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.”
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.”
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.”
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.