In light of the COVID-19 epidemic, efforts are being made to provide medical care while streamlining in-person interactions between clinicians and with patients. “Electronic consultations, or e-consults, are asynchronous clinician-to-clinician exchanges within the electronic health record (EHR),” explains S. Shahzad Mustafa, MD. “E-consults are not as formal as in-person consultations but they are more formal than ‘curbside’ discussions, in which physicians briefly consult with each other.”

Studies show that e-consults are feasible in a variety of settings and offer several potential advantages to in-person consultations, including improved access to specialist care, cost savings, and convenience for both clinicians and patients. Most of the currently available data addressing allergy/immunology (A/I) e-consults has come from the outpatient setting, but Dr. Mustafa says the inpatient setting may be a prime setting to incorporate these consultations because it may bridge the gap between outpatient and inpatient A/I availability.

A Closer Look

For a study published in the Journal of Allergy and Clinical Immunology: In Practice, Dr. Mustafa and colleagues assessed whether A/I inpatient consultations could be adequately conducted with e-consults while preserving satisfaction among referring inpatient providers. “We conducted this study due to a high demand for inpatient A/I consultations at our institution over the past several years, most commonly to evaluate adverse drug reactions,” Dr. Mustafa says.

E-consults were conducted in adult inpatients when appropriate and recommendations were made in the EHR. In-person consultations were performed when medically necessary. Of 109 inpatient consults studied, 78 were completed using e-consults and 31 via in-person consultations. Overall, the most common indication for inpatient consults was to evaluate penicillin allergy, which occurred in about two-thirds of cases. The most common reason for in-person consults was the need to complete penicillin skin testing (PST).

Saving Time & Money

According to the results, e-consults were conducted in less time than in-person consults (15 vs 60 minutes, respectively). Furthermore, e-consults were completed 6 hours sooner than in-person consults (median: 1 vs 7 hours, respectively). “E-consults were implemented efficiently and facilitated by medical records in the EHR during the course of an A/I physician’s outpatient responsibilities,” says Dr. Mustafa.  “This significantly reduced work hours when compared with in-person consultations.”

A cost analysis suggested that e-consults may yield cost saving for healthcare systems. “When evaluating inpatient penicillin allergy, the potential cost savings are even more pronounced because of the additional cost associated with PST versus a direct challenge,” says Dr. Mustafa. “Although direct reimbursement is significantly less for e-consults than in-person consults, the inpatient e-consult strategy can save time, which in turn enables clinicians to be more productive in the outpatient setting.”

Clinician Satisfaction

The study also demonstrated that requesting inpatient providers were satisfied with e-consults. The vast majority had “good” or “excellent” opinions of e-consults and were satisfied with this type of consultation when compared with traditional in-person consults (Table). “Importantly, regardless of type of consult used, patient management recommendations were followed at a similar rate,” Dr. Mustafa says. “Requesting physicians appreciated the efficiency of e-consults and the ability of implement recommendations in a more timely fashion.”

Important Implications

While findings on e-consult use in A/I inpatient evaluations were encouraging, Dr. Mustafa cautions that certain conditions may not be appropriate for these consultations. “In some cases, it will be medically necessary to conduct an in-person evaluation,” he says. “Examples include managing patients requiring PST and those with complex medical conditions.” He notes that it is important for clinicians to identify specialty-specific criteria for which e-consultation would be appropriately utilized.

Overall, the study provides evidence of the feasibility and utility of inpatient A/I e-consults. “E-consults are efficient, potentially cost saving, and can give patient management recommendations that are likely to be followed, all while maintaining adequate provider satisfaction,” says Dr. Mustafa. “The application of e-consults is especially timely given the current era of COVID-19. They involve no physical interaction and allow us to remain socially distant. E-consults will likely be an important strategy for optimizing access to inpatient A/I care, allowing providers to give their expertise by working smarter, not harder.”

References

Mustafa SS, Staicu ML, Yang L, Baumeister T, Vadamalai K, Ramsey A. Inpatient electronic consultations (E-consults) in allergy/immunology. J Allergy Clin Immunol Pract. 2020 Jun 22 [Epub ahead of print]. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7307996/.

Ramsey A, Mustafa SS, Holly AM, Staicu ML. Direct challenges to penicillin-based antibiotics in the inpatient setting. J Allergy Clin Immunol Pract. 2020;8:2294-2301.

Staicu ML, Holly AM, Conn KM, Ramsey A. The use of telemedicine for penicillin allergy skin testing. J Allergy Clin Immunol Pract. 2018;6:2033-2040.

Phadke NA, Wolfson AR, Mancini C, et al. Electronic consultations in allergy/immunology. J Allergy Clin Immunol Pract. 2019;7:2594-2602.

Vimalananda VG, Gupte G, Seraj SM, et al. Electronic consultations (e-consults) to improve access to specialty care: a systematic review and narrative synthesis. J Telemed Telecare. 2015;21:323-330.