HMA principals Greg Vachon, MD, MPH, and Jean Glossa MD, MBA, provide an overview of econsultations. Greg and Jean define econsults and provide an overview of the spectrum of econsult services in place today, evaluate the benefits and challenges of econsults, and look at recent developments in the econsult market.
Definition of an Econsult
An econsult is a modality in the field of telehealth that falls under the category of “store and forward.” The primary care provider (or other continuity provider) initiates the econsult through a traditional referral pathway, ideally supported by clinical checklists. The specialist then gives advice or renders an opinion that the primary care provider (PCP) receives and acts on. An econsult can be as simple as a “curbside” opinion between the specialist and PCP that is intentionally general, but most e-consults include signed, patient-specific clinical advice. Unlike a traditional consult, the patient does not have direct contact with the specialist at this point in the process. Oftentimes, the clinical question is answered solely via econsult, although the specialist will sometimes eventually see the patient in a face-to-face encounter. The rate of conversion to face-to-face depends on the clinical condition. When a face-to-face is required, only one visit will often be needed thanks to the pre-visit preparation completed via econsult.
Viewing diagnostic images at a time after data collection is another store and forward telehealth application with radiology, dermatology and ophthalmology (retinal scanning) being common examples. The line between this telehealth application and econsults is somewhat blurry, as econsult platforms are also able to store and forward images attached to the econsult.
A number of factors are leading to rapid adoption of econsults in certain areas of the healthcare marketplace, particularly where specialty access is challenging and pressures to increase value are more acute. The set of common experiences in ambulatory specialty practice described below illustrate opportunities where econsults could be used to improve physician satisfaction, patient experience, quality of care and utilization of specialty services.
- Incomplete work ups. Specialists often enter an examination room to see a patient referred by a PCP and find that not all of the tests needed to assess the question or problem have been done.
- Low value visits. Studies suggest that a significant percentage of referrals, depending on venue and specialty, are actually for issues that could be resolved and managed at the primary care practice level (Keely et al examples: neurology 17 percent, cardiology 36 percent, hematology 48 percent, nephrology 63 percent).
- The referral is directed to the wrong specialist. Much to the frustration of all involved, specialists sometimes see a patient for an initial consultation and discover the question or problem is not appropriate for their specialty practice.
- Poor access. PCPs and patients are often faced with long wait times to see a specialist.
- Feedback delayed/disconnected. In many systems, the results from a specialty consultation can take weeks or months to be returned to the PCP, decreasing the chances that the PCP will learn from each referral and, over time, make fewer referrals for the same clinical question.
Econsults are designed to address and mitigate each of these negative experiences.
Econsult implementation is not without challenges such as:
- Dual documentation. Providers are sometimes required to document in dual systems and are legitimately concerned about dual entry being time consuming and a potential source of errors.
- Lack of payment models. Payment models for econsults vary. Using econsults in a value based payment system is optimal. Those at risk need to be confident that if specialists are paid for econsults, face-to-face visits will actually decrease.
- Transitions of care from remote specialists. Econsults allow a specialist outside of a strained local network to provide access, but if there is a later transition to an in-network, in-person visit based on acuity, the transition can be challenging and can create redundancies and, therefore, must be monitored.
- Workflow consistency within practices. Using econsults for some patients and not others (for instance by payer) is difficult and may inhibit adoption.
- PCP adoption. Some referring providers will resist change and want their patients to be seen face-to-face. Identifying physician champions who understand the value of econsult is essential to the success of the model.
Evidence for the effectiveness of econsults in safety net healthcare is building. Several articles detailing outcomes in a safety net environment have begun to emerge. , These studies show high satisfaction among primary care providers, reductions of in-person consults of 40 percent, and overall cost savings.
This growing evidence is also translating into payment. The State of Connecticut’s Medicaid program has just begun paying for econsults initiated by PCPs at federally qualified health centers (FQHCs). Colorado and Oklahoma have pilot payment programs and Washington is planning a pilot. In California, where providers bear more risk than providers in other states (including risk for FQHCs in the near future), econsults have been implemented or are currently being implemented in a number of arrangements. The 1115 Waiver Global Payment Program in California specifically calls out econsults under a service category example. Continued dissemination of econsult use should be expected as local departments of public health begin to respond to the global budgets.
Econsultation is a telehealth solution that is gaining more widespread use. Companies have emerged to fulfill the need, offering SaaS models and pre-designed clinical checklists for referrals, as well as additional specialist capacity to address access problems. Market need, proven results, and commercially available products are likely to bring about rapid adoption in settings where specialty access is limited.
For more information or questions on this examination of econsults, or for more on HMA’s telehealth expertise, please contact Greg Vachon, MD, MPH ([email protected]) and Jean Glossa MD, MBA ([email protected]).
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 Keely et al, Utilization, Benefits, and Impact of an e-Consultation Service Across Diverse Specialties and Primary Care Providers, Telemedicine and e-Health, October 2013, 10.1089/tmj.2013.0007
 Liddy et al, What are the cost savings associated with providing access to specialist care through the Champlain BASE eConsult service? A costing evaluation. Health Economics, June 2016, 10.1136/bmjopen-2015-010920
 Gleason et al, Adoption and impact of an eConsult system in a fee-for-service setting. Healthcare, July 2016, 10.1016/j.hjdsi.2016.05.005