirteen participants were in a clinical leadership position at their site. Additionally, we interviewed 2 clinical leaders at the VISN level. See Table 1 for information about participants.

Recruitment and Data Collection

We identified prospective participants using public directories, internal email lists, and snowball sampling. Invitations to participate were sent via email; verbal informed consent was obtained prior to each interview. In interviews with PCCs and specialists, we elicited their personal experiences with and opinions on e-consults. Clinical leaders were asked about current practices and challenges related to e-consult use on the organizational level. In addition to broader exploratory questions about e-consults, we asked participants about characteristics of optimal/appropriate and suboptimal/inappropriate e-consult requests (see eAppendix [available at ajmc.com] for the interview guides). In this article, we report only on participants’ perceptions of e-consult requests; other facets of our findings are described elsewhere.^13,14 The interviews ranged from approximately 16 minutes to 60 minutes in length, with the mean being approximately 34 minutes. Interviews were audio recorded; transcripts were imported into NVivo (QSR International) qualitative data analysis software.

Data Analysis

We followed the principles of thematic analysis to produce a rich description of the range of perspectives in the data set without an a priori theoretical framework.¹⁵ Three authors (E.A., V.G.V., S.T.R.) coded the data set using a codebook that encompassed both deductive codes derived from literature (eg, access, triage, workload credit) and inductive ones derived from the interviews (eg, etiquette). During the coding process, it was decided that participants’ perspectives on features of appropriate/ideal e-consults and reasons for inappropriate/suboptimal e-consults were sufficiently rich to merit separate, in-depth analysis. At this stage, the co–first authors (E.A., A.K.) reviewed pertinent transcript excerpts and generated a preliminary outline of themes. The themes were developed and refined through iterative discussion with the full team.

RESULTS

Our analysis yielded 2 overarching themes regarding optimal vs suboptimal e-consults:

1. PCCs and specialists agreed on general features of an optimal/appropriate e-consult request, yet specialists also reported receiving too many suboptimal requests (ie, questions that were either too basic or too complex).
2. Interviewees pointed to several underlying causes for the discrepancy between the agreed-upon ideal and suboptimal reality of e-consult requests.

These themes are described in detail below, with illustrative quotations provided in Table 2 [part A and part B] and referenced in the text as Q1, Q2, etc.

Theme 1: Appropriate e-Consult Requests: Ideal vs Reality

Participants generally agreed that the best e-consult questions are focused, supported by adequate preliminary workup, and do not require lengthy chart review. One PCC emphasized that straightforward questions enable specialists to answer using existing medical record data (Q1). Another PCC suggested that the quality of specialists’ responses is contingent on a precise question with sufficient clinical history (Q2). A PCC opined that PCCs ought to do “due diligence” prior to submitting e-consult requests (Q3). Specialists agreed, as exemplified by a specialist who provided a model question that was, in the interviewee’s perception, an appropriate e-consult (Q4). These findings were consistent across specialists regardless of discipline and across PCCs regardless of location.

Despite this general agreement on the aspects of optimal e-consult requests, however, specialists felt that e-consult requests are frequently either too basic or too complex for the e-consult medium. These specialists concluded that appropriate e-consults are neither too simple to be addressed by PCCs themselves nor so involved that they warrant exhaustive chart review or direct patient interaction (Q5).

Overly simple questions were often viewed as a nuisance and not an effective use of the specialist’s time, as they could be readily answered by referencing a point-of-care resource or following an established algorithm for care (Q6). This sentiment was expressed by a neurologist who contrasted “generalist” and “subspecialized” questions, describing only the latter as appropriate for either in-person or electronic consults (Q7).

Conversely, many specialists said that e-consults were sometimes used for questions that were inappropriately complex and would be best addressed with an in-person consult. These questions concerned highly complex patients and situations that required a physical exam and/or a conversation with the patient (Q8). Submitting an e-consult on an excessively complex issue was perceived as increasing the workload for both the consultant (who would spend time on chart review in vain) and the requesting clinician (who would later need to submit an in-person appointment request), ultimately delaying patient care.

