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American Journal of Kidney Diseases

Electronic Consultations in Nephrology: Pilot Implementation and Evaluation

Published:August 05, 2016DOI:https://doi.org/10.1053/j.ajkd.2016.05.029
      To the Editor:
      The care of complex patients is fragmented and poorly coordinated between referring primary care providers (PCPs) and specialists. Systemic issues include ill-defined referral indications, poor communication between physicians, and recommendations from specialists that are thought by PCPs to be unclear.
      • Forrest C.B.
      A typology of specialists’ clinical roles.
      • Mehrotra A.
      • Forrest C.
      • Lin C.
      Dropping the baton: specialty referral in the United States.
      There is a need to improve the efficiency of delivering specialist services
      • Valderas J.M.
      • Starfiled B.
      • Forrest C.B.
      • Sibbald B.
      • Ronald M.
      Ambulatory care provided by office-based specialists in the United States.
      ; this involves ensuring that patients who benefit most from in-person consultation receive timely care and identifying patients for whom in-person consultation may not be necessary. The electronic health record (EHR) can potentially be leveraged to develop electronic consultation (e-consult) systems that improve specialty referrals by facilitating communication between providers and providing a platform for specialists to determine the need and urgency of a referral.
      A few health care systems have successfully implemented e-referral and/or e-consult tools.
      • Straus S.G.
      • Chen A.H.
      • Yee H.F.
      • Kushel M.B.
      • Bell D.S.
      Implementation of an electronic referral system for outpatient specialty care.
      • Liddy C.
      • Rowan M.
      • Afkham A.
      • Maranger J.
      • Keely E.
      Building access to specialist care through e-consultation.
      • Wasfy J.H.
      • Rao S.K.
      • Chittle M.D.
      • Gallen K.M.
      • Isselbacher E.M.
      • Ferris T.G.
      Initial results of a cardiac e-consult pilot program.
      San Francisco General Hospital developed a web-based referral system integrated into the existing EHR.
      • Straus S.G.
      • Chen A.H.
      • Yee H.F.
      • Kushel M.B.
      • Bell D.S.
      Implementation of an electronic referral system for outpatient specialty care.
      The e-consult tool led to decreased wait times for new appointments, lower rates of avoidable visits, and improved clarity regarding referral indication. Most PCPs thought that it improved overall clinical care. Analyzing e-consult by specialty may improve the efficacy of implementation because certain specialties may be better suited to an e-consult platform than others, based on the types of questions being posed and need for prioritization of certain patients.
      Nephrology is a specialty that could embrace an e-consult model given that: (1) chronic kidney disease (CKD) is common, yet many patients with early stable CKD do not need in-person consultation; (2) medication dosing questions are common and may be easily addressed through appropriate timely e-consult
      • Perazella M.A.
      Renal vulnerability to drug toxicity.
      ; and (3) patients with advanced CKD have improved outcomes when followed up by nephrologists,
      • Jones C.
      • Roderick P.
      • Harris S.
      • Rogerson M.
      Decline in kidney function before and after nephrology referral and the effect on survival in moderate to advanced chronic kidney disease.
      yet a substantial percentage are not referred for in-person visits and prioritization is warranted, which an e-consult program could facilitate. Studies outside the United States have examined e-consult for CKD care and prioritization of patients who require a nephrologist visit.
      • Scherpbier-de Haan N.D.
      • van Gelder V.A.
      • Van Weel C.
      • Vervoort G.M.
      • Wetzels J.F.
      • de Grauw W.J.
      Initial implementation of a web-based consultation process for patients with chronic kidney disease.
      • Stoves J1
      • Connolly J.
      • Cheung C.K.
      • et al.
      Electronic consultation as an alternative to hospital referral for patients with chronic kidney disease: a novel application for networked electronic health records to improve the accessibility and efficiency of healthcare.
      These investigators found that e-consults reduced the number of unnecessary visits and increased the number of appropriate visits.
      We conducted a pilot study to examine the impact of an e-consult system for patients with kidney-related conditions over the course of 15 months (September 2014 to December 2015) at primary care practices affiliated with Brigham and Women’s Hospital, a tertiary-care center in Boston, MA. Two nephrologists reviewed questions submitted by PCPs (n = 49) and provided recommendations within an EHR-integrated platform. The consulting nephrologists could either provide recommendations or suggest in-person referral. We sought to determine what types of kidney-related conditions were best suited for e-consults and how satisfied PCPs and nephrologists were with the model.
      During the study, 74 nephrology e-consults were completed. Detailed methods are provided in Item S1. Providers spent a median of 10 minutes per e-consult. Median turnaround time for completion, from time of request to time to completion by the nephrologist, was 3.13 (IQR, 0.55-7.86) hours in 50 e-consults with available data for timing. The number of traditional referrals during this time frame was fairly consistent, ranging from 50 to 60 new referrals a month without a clear trend. Nephrologists requested in-person visits in 16 (22%) cases. The most common kidney conditions leading to an e-consult were stage 3 CKD (16%), medication-related questions (14%), and abnormal imaging findings (11%; Table 1).
      Table 1Patient Demographics and Clinical Reasons for e-Consult in 74 Patients, Stratified by CKD Stage
      Stage 1-2

