Abstract
Background: Healthcare access disparities persist, particularly among Medicaid patients in regions like the Inland Empire, California. These patients often face prolonged wait times for primary and specialty care, compounded by difficulties in scheduling with providers. Leveraging eConsult platforms offers a potential solution to improve specialist care accessibility. This study examines the impact of the Inland Empire Health Plan's (IEHP) eConsult services on enhancing interactions between primary care providers (PCPs) and specialists and improving patient care.
Methods: We analyzed 2,505 eConsults conducted between January and June 2022 within the IEHP, focusing on dermatology, pulmonology, and urology. Each eConsult was categorized based on closure outcomes, advice provided, and authorization status. We cross-referenced eConsult data with claims and authorization records to determine encounter completion, particularly whether a face-to-face specialist visit occurred.
Results: Only a fraction of eConsults (27% dermatology, 25% pulmonology, 37% urology) resulted in specialist advice. In cases where eConsults did not suffice, specialists recommended in-person follow-up; however, a significant portion of patients (57% dermatology, 71% pulmonology, 53% urology) did not receive in-person specialty care.
Conclusion: This study highlights the potential of eConsults in improving specialty care access for Medicaid patients in underserved regions. While eConsults show promise in expediting specialist access, challenges such as varying PCP utilization and the need for in-person visits persist. Addressing these issues with standardized protocols and better triaging can significantly reduce healthcare disparities and improve patient outcomes.
- Dermatology
- Healthcare Disparities
- Health Services Accessibility
- Medicaid
- Patient Care
- Population Health
- Primary Health Care
- Pulmonary Medicine
- Remote Consultation
- Telemedicine
- Urology
Background and Significance
The Inland Empire, one of California's fastest-growing metropolitan areas, grapples with significant health care access challenges, particularly among its Medicaid population. Presently, over a quarter of the region's inhabitants rely on Medicaid, and with California's Medicaid expansion poised to further strain health care resources.1,2 Medicaid patients often encounter significant barriers to care, with studies showing up to half struggling to secure appointments and experiencing longer wait times compared with privately insured individuals.3 Moreover, the Inland Empire faces a scarcity of primary care physicians (PCPs) and specialists, with approximately 40 physicians per 100,000 people, underscoring the region's resource limitations.4–6
The Inland Empire Health Plan (IEHP), serving roughly 1.5 million Medicaid patients, implemented eConsult services in 2018 to improve care access and streamline communication between PCPs and specialists. eConsults, in this context, refer to asynchronous consultative interactions where PCPs electronically submit clinical questions, accompanied by relevant documentation, to specialists for advice. Unlike telehealth or direct verbal communication platforms, the eConsult system utilized here prioritizes efficient nonface-to-face evaluations, with PCPs encouraged to provide detailed clinical information to optimize specialist feedback. Although strongly emphasized by IEHP, eConsults are not mandatory, and PCPs retain clinical discretion to pursue alternative, albeit more cumbersome, referral pathways.7,8 To be noted, this eConsult service is a shared online platform not integrated with any one specific electronic health record (EHR). Due to integration limitations PCPs using any EHR system must pose a clinical question and upload relevant patient information including notes, pictures, and diagnostics for specialists to properly advise on. Furthermore, eConsults were integrated as one of the steps in the workflow for obtaining a face-to-face referral by the PCPs, which will be further elaborated on in the discussion.
The introduction of eConsult services represents a significant step forward. Since implementing eConsult in 2018, IEHP Member CAHPS Survey noted an increase in scores in several quality measures including “Getting Needed Care” which is ranked 66th nationally and “Getting Care Quickly which is ranked 33rd nationally.7 These services, integrated into IEHP's framework, aim to streamline communication between PCPs and specialists, thereby optimizing the referral process and potentially ameliorating patient care outcomes.
Studies of similar eConsult models have demonstrated improved access and efficiency, particularly in underserved populations.8,9 In addition, tools have been developed to assess the quality and impact of eConsults, shedding light on their efficacy and areas for enhancement.10 However, it is important to note that the present literature does not show the actual utilization or outcomes, rather it focuses on individual programs instead of a large sample of eConsult implementations and their corresponding use.
Against this backdrop, our study aims to evaluate how eConsults foster meaningful PCP-specialist interactions and their impact on patient care outcomes, addressing implementation challenges and opportunities for optimization, which we saw directly through our in-person visits to each clinic and analysis of dialog between PCPs and specialists on the eConsult platform.
Methods
A retrospective review was performed on eConsults submitted via the online Converge platform (Safety Net Connect, Newport Beach, CA) by PCPs under IEHP health plan. The study focused on analyzing 2,505 eConsults from dermatology, pulmonology, and urology, as these specialties represented the highest volume of eConsults and the most comprehensive datasets for the study period from January to June 2022 relative to 60 other specialties that were available for the PCPs to interact with, providing a robust foundation for analysis.
