Electronic Consultations Could Improve Access to Rheumatologic Care

As any patient awaiting a rheumatology appointment can tell you, there just aren’t enough rheumatologists to go around. Waitlists can be months to years long, wreaking havoc on patients’ joints, functional capacity and quality of life. The access situation is dire enough to prompt posts on patient support websites about how to handle the waiting period to see a rheumatologist.¹

Unfortunately, the problem is getting larger. As the population ages and senior rheumatologists retire, demand for rheumatologic care is projected to be more than twice the available supply in 2030, according to the 2015 ACR Workforce Study.² Communities with already-limited access to care, such as rural areas and states lacking Medicaid expansion, will be hit even harder.

Telehealth is one strategy to improve access to specialty care and reduce waiting times. Electronic consultations, or e-consults, are examples of an evolving telehealth modality with the potential to help patients access rheumatologic care in a cost-effective and efficient manner.

What’s an e-Consult?

In simple terms, e-consults are curbside consults with another provider—the sort of thing you’re probably already doing in the clinic hallway or via email, but conducted in a Health Insurance Portability and Accountability Act (HIPAA) compliant and billable fashion. For example, imagine a primary care provider has a question for a rheumatologist that would be better answered following a brief review of the patient’s chart. The question could be as simple as “Does this lab result matter?” In an ideal world, such a question would be answered in less than 24 hours. E-consults could help achieve this.

Although a formal definition does not yet exist, an e-consult involves an asynchronous, provider-to-provider electronic exchange within a shared electronic health record or HIPAA-compliant web-based platform. Specialists receive access to clinical notes, labs and studies to aid in answering the consulting question. The exchange then becomes a part of the patient’s permanent record.³

E-consults differ from synchronous telemedicine visits in that the specialist has no direct patient contact. The specialist offers recommendations, but enactment of treatment plans is at the discretion and responsibility of the original provider.

Experience from an e-Consult Company

Dr. Anderson

Daren Anderson, MD, founded the e-consult company ConferMED, Middletown, Conn., in 2015. With more than 17 years of experience as an internist caring for patients in safety net communities, Dr. Anderson noticed that “a main driver of inequity in healthcare outcomes was poor access, long wait times and poor communication with specialists,” he says. In addition, “rheumatology is the number one most requested e-consult specialty in the Central Valley of California, where wait times average nine to 12 months to see a rheumatologist … who may be several hours away by car.” 

E-consults can help weed out unnecessary referrals and avoid unnecessary face-to-face visits, saving time and money. The turn-around time for specialist response to a consulting provider at ConferMED is 24 hours, Dr. Anderson says. A recent analysis of ConferMED’s impact on Medicaid patients showed e-consults saving an average of $82 per patient per month for specialty care compared with face-to-face visits.³

Since ConferMED’s inception, rheumatology e-consults have eliminated 78% of unnecessary face-to-face visits. Of the 3,165 total rheumatology e-consults conducted, 1,193 occurred in the past year alone. Further, ConferMED is currently active in only 21 states but is expanding. “Our data show that an enormous number of rheumatology referrals probably don’t need a face-to-face visit. There just isn’t much rheumatology training in primary care. So a minimally positive anti-nuclear antibody (ANA) test results in a rheumatology referral no matter what,” Dr. Anderson says. In e-consults, specialists can include written explanations of recommendations, frequently supported by references from the literature. That means “we also get to capitalize on a teaching opportunity for the consulting provider, perhaps preventing another unneeded referral down the line,” he adds.

Benefits in Specialty Care

Although e-consults are relatively new, they are already showing measurable benefit in our field. A 2018 study showed that implementation of an e-consult service in Canada improved rheumatology care access, with a median response time by a rheumatologist to the consulting provider of just under two days. A face-to-face referral was avoided in 38% of cases.⁴ At a large healthcare center in Texas, e-consults for positive ANA test referrals were associated with decreased wait times for in-person visits, without a significant increase in resource utilization. Seventy-six percent of these referrals did not require an in-person visit after initial e-consult, and 73% ultimately did not have a rheumatologic diagnosis.⁵

Samantha C. Shapiro, MD, is an academic rheumatologist and an affiliate faculty member of the Dell Medical School at the University of Texas at Austin. She received her training in internal medicine and rheumatology at Johns Hopkins University, Baltimore. She is also a member of the ACR Insurance Subcommittee.

References

1. Andersen L. How to handle the waiting period to see a rheumatologist if you think you have rheumatoid arthritis. CreakyJoints. 2021 Jul 20.
2. Battafarano DF, Ditmyer M, Bolster MB, et al. 2015 American College of Rheumatology workforce study: Supply and demand projections of adult rheumatology workforce, 2015–2030. Arthritis Care Res (Hoboken). 2018;70(4):617–626.
3. Anderson D, Villagra VG, Coman E, et al. Reduced cost of specialty care using electronic consultations for Medicaid patients. Health Aff (Millwood). 2018 Dec;37(12):2031–2036.
4. Rostom K, Smith CD, Liddy C, et al. Improving access to rheumatologists: Use and benefits of an electronic consultation service. J Rheumatol. 2018 Jan;45(1):137–140.
5. Patel V, Stewart D, Horstman MJ. E-consults: An effective way to decrease clinic wait times in rheumatology. BMC Rheumatol. 2020 Oct 15;4:54.