The implementation of electronic hematology consults at a VA hospital.

The widespread implementation of electronic medical records (EMR) allow providers ready access to large amounts of patient information, and for some specialties much of the data needed to provide recommendations can be gathered electronically. Electronic consultation (e-consult) is a health care delivery method in which a consultant provides recommendations by reviewing the EMR without a face-to-face (FTF) encounter with the patient. e-consult may improve timeliness of care, save cost, prevent unnecessary visits, and address a shortage of specialists. e-consult was initially implemented in radiology and pathology, but it is now in broader use, including internal medicine subspecialties.Diagnostic accuracy of the electronic reviewof blood and bone marrow samples has been reported, but there is no published data regarding the effectiveness of other hematology e-consults. The Veterans Affairs Connecticut Healthcare System (VACT) initiated hematology e-consult in 2011 as part of a national initiative to improve access to care. Referring providers are given the choice between an e-consult and an FTF clinic visit, and make this decision in coordination with the patient. The majority of referrals to our service come from primary care clinicians, and guidelines called “service agreements” were developed with the primary care leadership to help referring clinicians determinewhich clinical issueswere appropriate for each type of consult. Board-certified/eligible attending hematologists review the EMR, peripheral blood smear, and imaging when appropriate, and document recommendations in the chart. Although the majority of Veterans Affairs (VA) patients are older with multiple morbidities, the VA EMR is comprehensive and it includes readily accessible problem lists, pharmacy records, laboratory data, imaging, and all provider visits, thus allowing efficient review of relevant information. For e-consults that come from outside the West Haven VA, theperipheral smear slides are courier-delivered to theWestHaven VA hematology laboratory from community-based sites. The hematologist may recommend additional testing and/or a referral for an FTF visit as appropriate, and the referring clinician communicates the recommendations to the patient. Workload credit is provided in proportion to the time spent completing the consult. Data on FTF and e-consults between the years 2009 and 2013 at VACT were abstracted from the EMR. We randomly selected for review 302 e-consults, 305 FTF consults before e-consult implementation, and 302 FTF consults after the implementation of e-consult. Patient and provider satisfaction with e-consults was evaluated by mailed anonymous patient surveys and e-mail surveys, respectively. The time to completion of e-consults was prospectively measured by one of the authors (M.G.R.) for 142 cases completed during thefirst year after implementation of an e-consult. SPSS version 22 was used for all statistical analysis with continuous variables compared by analysis of variance, whereas categorical variables were compared by the Pearson x test. Our hospital’s institutional review board approved this study. The annual number of FTF hematology consults at VACT decreased from 391 prior to the e-consult implementation, to 319 in the second year after implementation, whereas the overall patient population enrolled atVACT remained constant.More than 85%of consults originated from primary care providers in all 3 groups. e-consults were converted to FTF consults in 17% of cases. e-consult patients received a more timely evaluation and lived further from our clinic than patients seen in FTF consults (Table 1). The most common reason for consultation in all 3 groups was anemia, and the etiology of the anemia in the majority of the cases was benign disease (micronutrient deficiency, chronic kidney disease, and chronic disease) or presumed early myelodysplastic syndrome. The majority of coagulation-related e-consults were related to the management of venous thromboembolism, with few cases of atrial fibrillation management and von Willebrand disease. The mean time to complete an e-consult by one of our authors, who is a board-certified hematologist with more than 10 years of experience, was 14.5 minutes (standard deviation, 7.3). In comparison, we allot 30 to 60 minutes for FTF consults depending on the anticipated complexity of the clinical