Each eConsult was coded independently by authors, resolving differences through group discussions. Data were analyzed based on closure outcomes, advice provided, and authorization statuses. Additional claims and authorization records were cross-referenced to determine completion status, and am extensive categorization framework was developed which is displayed in Table 1 for easier readability. The data were analyzed in Microsoft Excel.
Category Dictionary
Results
eConsult Outcomes
Out of the 2,505 eConsults analyzed partial demographic data were available for 2,054 (Table 2). There was a total of 1,305 eConsults in the specialty of dermatology (Table 3). It was found that 68% of eConsults were closed as refer to in-person visit with no recommendations given and 16% of eConsults were closed as refer to in-person visit with recommendations given. 13% of eConsults were categorized as consults in which a referral or specialty change was not necessary; 1% of eConsults were closed as a specialty change, and the remaining 2% of eConsults were closed as consult canceled or expired. Approximately 27% of these eConsults included specialist advice or recommendations for the primary care physician. Of the advice provided, 95% included treatment recommendations while 22% included testing recommendations.
Consultation Demographics
Consult Outcomes by Specialty
A total of 537 eConsults in the specialty of pulmonology were analyzed (Table 3). It was found that 66% of eConsults were closed as refer to in-person visit with no recommendations given and 24% of eConsults were closed as refer to in-person visit with recommendations given; 6% of eConsults were categorized as consults in which a referral or specialty change was not necessary; 3% of eConsults were closed as a specialty change and the remaining 1% of eConsults were closed as consult canceled or expired. Approximately 25% of these eConsults included specialist advice or recommendations for the primary care physician. Of the advice provided, 43% included treatment recommendations while 85% included testing recommendations.
In the specialty of urology, a total of 663 eConsults were analyzed (Table 3). Among these, 61% were closed as referrals to in-person visits with no recommendations, while 34% were closed with recommendations given. In addition, 5% of eConsults did not require a referral or specialty change. Approximately 37% of eConsults included specialist advice for primary care physicians, with 67% involving treatment recommendations and 79% involving testing recommendations.
Authorization Status
For dermatology, of the 1,305 eConsults, 16% did not require a referral or appointment request. Of the remaining 1,096 eConsults that did require a referral or appointment request, 41% were authorized with an appointment completed, 57% were authorized but an appointment was not completed, and 2% were not authorized but an appointment was requested. Whereas for pulmonology, Of the 537 eConsults, 6% did not require a referral or appointment request. Of the remaining 429 eConsults that did require a referral or appointment request, 27% were authorized with an appointment completed, 71% were authorized but an appointment was not completed, and 3% were not authorized but an appointment was requested. Lastly, for urology of the 663 eConsults, 25% did not require a referral or appointment request. Among the remaining 495 eConsults, 28% were authorized with an appointment completed, 71% were authorized but no appointment was completed, and 2% were not authorized but an appointment was requested (Table 4).
Authorization by Specialty
Average Wait Time
The average time between consult creation and appointment date with a specialist was 44.5 days for dermatology, which is slightly lower than the 50-day average ambulatory referral wait time for a dermatology appointment for patients with Medicaid insurance.11 Our study showed an average of 36.75 days for pulmonology and 61.13 for urology. Whereas the national average for referral to in-person urologist appointments was 35 days for Medicaid patients.12 No reliable data for Medicaid patients seeking pulmonologists could be found, though it can be seen that the average wait-time for Medicaid patients exceeds those of non-Medicaid insured population (Figure 1) (Table 5).13,14
eConsult analysis: advice rates and wait times by specialty.
Comparison of Average Face-to-Face Appointment Wait Times
Discussion
The implementation of eConsults represents a promising avenue for enhancing access to specialty care, particularly for patients covered by Medicaid who often face prolonged wait times and clinician shortages. Our study underscores the significance of eConsults as a vital resource for facilitating faster access to specialist care, evident in the substantial proportions of dermatology (27%), pulmonology (25%), and urology (37%) eConsults that received specialist advice or recommendations. Notably, a noteworthy percentage of eConsults across specialties (6% in pulmonology, 13% in dermatology, and 5% in urology) were resolved without necessitating an in-person referral, showcasing the potential of eConsults to mitigate barriers to care associated with traditional referral processes, such as transportation challenges.
While recognizing the potential benefits of eConsults, it is essential to acknowledge the challenges inherent in their implementation. The relatively low rates of advice highlight variability in PCP engagement, often stemming from insufficiently detailed initial submissions. While the asynchronous nature of the system enhanced efficiency by allowing many consults to conclude without direct dialog, it also revealed missed opportunities for deeper consultative interactions. The eConsult implementation was integrated into the traditional referral authorization process, leading many PCPs to view it primarily as a mechanism for securing authorization rather than as a platform for clinical advice.
