Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.
Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.
JAMA Health Forum. 2021 May 21;2(5):e210456. doi: 10.1001/jamahealthforum.2021.0456. eCollection 2021 May.
Accessing specialty care continues to be a persistent problem for patients who use safety-net health systems. To address this access barrier, hospital systems have begun to implement electronic referral systems using eConsults, which allow clinicians to submit referral requests to specialty clinics electronically and enable specialty reviewers to resolve referrals, if appropriate, through electronic dialogue without an in-person visit.
Measure the effect of implementing an eConsult program on access to specialty care.
Using an interrupted time series design with data from 2016 to 2020, this study analyzed 50 260 referral requests submitted during the year before and the year after eConsult implementation at 19 New York City Health + Hospitals (NYC H+H) specialty clinics that spanned 7 NYC H+H hospital facilities and 6 unique specialties.
Referral request was submitted to a specialty clinic in the year following eConsult implementation.
Main outcomes included the fraction of referral requests resolved without an in-person visit following eConsult implementation; and, among requests triaged to have an in-person visit, the fraction of referrals with a successfully scheduled appointment, mean wait time to a specialty appointment, and the fraction of referral requests with a completed specialty visit. Changes associated with eConsult implementation were estimated using multivariate linear regression adjusting for patient age, gender, and specialty clinic fixed effects.
Across 19 NYC H+H specialty clinics, 26 731 referral requests were submitted in the year before and 23 529 referrals were submitted in the year after eConsult implementation. Following eConsult implementation, 13% of all requests were resolved electronically. Among requests requiring a follow-up visit, the fraction with an appointment successfully scheduled increased by 15.8%, from 66.5% to 82.3% ( < .001). The mean time to an appointment decreased from 61.0 days pre-eConsult to 54.1 days post-eConsult, an adjusted 8.2-day shorter wait time (or 13.3% reduction) following eConsult adoption ( < .001). The percentage of referrals with a completed follow-up visit with a specialist within 90 days of the request did not change (38.4% vs 37.9%, = .07). Changes in outcomes were mitigated during months when most clinics underwent an electronic health record transition after implementing eConsult.
In this quality improvement study, implementation of eConsults at a large multi-specialty safety-net system was associated with improvements in appointment scheduling rates and wait times. Despite an additional electronic health record transition, eConsults are a promising health care delivery tool for increasing access to specialty care.
对于使用安全网医疗系统的患者来说，获得专科护理仍然是一个持续存在的问题。为了解决这一获取障碍，医院系统已经开始实施使用电子咨询的专科转诊系统，该系统允许临床医生以电子方式提交转诊请求至专科诊所，并使专科审查员能够通过电子对话解决转诊问题，如果合适的话，而无需进行面对面访问。
衡量实施电子咨询计划对专科护理获取的影响。
设计、设置和参与者：本研究使用 2016 年至 2020 年的中断时间序列设计，分析了在纽约市健康与医院公司（NYC H+H）的 19 个专科诊所实施电子咨询后的一年中提交的 50260 份转诊请求，这些诊所分布在 7 家 NYC H+H 医院设施和 6 个独特的专科。
转诊请求在电子咨询实施后的一年中提交至专科诊所。
主要结果包括电子咨询实施后无需进行面对面访问即可解决的转诊请求比例；以及在需要面对面访问的请求中，成功预约的转诊比例、专科预约的平均等待时间以及完成专科就诊的转诊请求比例。使用多元线性回归调整患者年龄、性别和专科诊所固定效应，估计与电子咨询实施相关的变化。
在 19 个 NYC H+H 专科诊所中，在电子咨询实施前一年提交了 26731 份转诊请求，而在电子咨询实施后一年提交了 23529 份。电子咨询实施后，所有请求中有 13%通过电子方式解决。在需要后续就诊的请求中，预约成功安排的比例增加了 15.8%，从 66.5%增加到 82.3%（ < .001）。预约时间从电子咨询前的 61.0 天缩短至电子咨询后的 54.1 天，调整后的等待时间缩短了 8.2 天（或减少 13.3%）（ < .001）。在请求后 90 天内与专家进行专科就诊的转诊比例没有变化（38.4% 与 37.9%， = .07）。在实施电子咨询后，大多数诊所经历了电子病历转换的几个月中，结果的变化得到了缓解。
在这项质量改进研究中，在大型多专科安全网系统中实施电子咨询与预约安排率和等待时间的改善相关。尽管增加了电子病历的转换，电子咨询仍是增加专科护理获取的有前途的医疗保健提供工具。
