Development of a Virtual Benign Hematology Consultation Service: Results of a Pilot Project Involving 5 Medical Centers
Authors: Pai Ashok , Kotak Dinesh , Facher Nancy , Reader Kyle , Kong Kevin , Greyz Natalya , Tavakoli Jahan , Lopez Alfredo R. , Kim Jerome G. , Maloney Daniel , Liu Raymond , Kolevska Tatjana 
Published: October 2019

Abstract
Background:
Benign hematology consultations constitute a sizable proportion of community hematology/oncology practices. There is a need for physicians with adequate training, experience, interest and expertise in evaluating and treating patients with these disorders1,2. Some hematologic issues are complex and require in-person histories and examinations, while others can be handled with advice electronically after a thorough chart review3. To improve the quality of the care provided to these patients, a virtual benign hematology consultative service was created. This program was developed in the setting of a multi-specialty group with a commonly accessible EMR, servicing 15 medical service area centers, each with their own hematology/oncology department. A pilot project was designed to evaluate the feasibility of performing benign hematology consults virtually with the goal of improving quality of care while simultaneously enhancing the expertise of the physicians performing the consultations.
Methods:
The setting for this program is a multi-specialty group with a capitated reimbursement model. A pilot project was begun in October 2017 between 2 participating medical centers and was expanded to include a total of 5 medical centers by April 2018. All non-urgent benign hematology consultation requests were submitted electronically through an 'e-consult' portal. Evidence based work ups for common hematologic conditions were developed with consensus amongst all 15 hematology departments and provided on the e-consultation landing pages. All urgent questions and in-patient consults were called in directly to an on-call physician.
Results:
Data from October 2017 through April 2018 are reported. During this time, there were 2013 consults submitted electronically for review. Of this, 1107 came under the non-specific 'Ask the Specialist' code, and 906 under a specific diagnosis code. Regarding the consults with a designated diagnosis code, anemia 239 (26.3%), abnormal SPEP 208 (22.9%), anticoagulation 142 (15.6%), thrombocytopenia 103 (11.3%), leukocytosis 73 (8.1%), thrombocytosis 56 (6.2%), erythrocytosis 45 (5.0%), leukopenia 40 (4.4%) were the most common inquires. The requests that came under the 'Ask the specialist' code included questions regarding iron deficiency, easy bruising, macrocytosis without anemia, elevated ferritin levels and an elevated PT/PTT to name a few . Of the 1107 'Ask the specialist' consults, 941 (85.0%) were handled with advice given electronically while 116 (15%) were triaged to an in-person appointment. When evaluating the specific diagnosis codes, 575 (63.4%) were handled with advice given electronically. The most commonly triaged diagnosis for in-person appointments were thrombocytosis (60.7%), leukopenia (50.0%) and thrombocytopenia (47.6%). 90.3% of the consultation requests were addressed within 24 hours. When evaluating the number of consults on each day of the week, there were an average of 32.7, 25.8, 19.6, 24.4 and 18.2 consults triaged Monday through Friday respectively.
The time necessary to complete an electronic consult was calculated based on data from 7 hematologists with a sample size of 197 consults. It took an average of 14.47 minutes to complete each consultation when performed electronically (95% CI, 14.02 mins - 14.91 mins). This is similar to the time reported by Cecchini et al. in their experience with this program at the VA health system3.
All referring physicians were surveyed regarding their perceptions of the program, scaling their responses from 1 to 5. When asked if the work-up algorithms were helpful, if the recommendations received were clear and whether it was easy to access the specialist, the weighted average responses were 4.60, 4.50 and 4.0 respectively.
Conclusions:
This was a pilot program to assess the feasibility of a virtual hematology consultative service. The initial success of the program shows that it is possible to provide high value consultations to referring providers in an expeditious manner that enhances quality of care by having experts focused in the area perform the evaluation. Patients are also spared a visit to the hematology/oncology clinic to discuss a benign condition, and therefore has the added benefit of reduced anxiety4. Future studies will involve measuring outcomes of patients who were managed virtually, and the effect of the recommendations on the utilization of laboratory tests.

Disclosures
No relevant conflicts of interest to declare.