Association of eConsult Implementation With Access to Specialist Care in a Large Urban Safety-Net System

Abstract

Importance: Accessing specialty care continues to be a persistent problem for patients who use safety-net health systems. To address this access barrier, hospital systems have begun to implement electronic referral systems using eConsults, which allow clinicians to submit referral requests to specialty clinics electronically and enable specialty reviewers to resolve referrals, if appropriate, through electronic dialogue without an in-person visit.

Objective: Measure the effect of implementing an eConsult program on access to specialty care.

Design setting and participants: Using an interrupted time series design with data from 2016 to 2020, this study analyzed 50 260 referral requests submitted during the year before and the year after eConsult implementation at 19 New York City Health + Hospitals (NYC H+H) specialty clinics that spanned 7 NYC H+H hospital facilities and 6 unique specialties.

Exposures: Referral request was submitted to a specialty clinic in the year following eConsult implementation.

Main outcomes and measures: Main outcomes included the fraction of referral requests resolved without an in-person visit following eConsult implementation; and, among requests triaged to have an in-person visit, the fraction of referrals with a successfully scheduled appointment, mean wait time to a specialty appointment, and the fraction of referral requests with a completed specialty visit. Changes associated with eConsult implementation were estimated using multivariate linear regression adjusting for patient age, gender, and specialty clinic fixed effects.

Results: Across 19 NYC H+H specialty clinics, 26 731 referral requests were submitted in the year before and 23 529 referrals were submitted in the year after eConsult implementation. Following eConsult implementation, 13% of all requests were resolved electronically. Among requests requiring a follow-up visit, the fraction with an appointment successfully scheduled increased by 15.8%, from 66.5% to 82.3% (P < .001). The mean time to an appointment decreased from 61.0 days pre-eConsult to 54.1 days post-eConsult, an adjusted 8.2-day shorter wait time (or 13.3% reduction) following eConsult adoption (P < .001). The percentage of referrals with a completed follow-up visit with a specialist within 90 days of the request did not change (38.4% vs 37.9%, P = .07). Changes in outcomes were mitigated during months when most clinics underwent an electronic health record transition after implementing eConsult.

Conclusions and relevance: In this quality improvement study, implementation of eConsults at a large multi-specialty safety-net system was associated with improvements in appointment scheduling rates and wait times. Despite an additional electronic health record transition, eConsults are a promising health care delivery tool for increasing access to specialty care.

Figure 1.. Timeline of eConsult Adoption and Electronic Health Record Transitions at NYC Health + Hospitals Specialty Clinics

The triangles represent eConsult transition; the dots, electronic health record transition.

Figure 2.. Proportion of eConsults Where It Was Determined No Appointment Needed

The gray shaded region indicates months where 10 of 19 facilities transitioned electronic health record systems. Month 0 is the first 30 days of eConsult.

Figure 3.. Outcomes Among Referrals Triaged to Have a Follow-up Visit Scheduled, by Month Relative to eConsult Adoption

The gray-shaded region indicates months where 10 of 19 facilities transitioned electronic health record systems. Month 0 is the first 30 days of eConsult. A, Percentage of referrals with a scheduled appointment. B, Referrals without an appointment scheduled (n = 12 574) are excluded. C, Referrals resolved that occurred within 90 days of the end of the study period (n = 726) are excluded.