A Study of the Implementation of an Electronic Consultation (eConsult) Platform

Study Overview
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Brief Summary
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The purpose of this study is to evaluate the implementation of an electronic consultation model for specialty services (eConsults) to improve quality of care and reduce health system costs. An eConsult is a non-face-to-face consultation between a primary care provider and a specialist that takes place via secure messaging.

Detailed Description
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The study is a randomized, controlled trial where the intervention is the evidence-based eConsult model in which consults are submitted by electronic, secure messaging to a specialist for review and virtual consultation. Primary Care Providers will be randomized to the control or intervention group. In the intervention group, ALL new, non urgent, adult cardiology referrals will be submitted to the eConsult Cardiology team for an eConsult. Consults for children (age <18) and consults for patients who already have an established relationship with another cardiologist will not be eligible for an eConsult. Urgent consults, such as those for patients with active chest pain or other acute conditions, will not be submitted for eConsult and should instead be handled by the on-site care team as per the standard protocol. For eConsults, the consult will be submitted using the eConsult pathway within the electronic health record. eConsults will be created in the same way that standard referrals are created, with attachment of a treatment summary, EKG, relevant results, and specification of the consultative question. The eConsult will be received by the intervention Cardiology team and reviewed within 2 business days. One cardiologist per day will be assigned to review and respond to eConsults. The result will be received by the primary care provider who will be responsible for acting appropriately on the cardiologist's recommendations. Recommendations will be case specific and may include one of three broad areas of suggestion: 1) suggestions for ongoing management by the primary care provider, 2) suggestions for additional testing in advance of a cardiology face to face appointment or to better determine a next course of action, and 3) immediate cardiology referral. For each of these options, the primary care provider will be responsible for following up and implementing the recommendations made by the Cardiologist. When referral is recommended the primary care provider will refer the patient to the cardiologist of their choice based on their location and the patient's preference. While not required, they may refer the patient to the eConsult cardiology team at University of Connecticut for face to face care if desirable, but may also refer to other Cardiologists. The intervention will last one year. Providers randomized to the control group will provide standard care which involves a traditional referral for an in-person cardiology visit.

Official Title
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A Study of the Implementation of an Electronic Consultation (eConsult) Platform to Increase Specialist Access for Patients in Underserved Populations: Impact on Provider Experience, Wait Times and Cost

Conditions
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Cardiovascular Diseases

Intervention / Treatment
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* Other: eConsult


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Primary Care Provider at Community Health Center, Inc who work at least 30 hours per week and see adult patients Exclusion Criteria: -
Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| No Intervention: Control<br>Providers in the Control group followed standard care protocols. If they deemed a patient was in need of cardiology consultation, a referral was created using the standard process. The referral was processed by a referral coordinator and transmitted to an appropriate cardiologist. An appointment was then scheduled for the patient to have an in-person consultation with a cardiologist. | |
| Experimental: eConsult<br>The intervention consisted of an eConsult pathway and standardized protocol for PCPs to obtain cardiology consults using a secure messaging peer to peer (P2P) module embedded within the EHR. Intervention providers were asked to send all cardiology referrals for their adult patients through the eConsult system. Providers could bypass the eConsult pathway for patients with established relationships with a cardiologist or for whom providers felt a consult was urgent (required a face-to-face visit within a week or less). eConsults contain reason for consult, relevant test results, records or reports but are sent electronically to a Cardiology Consultant for review. eConsults were responded to within two business days. Responses were case-specific and generally contained recommendations for management, additional testing, or a face-to-face cardiology visit. The PCP was responsible for considering/acting upon recommendations and determining when an eConsult was complete. | Other: eConsult<br>* An electronic consultation or eConsult is a secure message consult that allows specialists to provide advice on cases without seeing a patient face to face. They contain a reason for consult, any relevant tests, procedures or reports. The responsibility lies with the primary care provider to act, or not act on the advice as they deem fit.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Time to first contact with a cardiologist | For eConsults, time to first contact is the time between the generation of the eConsults and when the Cardiologist replies to the eConsults. For traditional referrals, first contact is the time between the creation of the appointment and the in-person Cardiology visi. | 18 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Completion of referrals | The percent of referrals in each group that reached completion | 18 months | 
| Adverse events | Adverse cardiology events, including MI, following cardiology eConsult or referral | 18 months | 
| Hospital and Emergency Department Utilization | Use of the hospital or Emergency Department for a cardiology complaint following an eConsult or referral | 18 months | 
| Provider Satisfaction (survey) | A survey was administered to participants to measure their satisfaction with eConsults and/or the current referral process | Baseline, 6 months, 12 months | 
| Number of in-person cardiology visits | The number of traditional, control referrals and eConsults that resulted in an in-person consultation with a cardiologist. | 18 months | 
| Total Cost Per Patient | Clinical costs per patient in control and intervention group from claims data | 6 months pre and 6 months post intervention | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Health Services Accessibility