Theme 2: Explanations for the Discrepancy Between Optimal and Actual e-Consult Requests

Interviewees offered varied explanations for the discrepancy between the agreement on the features of optimal e-consult requests and the quality of actual requests, as presented here.

Subtheme 2a: limitations of the EHR user interface. Some interviewees suggested that the EHR interface itself may result in suboptimal e-consult requests. PCCs mentioned that the e-consult submission process does not generally aid the requesting clinician in determining whether the question is appropriate. One PCC described this concern by saying that the prompt is often very generic and not tailored to the receiving specialty (Q9). Another PCC interviewee similarly called for greater structure in templates (Q10).

Specialists made similar suggestions. A cardiologist proposed introducing a clearly defined, standardized checklist that would allow referring clinicians to determine whether e-consult was the best channel for their question (Q11). However, another specialist pointed out the importance of striking a balance between a complete lack of structure and overly prescriptive templates that may be cumbersome for referring clinicians (Q12). Similarly, a PCC advocated for templates that provide guiding questions to help the sending clinician formulate the request (Q13).

Subtheme 2b: divergence in areas of expertise. Some interviewees invoked the variable areas of expertise between PCCs and specialists to explain the existence of suboptimal e-consult requests. They hypothesized that specialists take certain areas of knowledge for granted due to the nature of their specialized clinical training, not realizing which questions may not be obvious to PCCs who have a more generalized field of expertise (Q14).

Several specialists acknowledged that they may take their established expertise for granted. One neurologist described giving authors of inappropriate e-consults the “benefit of the doubt” in light of different foci of medical training (Q15). According to one cardiologist, specialists themselves occasionally disagree on what PCCs are supposed to know, and e-consults may serve as an opportunity for an educational intervention (Q16). Finally, a neurologist reported including detailed information in the e-consult response on how a problem could be managed within primary care in the future, in the hope that this would ultimately benefit both parties (Q17).

Notably, PCCs did not share the opinion that suboptimal e-consults resulted from differences in knowledge. Indeed, one PCC interviewee challenged this assumption, saying that specialists sometimes assume that the PCC was unaware of guidelines and/or the need for preliminary workup, yet in reality the PCC was unable to provide guideline-concordant care due to patient preferences or other constraints (Q18).

Subtheme 2c: workload pressures and expectations. Finally, interviewees connected suboptimal e-consult requests to workload pressures and expectations affecting PCCs and specialists. Some specialists felt that PCCs unconscientiously used e-consults to shift “ownership” of the case to specialists and alleviate their own workload. For example, a neurologist opined that some PCCs submit e-consult requests because they are unwilling, for unspecified reasons, to address the problem in their own practice (Q19). Other specialists took a more sympathetic approach, gesturing to the pressures of busy primary care settings (Q20).

In fact, both specialists and PCCs felt that e-consults unfairly increased their workload. Specialists were concerned that lengthy chart review and deliberation were difficult to fit into a busy workflow and that the workload credit incurred by the e-consult was inadequate (Q21). Similarly, there were concerns that e-consults may create more work for PCCs in the form of laborious recommended workup (Q22) and that e-consults may inadvertently shift the tasks previously shared with specialists into the PCC domain (Q23).

Several participants advocated for a better alignment of PCC and specialist expectations regarding e-consult use to address this conundrum. One PCC suggested that PCCs and specialists discuss appropriate mutual responsibilities for various e-consult types (Q24). However, a clinical leader indicated that introducing clear guidelines for e-consult questions might be a challenging task because this could threaten clinicians’ perceptions of appropriate division of labor (Q25).

Clinical leaders further suggested that higher-level interventions may be needed to align expectations. One clinical leader called for raising awareness of the fact that the short-term benefits of shifting work onto colleagues may be offset by undesirable system-level consequences, such as unbalanced distribution of the workload (Q26). Another participant suggested that relationship-building initiatives could strengthen collegial communication by reminding the 2 groups of their shared goal: excellent patient care (Q27).