To address this perception, specialists were trained to provide proactive guidance, even in the absence of specific questions, particularly when they believed their input could enhance the quality of an in-person referral. However, because the process was tied to referral authorization, many PCPs did not fully recognize the value of posing clinical questions, focusing instead on obtaining in-person authorization. As a result, some PCPs perceived eConsults as an additional barrier to securing authorizations rather than as a tool to improve patient care.
Field visits further revealed variability in eConsult utilization, with some PCPs perceiving the system as an added workload rather than a consultative care tool. In addition, the pressure for face-to-face visits persisted, driven by PCPs’ preferences for traditional referrals and a reluctance to fully embrace the eConsult model. This insistence for face-to-face visits could explain why the wait times did not decrease. As discussed by Deeds’ et al, this variability may stem from the lack of standardized utilization protocols, the platform's lack of user-friendliness, and inadequate clinical information in eConsult requests, potentially hindering the delivery of specialist advice and diminishing the expected benefits.15 Such findings underscore the importance of enhancing education and adoption among PCPs and improving triaging and utilization protocols within eConsult systems.
Furthermore, as we think about the larger purpose of using specialists we can categorize the goal into 4 main areas: seeking advice about a medical condition, referral for procedural interventions, assistance in the comanagement of a longitudinal complex condition, or ultimately transition of care to a specialist. It is generally accepted that this would be the purpose of a referral, however in reviewing referrals in general we have seen an erosion in the quality of the referrals being placed. Subjectively, indeed there is an overwhelming majority of referrals that only consist of an ICD-10 code without any other information as to why a patient is being referred in the first place. Further complicating the transition, there are often confusing progress notes or no progress notes at all attached to the referral. Feedback from specialists laments frequently that the patients usually arrive at their consultation with minimal information, minimal work up, or limited awareness as to why they were being referred in the first place. eConsults can provide a valuable bridge into improving the overall care transition by providing the benefits previously discussed.
Conclusion
Looking ahead, future research endeavors should delve deeper into understanding the impact of primary care clinician engagement on the quality and effectiveness of eConsult outcomes, as well as the educational implications for primary care clinician. In addition, exploring the influence of eConsults on referral patterns, time-to-treatment, and patient satisfaction, especially if patients are informed of their clinician's use of the service, warrants further investigation.
While there is a need for further research to fully elucidate the role and impact of eConsults in patient care, our study offers valuable insights into its potential utility. By facilitating the provision of timely and high-quality specialist advice, eConsults hold promise in bridging the gap in specialty care access and improving patient outcomes, even without the need for an in-person specialist appointment.
Moving forward, addressing the challenges identified in our discussion section is crucial for optimizing the effectiveness of eConsults in bridging gaps in specialty care access. Our study faced several limitations. Due to ungrouped codes, summarizing diagnoses for patients seen in each specialty was challenging, preventing us from identifying meaningful patterns. In addition, we had no control over the open scheduling systems, and IEHP does not track scheduling data, limiting our ability to analyze specialist access. Although anecdotal evidence and national comparisons suggest an impact, IEHP's lack of visibility into scheduling practices is a significant constraint. In addition, the low response rates highlight the need for enhanced PCP education on effective submission practices and the absence of reimbursement for PCPs during the study likely contributed to perceived administrative burdens, a challenge mitigated by subsequent introduction of reimbursable codes.
This was a limited-scope study; future research should involve more comprehensive data and newer technologies, like the newer patient-facing IEHP Plan App. A broader, nationwide review of eConsult utilization is also needed for more robust insights. Future efforts should focus on developing standardized utilization protocols, enhancing clinical information exchange, and fostering a culture of collaboration and trust between primary care physicians and specialists. In addition, future research should consider narrowing the focus to a smaller group of physicians who fully understand and use the eConsult service as intended, allowing for a more accurate assessment of its true value and impact. By doing so, eConsults can emerge as a valuable tool for improving patient care outcomes and reducing unnecessary face-to-face visits, ultimately enhancing health care delivery efficiency.
Acknowledgments
We extend our gratitude to Sajid Ahmed, CEO of Afya Global, and Alvin Kwong, CTO, for their invaluable support in providing the necessary resources and data for this work.
Notes
This article was externally peer reviewed.
Funding: No funding was received for this article.
Conflict of interest: Dr. Frencher, Dr. Jih, and Waheed Baqai are officers of Afya Global. Moriah Maddalena and Birpartap Thind interned at Afya Global. Afya Global is a for-profit entity that helps maintain the technology for the eConsult system and are contracted with IEHP to provide this eConsult service as discussed in this article on behalf of IEHP.
To see this article online, please go to: http://jabfm.org/content/38/3/592.full.
- Received for publication August 28, 2024.
- Revision received January 22, 2025.
- Accepted for publication January 29, 2025.
