NEW YORK (Reuters Health) – Electronic consult (eConsult) systems are associated with improved access to specialists but also add to primary care physicians’ workloads, leading to variations in PCPs’ enthusiasm for the systems, researchers say.
“The bottom line is that delivery innovations can create new problems (e.g., shift of work to PCPs) as they solve old ones (e.g., poor specialty access),” said Dr. Michael Barnett of Harvard T. H. Chan School of Public Health in Boston.
Safety-net health systems in the U.S. are implementing eConsult systems in which PCPs submit all requests for specialty assistance electronically for review and discussion with specialists, Dr. Barnett and colleagues noted in a report in JAMA Internal Medicine.
To understand PCP perceptions and effects of these eConsults on PCP workflow, specialist access and patient care, the team conducted qualitative interviews with 40 safety-net PCPs exposed to the Los Angeles County Department of Health Services eConsult program, including internists, family physicians, and advanced practice clinicians. Overall, 68% were women; 45% practiced in a hospital setting; 45% had less than five years experience; and 60% performed five or more consults per week.
As reported April 12 online in the journal and in a presentation at the Society of General Internal Medicine meeting in Denver, participants’ perceptions encompassed four main themes: access and timeliness of specialty care, shift of work to PCPs, relationships with specialists, and eConsult interface issues.
Many PCPs liked the improved timeliness of specialist input and the added clinical and educational value of the dialogue with specialists. Additional positive perceptions included “reduces unnecessary visits” and “referrals more meaningful.”
However, they consistently felt that the eConsult shifted some of the work of the specialists onto them (for example, “PCP asked to do more testing and evaluation than PCP thinks appropriate for PCP to do”).
“The PCPs felt that the specialists were blocking them from just accepting patients for a referral,” Dr. Barnett explained. “For example, they might say, “get test A and B first; once those results are back, let’s see what to do.'”
While many PCPs felt the extra burden was worth the effort, others were frustrated by the increased administrative burden, greater clinical responsibility, and restructuring of specialty care delivery. Some also cited “impersonal communication and lack of trust with specialists” as negative factors.
Dr. Leora Horwitz, who directs the Center for Healthcare Innovation and Delivery Science at NYU Langone Health in New York City, told Reuters Health by email, “I feel strongly that eConsults are an effective, efficient and patient-centered means of improving access to specialist input whether in person or electronically.”
“However, this paper surfaces some very important challenges and burdens from the primary care perspective that must be addressed in designing such eConsult systems,” she said.
“I think the technology-related complaints we see in this paper are much more a reflection of a very poorly-designed system than of technophobia among some physicians,” she noted. “Creating a stand-alone separate electronic eConsult system is obviously going to create gross inefficiencies, duplicate work, ineffective communication and burden on PCPs.”
“Moreover,” she said, “not having readily accessible, standardized requirements and protocols prior to specialty referral probably produced much of the frustration of PCPs’ feeling they had to call patients back for preliminary testing prior to acceptance of the referral.”
Dr. Shaun Grannis, Director of Center for Biomedical Informatics at the Regenstrief Institute and Associate Professor of Family Medicine at Indiana University School of Medicine in Indianapolis commented by email, “Potential improvements to clinical workflow notwithstanding, we must also be mindful of unintended consequences when considering broader deployment.”
“Due to a perceived increase in administrative burden, clinicians may not leverage the system as it was intended, which may limit eConsult’s utility,” he noted.
“Consequently,” he said, “to maximize eConsult benefit, we must develop strategies to improve the perceived clinical inefficiencies and reduce the perceived increased care burden imposed by such approaches.”
“Key success factors for successful deployment of these types of systems include ensuring the value of the tools are well understood, and that the users perceive a commitment to continuous improvement of the nascent process,” Dr. Grannis concluded.
Dr. Daniel Barchi, Chief Information Officer at NewYork-Presbyterian in New York City noted, “eConsults force an online dialogue between PCPs and specialists in a way that simple referrals do not. Although the process for use of eConsults could be optimized, coordination of care by both physicians should benefit the patient.”
“Even well developed technology is limited by the skill and engagement of the clinicians that use it,” he said. “Healthcare technology is 80% people, 15% process, and only about 5% technology. (It) works best when it enhances well run processes, not when it replaces the skill and judgment of physicians.”
SOURCE: http://bit.ly/2ETkkLP and http://bit.ly/2EVMupq
JAMA Intern Med 2018.
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