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June 27, 2019

Reimagining Specialty Consultation in the Digital Age: The Potential Role of Targeted Automatic Electronic Consultations

Author Affiliations
  • 1Division of Hospital Medicine, Department of Medicine, University of California, San Francisco
JAMA. 2019;322(5):399-400. doi:10.1001/jama.2019.6607

The complexity of medical care ensures that no single physician can know everything, which makes specialist involvement essential for providing optimal management for many conditions. However, in many hospitals the only formal way to obtain specialty expertise is to request a traditional consult, which includes chart review, history, physical examination, and a detailed note with recommendations. Because such consults are time consuming and resource intensive, no health care system has the capacity to offer them for every patient who might benefit. This forced duality—traditional consult vs nothing—leads to a brisk market in “curbside consults,” which are limited by incomplete information exchange and can result in inaccurate recommendations.1

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    2 Comments for this article
    Interesting Concept
    Gayle Minard, MD | The University of Tennessee Health Science Center, Department of Surgery
    This a very interesting concept. I worked in the VA system for almost 30 years and e-consults were very helpful. Of course they had be generated by a healthcare professional which limited the questions to things we really needed to know. I am Boarded in critical care so I am very comfortable managing a wide variety of acute care issues. But being able to get a quick answer from cardiology or other services was very helpful. Frequently the patients were being seen as an outpatient by that service, so they weren’t random questions in unfamiliar patients.

    On the other
    hand, I work in our extremely busy level one trauma center as a trauma surgeon. Our electronic health record, Cerner, flags patients who appear to be septic. That flag occurs on every single trauma patient shortly after admission due to their SIRS response. Clearly we would not need consults on those people for that. Since we are all boarded in critical care, we really don’t need outside consults for managing much of anything in our unit. In addition, I am the medical director of our nutrition support service. We are very comfortable & competent managing all electrolyte abnormalities along with glucose management, and don’t need a consult from some other service to help with that in the acutely ill patient.

    With the correctly designed system, this could certainly benefit patient care (different criteria for consults depending on what unit the patient was in and what physicians were managing them). I also foresee consultants that never see patients and just manage the e-consults, which would be a brand new specialty for people who love patient management but not the patients!
    Targeted Consultations & Interaction with Prooactive Integrative Care
    Stephen Strum, MD, FACP | Community Practice of Hematology & Oncology
    Wachter et al. describe an approach that involves targeting a subset of critical issues within a particular illness such as diabetes mellitus (e.g., hypo- or hyperglycemia) based on EHR (electronic health record) "tell-tales." Importantly, they are using a computer-created module to analyze those cases and then provide feedback to the treating physician. In my experience of reviewing medical records from across the country, the current EHR is essentially a cut and paste approach to bill the insurer for the highest level of reimbursement. What it "achieves" is bloating the medical record and diffusing attention from issues that often are unattended and become critical and costly. Therefore, the targeted automatic e-consultation is a serious step in the right direction (for a change).

    But despite this advance, what is left is a morass of poorly cared-for patients where a proactive stance is missing, and integration of care is lacking. The current EHR is not resolution-based, but it perpetuates or continues the patient's problems, akin to being trapped in a revolving door. I believe it is critical to whatever healthcare plan is adopted in our country to focus on resolving illness and not "revolving" illness. An EHR can easily become resolution based. It can also have embedded modules, just as in Wachter et al. 's model, programs to generate graphs and kinetics showing trends that will pre-empt overt clinical illness. Such a proactive integrative care (PIC) model does involve work to move current medical information into a format that helps to identify problems earlier & to focus on their resolution. Such labor requires training personnel about how to abstract data and present it with a PIC focus. Some of the manipulations of data are likely amenable to computer-assisted functions, but others require human interaction. Such an enterprise involves the creation of many new jobs, but it also is a significant advance that pays for itself by earlier diagnosis and prevention of critical illnesses.