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Health Informatics

Trends in Utilization of Electronic Consultations Associated With Patient Payer and Language Among US Academic Medical Centers During the COVID-19 Pandemic

Educational Objective
To identify the key insights or developments described in this article

1 Credit CME

JAMA Network Open

Published Online: July 29, 2022

Original Investigation

Article Information and Disclosures

Anita Arora, MD, MBA, MHS¹;

Renee Fekieta, PhD, MA¹;

Zakia Nouri, MA²;

Danielle Carder, MSc²;

Megan M. Colgan, BA³;

Anne Fuhlbrigge, MD, MS⁴;

Sara L. Jackson, MD, MPH⁵;

Samuel Collins, DrPH⁶;

Nathaniel Gleason, MD⁷;

Julia Chen, MD⁸

Author Affiliations

¹Yale School of Medicine, New Haven, Connecticut
²Association of American Medical Colleges, Washington, District of Columbia
³Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
⁴University of Colorado School of Medicine, Aurora
⁵University of Washington School of Medicine, Seattle
⁶University of Virginia, Charlottesville
⁷University of California, San Francisco
⁸University of Michigan, Ann Arbor

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Key Points

Question How did utilization of electronic consultations (eConsultations) change during the COVID-19 pandemic for US academic medical centers with mature eConsultation programs?

Findings In this cohort study including 14 545 completed eConsultations, eConsultations as a proportion of all specialty consultations significantly increased in the first week of the pandemic. This held true for both English- and non-English–speaking patients and across all payer types, except for self-pay and uninsured patients.

Meaning These findings suggest that eConsultations provided an accessible mechanism for clinicians to receive specialist input when in-person care was limited.

Abstract

Importance Electronic consultations (eConsultations) are increasingly used to obtain specialist guidance, avoiding unnecessary face-to-face patient visits for certain clinical questions. During the COVID-19 pandemic, when in-person care was limited, eConsultations may have helped clinicians obtain specialist input to guide patient care.

Objective To understand how the use of eConsultations changed during the COVID-19 pandemic and whether trends in eConsultation utilization differed based on patient’s payer and primary language.

Design, Setting, and Participants This retrospective cohort study was conducted at 6 academic medical centers in the United States, all participating in the Association of American Colleges Coordinating Optimal Referral Experiences program. Participants included adult patients who had an outpatient visit, referral, or eConsultation during the study period. Data were analyzed from June 4, 2019, to July 28, 2020.

Main Outcomes and Measures The primary outcome was the eConsultation proportion of specialty contact, defined as the number of completed eConsultations divided by the sum of the number of completed eConsultations and specialty referrals, expressed as a percentage. eConsultation percentages of specialty contact were further stratified by payer type and language. Payers included commercial, Medicare, Medicaid, self-pay or uninsured, and other. Primary language included English and non-English languages.

Results A total of 14 545 completed eConsultations and 189 776 referrals were included. More eConsultations were completed for English-speaking patients (11 363 eConsultations [95.0%]) than non-English–speaking patients (597 eConsultations [5.0%]). Patients with commercial insurance represented the highest number of completed eConsultations (8848 eConsultations [60.8%]) followed by Medicare (3891 eConsultations [26.8%]), Medicaid (930 eConsultations [6.4%]), other insurance (745 eConsultations [5.1%]), and self-pay or no insurance (131 eConsultations [0.9%]). At the start of the pandemic, across all academic medical centers, the percentage of specialty contact conducted via eConsultation significantly increased by 6.21% (95% CI, 4.97%-7.44%; P < .001). When stratified by payer and language, the percentage of specialty contact conducted via eConsultation significantly increased at the beginning of the pandemic for both English-speaking patients (change, 6.09% (95% CI, 4.82% to 7.37%; P < .001) and non-English–speaking patients (change, 8.48% [95% CI, 5.79% to 11.16%]; P < .001) and for all payers, except self-pay and uninsured patients (change, −0.21% [95% CI, [−1.35% to 0.92%]; P = .70).

Conclusions and Relevance This retrospective cohort study found that eConsultations provided an accessible mechanism for clinicians to receive specialist input when in-person care was limited.

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Article Information

Accepted for Publication: June 15, 2022.

Published: July 29, 2022. doi:10.1001/jamanetworkopen.2022.24628

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Arora A et al. JAMA Network Open.

Corresponding Author: Anita Arora, MD, MBA, MHS, Yale School of Medicine, PO Box 208088, New Haven, CT 06520 (anita.arora@yale.edu).

Author Contributions: Dr Fekieta had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Arora, Nouri, Carder, Colgan, Fuhlbrigge, Jackson, Collins, Gleason, Chen.

Acquisition, analysis, or interpretation of data: Arora, Fekieta, Nouri, Carder, Fuhlbrigge, Jackson, Collins, Chen.

Drafting of the manuscript: Arora, Fekieta, Nouri, Fuhlbrigge, Jackson, Collins, Chen.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Fekieta, Nouri, Carder, Fuhlbrigge, Collins, Chen.

Administrative, technical, or material support: Carder, Colgan, Jackson.

Supervision: Arora, Gleason, Chen.

Conflict of Interest Disclosures: None reported.

Additional Contributions: Scott Shipman, MD, MPH (AAMC), contributed to conception and design of the study and interpretation of data. Lisa Chew, MD, MPH (Harborview Medical Center), contributed to conception and design of the study. Lisa DeAngelis, BA (University of California, San Francisco), and Nicholas Tacconelli, BS (University of Michigan), helped with data acquisition. Matthew Thompson, MBA (University of Colorado), helped with conception and design of the study and data acquisition. They were not compensated outside of their normal salaries.

References

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AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.