DISCUSSION

In this multisite qualitative study, we sought to understand the perspectives of VA PCCs and specialists on what constitutes an optimal e-consult request.

Our first finding was that PCCs and specialists agreed on the characteristics of an optimal e-consult request (focused, precise, not requiring time-consuming chart review, and incorporating results from preliminary workup), yet specialists frequently perceived initial e-consult requests as inadequate. This finding largely aligns with the conclusions of another VA study of primary and specialty care providers’ perceptions of e-consults.¹⁶ Our contribution to the literature lies in our identification of a constellation of contextual factors contributing to this discrepancy that go beyond the VA setting—namely, limitations of the EHR user interface, divergence in areas of expertise between PCCs and specialists, and workload pressures and expectations. We posit that health systems would do well to identify and address these factors in their own organizational context.

The first factor our participants identified as conducive to suboptimal e-consult requests was the design of the EHR user interface, which was seen as unable to provide adequate guidance for formulating a more precise question and/or deciding whether the question is best answered as an e-consult. In the VA system, the specifics of each e-consult template are left up to individual departments, resulting in a large amount of variation. This misalignment may express itself differently in other organizational contexts. Context-specific details aside, the e-consult interface must support a clear, consistent, well-structured workflow that can be easily completed.

Little has been published specifically on e-consult templates, but literature on referrals suggests that well-designed templates may prompt referring clinicians to include an appropriate amount of clinical detail and may reduce suboptimal referrals.¹⁷ However, when overly restrictive, templates may themselves undermine e-consult request quality. Indeed, a study of computerized consultation order templates in the VA demonstrated that many referral templates fail to support clinicians’ information needs and create cumbersome steps, with negative implications for care efficiency and safety.¹⁸ Therefore, it is important to incorporate clinician input in template creation or redesign efforts.¹⁹

A second factor that our participants saw as contributing to suboptimal e-consult requests was divergent areas of expertise between PCCs and specialists. Specialists have greater exposure to up-to-date expert knowledge in their circumscribed field and easier access to specific tests and treatments. Therefore, it is not surprising that specialists might designate some problems as “simple.”

In spite of this discordance, e-consults can help bridge the knowledge and skill gap in both directions—empowering PCCs to manage a broader set of problems in their own practice in some contexts²⁰ while facilitating comanagement of complex cases by primary and specialty care in others. Indeed, e-consults may enable mutually beneficial exchange between PCCs’ longitudinal, contextual knowledge about patients and specialists’ disease- or organ-specific expertise.²¹ Health systems ought to encourage direct conversations between PCCs and specialists that may enhance shared understanding and commitment to process improvement. For example, PCCs and specialists may form a work group to collaboratively develop standards for e-consult requests as well as delineate roles and responsibilities. The mutual understanding generated through this discussion could then be embedded into e-consult workflows through a variety of tools, from service agreements to referral templates.¹⁷ Although the work group could be temporary, an ongoing quality improvement effort would be beneficial to support both iterative improvements and meaningful relationship-building between clinicians.

Finally, our interviewees highlighted workload pressures and expectations affecting specialists and PCCs. Overburdened by competing demands on their time, PCCs may bristle at the work involved in submitting the e-consult and implementing the specialist’s recommendations.^22,23 Furthermore, in an integrated health system like the VA, organizational and technological structures facilitate task delegation and time pressures incentivize it.²⁴ When division of responsibilities is unclear and time pressures are prominent, qualms about added workload are not surprising. In another study’s apt phrasing, it is important that PCCs and specialists feel that they are “sharing the load” with e-consults rather than left “holding the bag.”²⁵ To optimize e-consult use, health systems must consider implementing process redesign initiatives that would reduce avoidable workload pressures on clinicians (eg, increasing clerical support, promoting team-based care, modifying work schedules).²⁶ Introducing a clearer division of roles and responsibilities around e-consults via iterative discussions between PCCs and specialists to align expectations, as suggested earlier, would also be beneficial.

