Electronic consultations (e-consults) to improve access to specialty care: a systematic review and narrative synthesis

Abstract

Background: We define electronic consultations ("e-consults") as asynchronous, consultative, provider-to-provider communications within a shared electronic health record (EHR) or web-based platform. E-consults are intended to improve access to specialty expertise for patients and providers without the need for a face-to-face visit. Our goal was to systematically review and summarize the literature describing the use and effects of e-consults.

Methods: We searched PubMed, EMBASE, the Cochrane Library, and CINAHL for studies related to e-consults published between 1990 through December 2014. Three reviewers identified empirical studies and system descriptions, including articles on systems that used a shared EHR or web-based platform, connected providers in the same health system, were used for two-way provider communication, and were text-based.

Results: Our final review included 27 articles. Twenty-two were research studies and five were system descriptions. Eighteen originated from one of three sites with well-developed e-consult programs. Most studies reported on workflow impact, timeliness of specialty input, and/or provider perceptions of e-consults. E-consultations are used in a variety of ways within and across medical centers. They provide timely access to specialty care and are well-received by primary care providers.

Discussion: E-consults are feasible in a variety of settings, flexible in their application, and facilitate timely specialty advice. More extensive and rigorous studies are needed to inform the e-consult process and describe its effect on access to specialty visits, cost and clinical outcomes.

Keywords: e-consults; remote consultation; teleconsulting; telehealth; telemedicine.

Figure 1.

PRISMA flow diagram for literature on e-consults.

Figure 2.

Basic steps of an e-consultation (e-consult). The flow diagram indicates the steps involved in a typical e-consult, though not all the steps occur for every e-consult in every system. PCPs and other types of requesting providers may judge it necessary to discuss the decision to place an e-consult with the patient. They request the e-consult within the EHR or secure Web-based portal. The request may be templated, rely on free text entry of relevant data, or both. The specialist receives and reviews the e-consult, referring if appropriate and feasible to the EHR for supporting information. The specialist has the option to arrange for or suggest a face-to-face specialty clinic visit, complete and deliver the e-consult electronically, or request additional information which would inform either decision. Additional information may include details of the history, exam, or test results, but may also include recommendations for work-up and testing that can be completed prior to a face-to-face consultative visit.