      (n = 36)
      Stage 3a

      (n = 14)
      Stage 3b

      (n = 13)
      Stage 4

      (n = 5)
      Stage 5

      (n = 6)
      Patient characteristics
       Male15 (20%)7 (10%)3 (4%)2 (3%)3 (4%)
       Age, y, median [IQR]53 [37-66]61 [57-70]71 [59-75]72 [63-80]43 [34-49]
      Race
      White19 (26%)13 (18%)8 (11%)2 (3%)
      African American8 (11%)1 (1%)4 (5%)2 (3%)3 (4%)
      Hispanic5 (7%)1 (1%)1 (1%)3 (4%)
      Asian4 (5%)
      Diabetes diagnosis5 (7%)4 (5%)6 (8%)3 (4%)3 (4%)
      Kidney failure risk
      By kidney failure risk equation.
       Mean 2-y risk (range)NA0.1% (0%-0.4%)0.5% (0%-2.2%)4.8% (0.6%-12.9%)86.5% (79.3%-93.6%)
       Mean 5-y risk (range)NA0.5% (0.1%-1.4%)1.6% (0%-6.8%)13.4% (1.4%-35.1%)99.7% (99.3%-100%)
      Kidney conditions
       CKD management2 (3%)6 (8%)6 (8%)2 (3%)1 (1%)
       Medication related2 (3%)3 (4%)2 (3%)3 (4%)
       Abnormal imaging finding3 (4%)3 (4%)2 (3%)
       Electrolytes5 (7%)2 (3%)
       Proteinuria6 (8%)
       Acute kidney injury3 (4%)2 (3%)
       Hematuria4 (5%)
       Hypertension1 (1%)1 (1%)
       Abnormal urinalysis2 (3%)
       Single kidney2 (3%)
       Stone disease2 (3%)
       Other
      Other conditions included the following: lupus nephritis, edema, anemia, paraprotein, renal papillary necrosis, bone mineral disease, postnephrectomy CKD, polycystic kidney disease, and lab ordering question.
      4 (5%)1 (1%)2 (3%)2 (3%)
      Note: Percentages based on 74 total patients in study. Abbreviation: NA, not applicable.
      a By kidney failure risk equation.
      b Other conditions included the following: lupus nephritis, edema, anemia, paraprotein, renal papillary necrosis, bone mineral disease, postnephrectomy CKD, polycystic kidney disease, and lab ordering question.
      As Table 2 shows, satisfaction with the e-consult was high among nephrologists (96% survey completion) and PCPs (66% survey completion). In the majority of cases, nephrologists and PCPs (99% and 96%, respectively) thought that the e-consult was efficient. In most cases, nephrologists and PCPs (65% and 69%, respectively) thought that the patient could be managed after e-consult without an in-person referral. In 96% of cases, PCPs thought that the e-consult answered the clinical question posed, and in 85% of cases, nephrologists thought that the e-consult was appropriate.
      Table 2Nephrology and PCP Satisfaction With e-Consult Tool
      Survey QuestionNephrologists’ ResponsesPCPs’ Responses
      Did you believe that was an appropriate e-consult?
       Yes60/71 (85%)NA
      Not applicable (because question was not asked).
       No, in-person referral preferred9/71 (13%)NA
      Not applicable (because question was not asked).
       No, neither e-consult nor in-person referral warranted2/71 (3%)NA
      Not applicable (because question was not asked).
      Did the e-consult answer the clinical question you posed?
       YesNA
      Not applicable (because question was not asked).
      47/49 (96%)
       NoNA
      Not applicable (because question was not asked).
      2/49 (4%)
      If e-consult did not exist, do you believe PCP would have sought informal or formal nephrology care?
       Yes59/71 (83%)NA
      Not applicable (because question was not asked).
       No12/71 (17%)NA
      Not applicable (because question was not asked).