As e-consults continue to gain ground, clear, productive communication between clinicians is more important than ever. Suboptimal e-consult requests present a challenge to such communication. To address this challenge, one-step solutions are insufficient. Instead, health systems ought to consider the complex and dynamic interplay of multilevel factors, from the specifics of the e-consult platform design to the organizational rules and incentives. Health system leaders may look to existing theories, models, and frameworks in implementation science and organizational studies for ideas on identifying and operationalizing such factors.^27-29 However, how these factors manifest themselves will inevitably be context specific for each organization, and no generic framework may replace an iterative, participatory quality improvement effort.

Limitations

This study has several limitations. The VA’s organizational context has unique features. For example, VA physicians, although compensated for productivity, are paid on a salaried basis, and there is no financial incentive to accept more in-person consults vs e-consults. However, studies from non-VA settings describe similar challenges related to e-consults.³⁰ Furthermore, the factors identified by our participants are not bound by the VA context, and the larger lessons are thus applicable to other organizations. Additionally, we focused on 3 clinical specialties; including other specialties could have yielded additional nuances. We also did not interview patients, nor did we examine actual e-consult requests or use them to prompt interviewees. Future studies should elicit the widest possible range of perspectives from all stakeholders. Finally, this study was conducted prior to the COVID-19 pandemic. Some of the sociotechnical challenges may have become less prominent (eg, improvement in EHR interface in response to the explosion in telehealth use), whereas others have become more aggravated (eg, time pressures on PCCs).

CONCLUSIONS

We found that the e-consult request was a frequent source of contention between senders and receivers of e-consults in the VA, with the reasons for suboptimal e-consult requests attributed to diverse, multilevel factors. Our findings contain broader lessons for other organizations that seek to optimize the use of e-consults as a care delivery tool. We recommend that health systems invest in e-consult platforms that support a clear and well-structured workflow, create opportunities for conversations between primary and specialty care clinicians that would improve mutual understanding and respect, and attend to high-level organizational barriers to effective use of e-consults, such as excessive workload and unclear division of roles and responsibilities in the organization.

Acknowledgments

Ekaterina Anderson, PhD, and Ariella Krones, MD, contributed equally to this work and are listed as co–first authors.

Author Affiliations: Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System (EA, VGV, SLC, STR), Bedford, MA; Division of Health Informatics and Implementation Science, Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School (EA, SLC), Worcester, MA; Section of Pulmonary and Critical Care (AK, STR), Section of Diabetes, Endocrinology, Nutrition, and Weight Management (VGV), and Department of Medicine (JDO), Boston University Chobanian and Avedisian School of Medicine, Boston, MA; Medical Service (JDO, JLS), Section of General Internal Medicine (JDO), and Section of Infectious Diseases (JLS), VA Boston Healthcare System, Boston, MA; Medical Service and Section of Infectious Diseases, Harvard Medical School (JLS), Cambridge, MA.

Source of Funding: This work was supported by the US Department of Veterans Affairs (VA) Health Services Research and Development Service Career Development Award for Dr Rinne (1IK2HX002248) and the Veterans Integrated Service Network 1 Access Initiative Award for Dr Rinne and Dr Vimalananda. This material is the result of work supported with resources and the use of facilities at the Bedford and Boston VA Healthcare Systems. The contents of this article do not represent the views of the VA or the US government.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (EA, AK, VGV, SLC, JDO, JLS, STR); acquisition of data (EA, VGV); analysis and interpretation of data (EA, AK, VGV, SLC, JDO, JLS, STR); drafting of the manuscript (EA, AK, STR); critical revision of the manuscript for important intellectual content (EA, AK, VGV, SLC, JDO, JLS, STR); obtaining funding (VGV, STR); and supervision (STR).

Address Correspondence to: Ekaterina Anderson, PhD, Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, 200 Springs Rd, Bedford, MA 01730. Email: ekaterina.anderson@va.gov.

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