Kirsh Susan, Carey Evan, Aron David C, Cardenas Omar, Graham Glenn, Jain Rajiv, Au David H, Tseng Chin-Lin, Franklin Heather, Ho P Michael
Case Western Reserve University School of Medicine, 10701 East Blvd, Cleveland, OH 44106. E-mail:
Am J Manag Care. 2015 Dec 1;21(12):e648-54.
To assess the early impact of implementation of the electronic consults (e-consults) initiative by the Veterans Health Administration (VHA), designed to improve specialty care access.
Observational cohort study exploiting a natural experiment begun in May 2011 at 12 VHA medical centers and expanded to 122 medical centers by December 2013.
The following were assessed: 1) growth of e-consults by VHA regional networks, medical centers, and specialty; 2) location of patient's primary care provider (medical center vs community-based outpatient clinic [CBOC]); 3) potential patient miles needed to travel for a specialty care face-to-face consult in place of the observed e-consults using estimated geodesic distance; 4) use of specialty care subsequent to the e-consult.
Of 11,270,638 consults completed in 13 clinics of interest, 217,014 were e-consults (adjusted rate, 1.93 e-consults per 100 consults). The e-consult rate was highest in endocrinology (5.0 per 100), hematology (3.0 per 100), and gastroenterology (3.0 per 100). The percentage of e-consult patients with CBOC-based primary care grew from 28.5% to 44.4% in the first year of implementation and to 45.6% at year 3. Of those e-consult patients from community clinics, the average potential miles needed to travel was 72.1 miles per patient (SD = 72.6; median = 54.6; interquartile range = 17.1-108), translating to a potential savings of 6,875,631 total miles and travel reimbursement costs of $2,853,387.
E-consult volume increased significantly since inception within many medical and surgical specialties. For patients receiving primary care at one of more than 800 CBOCs, e-consults may decrease travel burden and direct travel costs for patients.
评估退伍军人健康管理局（VHA）实施电子会诊（e-consults）举措的早期影响，该举措旨在改善专科护理的可及性。
观察性队列研究，利用一项始于2011年5月的自然实验，该实验在12个VHA医疗中心开展，并于2013年12月扩展至122个医疗中心。
评估以下内容：1）VHA区域网络、医疗中心和专科的电子会诊增长情况；2）患者初级保健提供者的所在地（医疗中心与社区门诊诊所[CBOC]）；3）使用估计的测地距离来代替观察到的电子会诊进行专科面对面会诊时患者可能需要出行的英里数；4）电子会诊后专科护理的使用情况。
在13个感兴趣的诊所完成的11,270,638次会诊中，有217,014次是电子会诊（调整率为每100次会诊中有1.93次电子会诊）。电子会诊率在内分泌科最高（每100次中有5.0次）、血液科（每100次中有3.0次）和胃肠病科（每100次中有3.0次）。在实施的第一年，以CBOC为基础的初级保健的电子会诊患者百分比从28.5%增长到44.4%，到第3年增长到45.6%。在那些来自社区诊所的电子会诊患者中，每位患者平均可能需要出行的英里数为72.1英里（标准差 = 72.6；中位数 = 54.6；四分位间距 = 17.1 - 108），这意味着总共可能节省6,875,631英里的行程以及2,853,387美元的差旅报销费用。
自开展以来，许多内科和外科专科的电子会诊量显著增加。对于在800多个CBOC之一接受初级保健的患者，电子会诊可能会减轻患者的出行负担并直接降低出行成本。
