E-Consult Innovation: A Middle-Ground Model To Enhance Adoption and Improve Care

“At HealthPartners, we envisioned a middle ground between curbside and face-to-face consultation in which referring clinicians and patients could access specialty advice in a timely manner that would be documented and billable, but at a rate lower than for a face-to-face visit. We decided to adopt the e-consult model and use it as an option rather than a requirement for all involved: patients, referring clinicians, and specialists. Referring clinicians could decide when ordering: do they want a face-to-face consultation or could the need be met with an e-consult? Patients could see a specialist in person if they preferred but would also be offered e-consult if appropriate. We created a simple document to share with patients to describe the e-consult option.

[..] an important distinction of the e-consult model we developed is the multiple opt-in, opt-out points: the patient can choose it or not, the referring clinician can choose it or not, and the specialist can address as an e-consult or not.

[..] There were two technical options that seemed feasible: one workflow that was messaging-based (using requests generated from the InBasket to initiate and complete an e-consult) and another that was order-based (using orders unique to each specialty to generate an e-consult request to an InBasket pool managed by that specialty). Recognizing that our workflow for an in-person consultation was order-based, we felt the symmetry of having an order for both made the most sense for our organization.

[..] When these conversations began, no code existed to bill for the work we imagined doing; there were some interprofessional care or Internet-based codes, but none was a perfect match for what we saw the work or the value to be. Therefore, we set out to make a case for the value we thought this service would provide and propose a de novo value to our local third-party payers. Partnership with our finance and payer relations teams was critical to assessing likely financial impacts (our goal was not to make substantial revenue but simply to break even) and to facilitate conversation with our payers. The conversations were productive, with payers appreciating the potential benefit to their members of substituting a lower-cost e-consult for a more costly face-to-face visit when appropriate. (The early buy-in from our internal payer colleagues was especially helpful.)

In 2018, we became aware that a new code would be introduced in 2019, 99451, which would allow for payment of electronic medical record–based review and assessment with written feedback provided to the requestor. The work relative value unit (wRVU) of this code, 0.70, was in line with what we had proposed, so we adopted this code for use in our e-consult process.

[..] Billing for the service would be CPT code 99451 from the specialist, and the organization would collect revenue for the associated 0.7 wRVU. For the work involved for both parties, both the specialist and referring provider would be compensated. There would be no compensation for either party if 99451 was not billed. Code 99452 could be used by referring providers, but requirements of that code would not generally be met in our process. Therefore, recognizing the work on the part of the referring clinician to communicate and execute the treatment plan with the patient, our organization made an internal decision to also compensate the referring provider.

[..] we decided that it is fair to ask anything of a specialty department for an e-consult, and the specialty department decides on a case-by-case basis if the question qualifies as a good e-consult. Still, to help clinicians in adopting the new model, specialty groups were asked to provide good examples of potential e-consults to share with referring partners, and referring clinicians were encouraged to use the pathway if they thought it might make sense but never would be required to do so [see Appendix]. This resulted in a relatively consistent conversion rate of about 50% of e-consult requests resulting in a billed e-consult (generally requiring more than 5 minutes, but less than 15), 25% generating a short response but no bill (less than 5 minutes), and 25% requesting the patient be seen in-person in the specialty department (if more than 15 minutes would be required or if the specialty clinician determined the question did not lend itself to the e-consult model).

[..] Our law and risk management colleagues concluded that the e-consult process decreased the risk of liability in comparison with the traditional curbside consultation because it follows an established process, it allows the specialists to gather all of the facts necessary to render an opinion, it allows the specialist to convert to an in-person visit if necessary, and it provides a mechanism for the specialist to document his or her clinical recommendation.

[..] The most consulted specialties using e-consult have been medical subspecialties (endocrinology, oncology/hematology, infectious disease, cardiology, and gastroenterology) and neurology. The department that has the highest proportion of billed e-consult in comparison with those requested is thrombosis and anticoagulation, with about 81% of requests resulting in a billed encounter.

[..] A majority of requested e-consults (61%) are completed the same day, with an additional 21% completed the next day and 6% in 2 days. While 12% of requests have taken more than 2 days to resolve, many of these have fallen over a weekend and remain consistent with our objective to have a 2-business-day turnaround.

[..] We learned that specialists are slightly less satisfied than are primary care clinicians with the process, likely attributable to the fact that this is an additional task that they have taken on without dedicated time to do so. However, on the whole, both specialists and primary care providers rate the process favorably on all three questions.

[..] For organizations that are considering starting or reviewing an e-consult model, we suggest several focus areas:

    Start by building a multidisciplinary coalition of both referring and receiving providers. Understand their needs and preferences and develop a workflow that best matches your practice.

  • Seek broad organizational leadership support. For us to successfully implement this workflow and tool across a multispecialty group, it was critical that leaders from across all of our areas had prioritized the work.
  • Ask others to poke holes in the concept; we learned the most and made the best improvements from challenges that arose, particularly workflow or medicolegal questions.
  • Partner with your technical teams to understand what options already exist. Particularly for Epic users, there are multiple ways of doing this, so there is no need to reinvent the wheel.

[..] An additional opportunity we have would be to take a closer look into what a recent article described as “appropriateness,” using the following questions: (1) Was it something a point-of-care reference may have been able to address? (2) Was the question merely logistical in nature (i.e., “where do I schedule a patient for a particular service in your department?”)? (3) Was the question too urgent to be addressed in an e-consult? (4) Was the question too complex to be addressed as an e-consult?

[..] Many specialties have begun to identify frequently asked questions and themes in e-consult requests; some of the most common reasons for an e-consult order we have seen organizationally are described in the Appendix. For example, hematology has seen many requests for polycythemia and has a standard approach for workup of these patients that they can recommend in a very standard way. One way we envision better supporting our specialists in this workflow is developing SmartTools (standard text that can be used to respond to common questions) for scenarios such as this one.”

Full article, Larson A and Wheeler J. NEJM Catalyst: Innovations in Care Delivery November-December 2020