A Study of the Implementation of an Electronic Consultation ("eConsult") Platform

Cardiovascular Diseases Clinical Trial

Official title:

A Study of the Implementation of an Electronic Consultation ("eConsult") Platform to Increase Specialist Access for Patients in Underserved Populations: Impact on Provider Experience, Wait Times and Cost

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT02376855
• Other study ID #: 1023
• Status: Completed
• Phase: N/A
• First received: February 26, 2015
• Last updated: March 2, 2015
• Start date: October 2011
• Est. completion date: December 2013

Study information

• Verified date: February 2015
• Source: Community Health Center, Inc.
• Contact: n/a
• Is FDA regulated: No
• Health authority: United States: Institutional Review Board
• Study type: Interventional

Clinical Trial Summary

The purpose of this study is to evaluate the implementation of an electronic consultation model for specialty services (eConsults) to improve quality of care and reduce health system costs. An eConsult is a non-face-to-face consultation between a primary care provider and a specialist that takes place via secure messaging.

Description:

The study is a randomized, controlled trial where the intervention is the evidence-based eConsult model in which consults are submitted by electronic, secure messaging to a specialist for review and "virtual" consultation. Primary Care Providers will be randomized to the control or intervention group. In the intervention group, ALL new, non urgent, adult cardiology referrals will be submitted to the eConsult Cardiology team for an eConsult. Consults for children (age <18) and consults for patients who already have an established relationship with another cardiologist will not be eligible for an eConsult. Urgent consults, such as those for patients with active chest pain or other acute conditions, will not be submitted for eConsult and should instead be handled by the on-site care team as per the standard protocol. For eConsults, the consult will be submitted using the eConsult pathway within the electronic health record. eConsults will be created in the same way that standard referrals are created, with attachment of a treatment summary, EKG, relevant results, and specification of the consultative question. The eConsult will be received by the intervention Cardiology team and reviewed within 2 business days. One cardiologist per day will be assigned to review and respond to eConsults.

The result will be received by the primary care provider who will be responsible for acting appropriately on the cardiologist's recommendations. Recommendations will be case specific and may include one of three broad areas of suggestion: 1) suggestions for ongoing management by the primary care provider, 2) suggestions for additional testing in advance of a cardiology face to face appointment or to better determine a next course of action, and 3) immediate cardiology referral.

For each of these options, the primary care provider will be responsible for following up and implementing the recommendations made by the Cardiologist. When referral is recommended the primary care provider will refer the patient to the cardiologist of their choice based on their location and the patient's preference. While not required, they may refer the patient to the eConsult cardiology team at University of Connecticut for face to face care if desirable, but may also refer to other Cardiologists. The intervention will last one year. Providers randomized to the control group will provide standard care which involves a traditional referral for an in-person cardiology visit.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 36
• Est. completion date: December 2013
• Est. primary completion date: September 2013
• Accepts healthy volunteers: Accepts Healthy Volunteers
• Gender: Both
• Age group: N/A and older

Eligibility

Inclusion Criteria:

• Primary Care Provider at Community Health Center, Inc who work at least 30 hours per week and see adult patients

Exclusion Criteria:

Study Design

Allocation: Randomized, Endpoint Classification: Efficacy Study, Intervention Model: Parallel Assignment, Masking: Single Blind (Investigator), Primary Purpose: Health Services Research

Related Conditions & MeSH terms

• Cardiovascular Diseases

Intervention

Other:
• eConsult
An electronic consultation or "eConsult" is a secure message consult that allows specialists to provide advice on cases without seeing a patient face to face. They contain a reason for consult, any relevant tests, procedures or reports. The responsibility lies with the primary care provider to act, or not act on the advice as they deem fit.

