E-Consults

An efficient virtual channel for provider-to-provider consultation

Opportunity

Primary care providers (PCPs) help patients access a range of specialty services when necessary.

However, traditional methods for obtaining specialist input are suboptimal. PCPs often pursue "curbside consults" with specialists - reaching out via email or phone for advice. This outreach can feel disjointed as the PCP may not have an established relationship with the specialist. Additionally, specialists don't always have all the information they need to weigh-in. When feedback is obtained, it is not accounted for in the electronic health record (EHR) as part of formal patient care.  

Without a standardized and reliable approach to gain specialist input, many patients who could be managed in primary care with specialist input end up getting referred for new patient visits with specialists. Wait times for such appointments can be lengthy due to high demand. 

These obstacles delay treatment for sick patients and burden already busy providers.

Intervention

E-consults streamline communication between PCPs and specialty providers by enabling providers to request specialist feedback through the EHR. PCPs placing E-consult orders are prompted to ask a specific clinical question and detail key background information for the specialist to reference. Specialists are alerted in their In basket when a request comes through, and the entire exchange is captured in the patient’s chart as a telephone encounter.

Impact 

E-consults enable PCPs to quickly obtain specialist input so that timely high-value care can be provided to patients in the appropriate care setting.   

In the initial one-month pilot, E-consults reduced unnecessary specialist visits,  enhanced access for the sickest patients, improved satisfaction among patients and providers, and increased downstream revenue to the health system. With E-consults, the wait time for specialist input dropped dramatically - from a three to six-month wait for an in-person visit to 72 hours, which is the required turnaround time for an E-consult.  

Based on these results and accelerated by the need for virtual care options during the COVID-19 pandemic, E-consults for diabetes, endocrine, cardiology, rheumatology, renal, genetics, sleep, gastroenterology, and other specialties were implemented in early 2020.  Providers at Penn Medicine conducted more than 150 E-consults in the first two months of adoption at scale, and approximately 30 to 40 percent of cases prevented unnecessary specialist visits.

Phase 3: How we work
Collaborators

Matthew Press, MD
Marcie Ordowich, MPH, MBA
Sebastian Haines
Jill Lentz
Jonathan Glick, MD
Aby Mathew

Innovation leads

Nicole Giampapa, PharmD
Katherine Choi, MD
Stacey Hirsh, PhD
Shivan Mehta, MD, MBA, MSHP

Innovation Methods

Fake back end
It is essential to validate feasibility and understand user needs before investing in the design and development of a product or service.
 
A fake back end is a temporary, usually unsustainable, structure that presents as a real service to users but is not fully developed on the back end.
 
Fake back ends can help you answer the questions, "What happens if people use this?" and "Does this move the needle?"
 
As opposed to fake front ends, fake back ends can produce a real outcome for target users on a small scale. For example, suppose you pretend to be the automated back end of a two-way texting service during a pilot. In that case, the user will receive answers from the service, just ones generated by you instead of automation.
Fake back end

In the first iteration of E-consults, we used existing In basket functionality to streamline clinician workflows and simulate a future, chart-based billable encounter flow.

Piloting the first iteration as a fake back end allowed us to test various approaches to templated questions and menu options quickly - without requiring an Epic build. It also revealed provider best practices and enabled us to measure satisfaction and identify key use case scenarios for optimal consults.