      If e-consult did not exist, would you have referred your patient to see a nephrologist?
       YesNA
      Not applicable (because question was not asked).
      27/49 (55%)
       NoNA
      Not applicable (because question was not asked).
      22/49 (45%)
      If e-consult did not exist, would you have sought any informal nephrology advice by e-mail or telephone?
       YesNA
      Not applicable (because question was not asked).
      29/49 (59%)
       NoNA
      Not applicable (because question was not asked).
      20/49 (41%)
      Do you feel confident that the patient can be managed without an in-person referral?
       Yes46/71 (65%)34/49 (69%)
       No5/71 (7%)4/49 (8%)
       In-person referral was recommended20/71 (28%)11/49 (22%)
      How many minutes did you spend using the e-consult for the patient?
       Median [IQR]10 [10-15]10 [5-10]
      Did you believe the e-consult was efficient?
       Yes70/71 (99%)47/49 (96%)
       No1/71 (1%)2/49 (4%)
      Note: Survey provided to 2 nephrologists (71 responses collected) and 49 PCPs (49 responses collected) for e-consults completed.
      a Not applicable (because question was not asked).
      In this pilot involving patients with kidney conditions, we found that e-consults were efficient, were well received, and could improve the appropriateness of in-person nephrology referral. Issues related to stable stage 3 CKD, medication safety, and kidney imaging are likely most appropriate for e-consult, but the findings of this pilot indicate that it may be worth implementing as a screening step to improve the efficiency of the referral process. It is notable that in a substantial percentage of cases, PCPs stated that they would not have sought nephrology advice, raising the possibility that e-consult may lead to increased access to nephrology services for patients who could benefit from nephrology input. The findings of this pilot are limited, and it would be prudent to pursue further investigation across multiple sites, incorporating patient satisfaction and outcomes. E-consults for nephrology should be explored further by the kidney disease community as an innovative care model that could increase appropriateness of referral and access to nephrology services.

      Acknowledgements

      Support: None.
      Financial Disclosure: The authors declare that they have no relevant financial interests.
      Contributions: Research idea and study design: MM, AL, JG, SS, SW; data acquisition: AL, SS, MM, GM; data analysis/interpretation: MM, SW; statistical analysis: MM, SW; supervision or mentorship: JG, SW. Each author contributed important intellectual content during manuscript drafting or revision and accepts accountability for the overall work by ensuring that questions pertaining to the accuracy or integrity of any portion of the work are appropriately investigated and resolved. SW takes responsibility that this study has been reported honestly, accurately, and transparently; that no important aspects of the study have been omitted, and that any discrepancies from the study as planned have been explained.
      Peer Review: Evaluated by 2 external peer reviewers, a Co-Editor, and the Editor-in-Chief.

      Supplementary Material

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