What Do Primary Care Providers Really Think About eConsult Systems?

What do primary care providers really think about using electronic consultation (eConsult) systems to confer with specialists?

eConsults are non—face-to-face (F2F) consultations between a primary care provider (PCP) and a specialist. eConsults provide a virtual consultation by the specialist after clinical information sent by the PCP is reviewed and returned with recommendations. The patient may never be seen in person by the specialist.

The American Journal of Managed Care® recently reported on a randomized controlled trial of eConsults for cardiology, which demonstrated that they resulted in reduced total healthcare costs for Medicaid members’ care.¹ Other studies have found the systems improve specialty access, reduce wait times, and decreased F2F consultations.

As with provider frustrations in working with electronic health records (EHRs), however, there is a question whether these new technologies play a role in physician burnout.

To examine that issue, researchers performed a qualitative study of 40 safety-net providers who use the Los Angeles County Department of Health Services (DHS) eConsult system. Of the 40 participants, 27 (68%) were women; 24 (60%) PCPs performed 5 or more eConsults per week.

The study, published in JAMA Internal Medicine, found that primary care providers viewed eConsult as shifting some specialty work to them.² This increase in responsibility was seen by some as a worthwhile inprovement, while others were frustrated. The study shows how delivery transformations can create new perceived barriers to care and resistance to change, even as it improves access to specialists.

eConsult implementation in the county health system elicited a range of positive and negative perceptions among clinicians.

Their perceptions of eConsult clustered around 4 main themes:

• Access and timeliness of specialty care
• Shift of work to PCPs
• Relationships with specialists
• eConsult interface issues

Three areas of conflict surfaced:

• Perceived effect of eConsult on access and timeliness of care delivery
• Acceptability of the shift of responsibility of specialty care to the PCP
• Result for relationships with specialists.

Many providers believed that it improved the timeliness of specialty input and appreciated the opportunity to manage a broader spectrum of care. These providers were particularly enthusiastic about the mission of eConsult. Others believed that eConsult slowed the process of obtaining a referral as the key goal and were frustrated by the need to follow specialists’ electronic suggestions.

The researchers wrote that the results show further work may be needed to address assumptions about the goals of eConsult and the role of PCPs in providing specialty care. For instance, there were different beliefs about eConsult’s outcome on access to care.

Some doctors referred to having their eConsults accepted or approved for a visit, implying that a successful eConsult is one that results in a specialist visit. However, a payer or public healthcare system might view an eConsult that results in a personal visit with a specialist as a failure.

Perceptions of reduced wait times achieved by eConsult may be viewed as an obstruction in cases where a referral was denied.

The shift of responsibility also spurred different reactions, with some doctors feeling empowered and others feeling like they had been reduced to “support staff.”

Doctors also reported being frustrated by information technology, in particular a lack of integration with EHRs.

In an accompanying editorial, the authors wrote that there is “a close link between technological interventions and professional burnout among physicians, and the number of electronic health record functions correlates directly with greater stress and lower physician satisfaction."³

The appeal of eConsults may be outweighed by “patient visit volume, staff support shortages, perceptions about compensation, the excessive burden of administrative and clerical tasks, and institutional culture.”

Using standard referrals to a specialist may be view more positively by a provider with many medically complex patients. Using eConsults, time is increased for the doctor when they have to go through multiple steps, the editorial noted. Improving acceptance of eConsults while addressing provider concerns, and thus avoiding burnout, will involve shedding low-value tasks, looking at reimbursement, and improving usability of the technology.

Reference

1. Anderson D, Villagra V, Coman EN, et al. A cost-effectiveness analysis of cardiology eConsults for Medicaid patients. Am J Manag Care. 2018;24(1):e9-e16

2. Lee MS, Ray KN, Mehrotra A. Primary care practitioners’ perceptions of electronic consult systems. JAMA Intern Med. doi:10.1001/jamainternmed.2018.0738. Published online April 12, 2018.

3. Gleason N, Ackerman S, Shipman SA. eConsult—transforming primary care or exacerbating clinician burnout? JAMA Intern Med. doi:10.1001/jamainternmed.2018.0762. Published online April 12, 2018.