Integrating Telemedicine Into Training: Adding Value to Graduate Medical Education Through Electronic Consultations.

L ack of timely access to high-quality specialty care in the United States remains an enormous challenge, especially for uninsured and rural populations. Over 70% of federally qualified health centers reported barriers to specialty care for their patients, leading to diagnostic delays and poor health outcomes. A recent study found that 86% of referral coordinators in a community health center cited patient insurance as the most important driver of poor access to specialty care. The increasing pressure for primary care clinicians to manage complex patients in shorter visits may also incentivize over-referrals: The US referral rates doubled from 1999 to 2009. These trends, as well as an ongoing national emphasis on cost savings in health care, have led to a recent increase in the use of telemedicine. Learning how to utilize telemedicine has become more relevant for trainees preparing to enter the physician workforce. Integrating telemedicine into graduate medical education (GME) curricula provides an important mechanism for improving trainee education on value-based care and increasing access to specialty care. Electronic consultation allows primary care clinicians to submit electronic clinical referrals and inquiries to specialists and engage in virtual dialogue regarding patient management. Specialists communicate with the requesting clinician and either give clinical management recommendations or determine that an in-person specialist visit is required. Electronic consultation systems have helped increase access to specialty care by reducing unnecessary in-person visits and decreasing wait times. Such platforms have been implemented across academic and community-based settings, and early studies have demonstrated tremendous potential to increase specialty care access and help educate primary care clinicians. Despite their clinical value, most medical schools, residency programs, and fellowships have not directly integrated methods of providing and requesting electronic consultations into training. This presents an opportunity to better engage future clinicians in the management of their patients, improve coordination of care with specialists, and ultimately improve access to specialty care using technology. Primary care clinicians who use electronic consultations have endorsed the technology’s educational impact, recognizing its potential for inclusion in GME curricula. Up to 90% of surveyed primary care physicians reported that electronic consultations enhanced their knowledge of new specialties and conditions and improved their clinical confidence when managing subsequent similar patients. Electronic consultations may have the most educational benefit for those in the earliest stages of their careers. Nurse practitioners, physician assistants, trainee physicians, and primary care physicians with fewer than 10 years of clinical experience were more likely to report greater benefit, especially for such labbased diagnosis and management as abnormal liver function tests and anemia. These skills directly reflect multiple Accreditation Council for Graduate Medical Education (ACGME) core competencies, including systems-based practice and practice-based learning and improvement, which all GME trainees are expected to cultivate during their clinical training. Given the data supporting the educational impact of training on the use of electronic consultations, those creating GME curricula should consider incorporating training on the appropriate request for and provision of electronic consultations. Electronic consultation questions associated with the highest rate of avoided referrals included those pertaining to diagnosis, nonspecific requests for direction, questions without specified interventions or outcomes, and questions concerning dermatology cases. Additionally, as prior studies have suggested that the highest rate of avoided referrals stems from electronic consultations for dermatology, hematology, and endocrinology, specific curricula in these fields would help maximize the appropriateness of electronic consultation referrals. DOI: http://dx.doi. org/10.4300/JGME-D-18-00754.1