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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
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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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

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.

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