Locations

Country	Name	City	State
United States	Community Health Center, Inc	Middletown	Connecticut

Sponsors (4)

Lead Sponsor	Collaborator
Community Health Center, Inc.	Connecticut Health Foundation, University of Connecticut, University of Connecticut Health Center

Country where clinical trial is conducted

United States, 

References & Publications (10)

Bindman AB, Chen A, Fraser JS, Yee HF Jr, Ofman D. Healthcare reform with a safety net: lessons from San Francisco. Am J Manag Care. 2009 Oct;15(10):747-50. — View Citation

Chen AH, Kushel MB, Grumbach K, Yee HF Jr. Practice profile. A safety-net system gains efficiencies through 'eReferrals' to specialists. Health Aff (Millwood). 2010 May;29(5):969-71. doi: 10.1377/hlthaff.2010.0027. — View Citation

Chen AH, Yee HF Jr. Improving primary care-specialty care communication: lessons from San Francisco's safety net: comment on "Referral and consultation communication between primary care and specialist physicians". Arch Intern Med. 2011 Jan 10;171(1):65-7. doi: 10.1001/archinternmed.2010.484. — View Citation

Fischer BS, Martinez E, Driscoll M, Conway T. Practice profile. Chicago: using evidence-based rules to make smarter referrals. Health Aff (Millwood). 2010 May;29(5):972-5. doi: 10.1377/hlthaff.2010.0068. — View Citation

Foy R, Hempel S, Rubenstein L, Suttorp M, Seelig M, Shanman R, Shekelle PG. Meta-analysis: effect of interactive communication between collaborating primary care physicians and specialists. Ann Intern Med. 2010 Feb 16;152(4):247-58. doi: 10.7326/0003-4819-152-4-201002160-00010. — View Citation

Katz MH. Golden gate to health care for all? San Francisco's new universal-access program. N Engl J Med. 2008 Jan 24;358(4):327-9. doi: 10.1056/NEJMp0706590. — View Citation

Kim Y, Chen AH, Keith E, Yee HF Jr, Kushel MB. Not perfect, but better: primary care providers' experiences with electronic referrals in a safety net health system. J Gen Intern Med. 2009 May;24(5):614-9. doi: 10.1007/s11606-009-0955-3. Epub 2009 Mar 24. — View Citation

Kim-Hwang JE, Chen AH, Bell DS, Guzman D, Yee HF Jr, Kushel MB. Evaluating electronic referrals for specialty care at a public hospital. J Gen Intern Med. 2010 Oct;25(10):1123-8. doi: 10.1007/s11606-010-1402-1. Epub 2010 May 29. — View Citation

Weiner M, El Hoyek G, Wang L, Dexter PR, Zerr AD, Perkins AJ, James F, Juneja R. A web-based generalist-specialist system to improve scheduling of outpatient specialty consultations in an academic center. J Gen Intern Med. 2009 Jun;24(6):710-5. doi: 10.1007/s11606-009-0971-3. Epub 2009 Apr 15. — View Citation

Yee HF Jr. The patient-centered medical home neighbor: A subspecialty physician's view. Ann Intern Med. 2011 Jan 4;154(1):63-4. doi: 10.7326/0003-4819-154-1-201101040-00011. — View Citation

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Time to first contact with a cardiologist	For eConsults, time to first contact is the time between the generation of the eConsults and when the Cardiologist replies to the eConsults. For traditional referrals, first contact is the time between the creation of the appointment and the in-person Cardiology visi.	18 months	No
Secondary	Completion of referrals	The percent of referrals in each group that reached completion	18 months	No
Secondary	Adverse events	Adverse cardiology events, including MI, following cardiology eConsult or referral	18 months	Yes
Secondary	Hospital and Emergency Department Utilization	Use of the hospital or Emergency Department for a cardiology complaint following an eConsult or referral	18 months	Yes
Secondary	Provider Satisfaction (survey)	A survey was administered to participants to measure their satisfaction with eConsults and/or the current referral process	Baseline, 6 months, 12 months	No
Secondary	Number of in-person cardiology visits	The number of traditional, control referrals and eConsults that resulted in an in-person consultation with a cardiologist.	18 months	No
Secondary	Total Cost Per Patient	Clinical costs per patient in control and intervention group from claims data	6 months pre and 6 months post intervention	No