As the volume of nonmalignant hematology consults grows and the potential provider pool of nonmalignant hematologists shrinks, questions on how to optimize the care of patients with nonmalignant hematologic disorders have become increasingly pressing.1,2
In a recent letter to the editor published in Blood, Dr. Ashok Pai and colleagues presented the results of their effort to meet this need with a virtual nonmalignant hematology consultation service, commonly referred to as an electronic consultation (e-consult), across five medical centers within the Kaiser Permanente health system in California. With this program, all nonurgent consults were submitted via an electronic portal, while any urgent or inpatient consults continued to be called directly to a physician. One hematologist triaged consult requests for two to three medical centers for a week at a time, determining whether the request could be answered electronically (with chart review and documentation of recommendations in the medical record) or whether an in-person appointment was needed. The triaging hematologist was equipped with tools including consensus recommendations, ordering panels for the laboratory workup of common disorders, and pre-populated templates for frequently asked questions. A weekly conference was also set up to discuss challenging cases and differences in opinions between providers.
In a seven-month trial period, 2,013 consults were submitted for a wide range of nonmalignant hematologic disorders, with an average range of 18.2 to 32.7 consults per day across the five medical centers. Most consults (75%) were managed electronically. Of the consults that required in-person evaluation, most were for blood cell count abnormalities that warranted further evaluation, often a bone marrow biopsy. Response to consults was timely, with 90.3 percent addressed within 24 hours, and in-person appointments arranged within seven days of request. The average time for a hematologist to complete an e-consult was 14.5 minutes (95% CI, 14.0-14.9). A survey of participating providers revealed a high level of satisfaction in both referring physicians and hematologists.
Other practice environments have similarly incorporated e-consult in recent years.3 Dr. Michael Cecchini and colleagues at the Veterans Affairs Connecticut Healthcare System were first to publish results on hematology e-consult, reporting that consult volume increased while in-person consultation decreased by 18 percent, with a similar mean time of e-consult completion of 14.5 minutes (SD, 7.3) compared to 30 to 60 minutes allotted for in-person appointments.4
Despite these successes, many questions remain regarding the role of e-consult in the future of nonmalignant hematology within the United States health care system as a whole. Dr. Pai and colleagues practice in a capitated payment model with a shared electronic medical record (EMR), and therefore have existing means for reimbursement and interprovider communication. E-consult becomes more complex in fee-for-service models, but this system is evolving as well. As of 2019, the Centers for Medicare & Medicaid Services (CMS) has included Current Procedural Terminology (CPT) codes for what is termed “interprofessional internet consultation,” thereby creating an avenue for e-consult billing.5,6 However, challenges of interinstitutional variation in EMRs remain.
Furthermore, the effects of e-consult on consult volume and patient outcomes require further investigation. Results from Dr. Cecchini and colleagues suggest that e-consult decreased in-person consult volume but significantly increased total consult volume, raising concerns that the ease of requesting an e-consult may increase the collective workload of the consultant.5 Additionally, the need for physicians to spend even more time in EMRs, reviewing, documenting, and communicating electronically, may have negative consequences: increased clerical burden, which is heavily influenced by the extensive use of EMRs, has already been identified as the top factor contributing to physician burnout.7 Finally, neither study evaluated whether more rapid access to subspecialist input or less access to face-to-face encounters had an effect on patient outcomes.
As the needs of our patients and the structure of our health care system rapidly evolves, Dr. Pai and colleagues present an exciting, promising new approach that maximizes access to nonmalignant hematology expertise. Efforts to more broadly implement and evaluate e-consult are ongoing, most notably via Project CORE, a multi-institutional effort lead by the Association of American Medical Colleges.8 This effort and others will shed further light on the role of e-consult in other health care models and how it may improve effective and efficient delivery of hematologic care.
Marshall AL, Jenkins S, Mikhael J, et al. Determinants of hematology-oncology trainees' postfellowship career pathways with a focus on nonmalignant hematology. Blood Adv. 2018;2:361-369.
Wallace PJ, Connell NT, Abkowitz JL. The role of hematologists in a changing United States health care system. Blood. 2015;125:2467-2470.
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.
Cecchini M, Rose MG, Wong EY, et al. The implementation of electronic hematology consults at a VA hospital. Blood. 2016;127:1610-1611.
Henry TA. 2019 CPT codes offer new paths to payment for digital medicine. AMA. 2018; Oct 17.
Final policy, payment, and quality provisions changes to the Medicare physician fee schedule for calendar year 2019. CMS. 2018; Nov 1.
Project CORE: Coordinating optimal referral experiences. AAMC.
Swensen S, Shanafelt T, Mohta NS. Leadership survey: Why physician burnout is endemic, and how health care must respond. NEJM Catalyst. 2016; Dec. 8.
Conflict of Interests
Dr. May indicated no relevant conflicts of interest. Dr. Moll has been a consultant for Janssen.
back to top