xRead Article 1 - Electronic Consults in Otolaryngology

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Gilani et al

2 to 9. 12 Although this is a pilot study and might not repre sent the full volume of eConsults if an entire institution par ticipated, it is reasonable to extrapolate the ratio of one specialist to 42 primary care physicians when estimating the time that would need to be spent answering eConsults on a monthly basis. Response rate and time are particularly important given that the majority of these initial responses were conclusive and did not require further follow-up with otolaryngology. Previous studies have shown that tradi tional referrals can have up to 6months of wait times and patient satisfaction is low. 16-18 A large study by the Canadian Medical Association found that 58% of PCPs surveyed about their referral practices used wait time as a determi nant of whether or not to refer a patient to an otolaryngolo gist. 10 Our findings build on the findings of previous studies suggesting that eConsults could streamline the referral pro cess and ensure that patients who have complaints that do not need to be addressed in-person do not have to wait long periods of time for a specialist appointment. This could simultaneously increase the availability of appointments for patients whose complex problems require in-person otolar yngology visits. Although we found that the average time to convert an eConsult to an in-person visit was 91days, it ranged from 2days to 405days. This suggests that appoint ments were scheduled based on clinical context and it is therefore unclear whether the reason for the delay is due to a lack of available appointments or a lack of urgency in scheduling the in-person visit. The major strength of this study is that to our knowledge no other study has reported on the use of eConsult in otolar yngology. A limitation of this pilot study is the retrospective design from a single center and by a single case reviewer. Future studies should be conducted prospectively across several institutions and with multiple providers within each institution. Additionally, it would be interesting to survey PCPs to determine how the introduction of the eConsult sys tem has modified their workflow and referral patterns within the field of otolaryngology. An important next step in evalu ating the feasibility of eConsults in otolaryngology would be to monitor patient and provider satisfaction before and after the introduction of the eConsult system once it has been extended to the entire otolaryngology division. Based on previous studies, some possible metrics for evaluation are wait times, patient travel times, educational value, and access to specialty input. 10,19 At our institution, we did not do cost analysis for this project. We promoted the eConsult pos sibility among our physicians using established existing communication channels such as electronic newsletters and presentations at division meetings. Future studies could study cost savings and cost avoidance in determining which of the patient satisfaction metrics, if any, are most tied to the potential cost savings that eConsults could provide. Future studies could also study reimbursement requirements for such services.

Discussion The interplay between PCPs and specialists is essential to providing patients with the best care. This pilot study focused on a retrospective analysis of 64 patients who had eConsults placed to the University of California, San Diego Department of Otolaryngology by their UCSD PCPs. PCPs at our institu tion were reimbursed for placing eConsults by half work relative value units (wRVUs) and the participating specialist was paid $50per eConsult. Both were paid internally by fac ulty to encourage use of the system. Under current Centers for Medicare and Medicaid (CMS) guidelines, our institution does not charge for eConsults; however, this may change as the guidelines continue to take shape. We found that the aver age response time to the initial consult was 2days and only 17.2% of all patients required follow-up office visits. Our study provides new information regarding eConsult referral patterns in otolaryngology and corroborates existing studies about common complaints seen in otolaryngology offices. 2,3 As other studies have shown, we found that the majority of eConsults were for ear (41%) or throat (29%) related complaints. 8 Our data indicate that the vast majority of eConsults could be handled with medical management by the PCP (67.2%) or education only (12.5%), and most patients across both groups did not require an in-person office visit. It is not surprising that most visits did not require additional follow-up because many problems in oto laryngology can be managed without surgical interven tion. 13 Tinnitus and hearing loss were the two most common complaints in our study and others. 13-15 This is in contrast to a large study by Kohlert et al 12 in 2017, in which thyroid goiter and oral mucosal lesions were the most commonly identified topics for eConsult placement. eConsults are par ticularly useful in this case for educating the patient and PCP about how to manage this condition over time and when additional workup by an otolaryngologist might be necessary. The most commonly proposed interventions in these situations were audiograms. If there was concern for a sudden change in hearing, in-person consultation with ENT was recommended. A similar recommendation for medical management followed by in-person visit for persistent symptoms was made for other common complaints, such as chronic sinus issues or hoarseness. In cases where conser vative management was recommended, another treatment modality or in-person referral were indicated as alternatives if the initial plan was not successful within a given time period. This provided PCPs with multiple courses of action as well as a guide for when a further consultation with a specialist might be warranted. One benefit that our study identified is the quick response time to eConsults, which was 2days on average (Table 1). The quick response time is consistent with other studies and could be due to the fact that the volume of eConsults was not overwhelming, averaging 5 per month but ranging from