MD Associate Chief Medical Officer of the Los Angeles County Department of Health Services.

Paul Giboney

Physicians, in general, can often be beholden to the “tried and true” ways of conducting their clinical work.  In twenty years of caring for patients as a Family Medicine doctor, I have often relied on the patterns and approaches I learned in residency back in the 1990s.  However, as new tools emerge to better care for patients, we as physicians need to question our assumptions and habits.  One of these assumptions is that a face-to-face visit to the doctor is always the best option for patients.  Over the past decade, my experience (and that of my patients) with electronic consultation has challenged the notion that “in-person” is always preferred.

Electronic consultation or “eConsult” is a secure, HIPAA-compliant, web-based, or EMR-integrated communication technology that connects a Primary Care Provider (PCP), like me, with a specialist expert.  When the PCP has a question about patient care or believes their patient needs to see the specialist, eConsult allows the PCP to pose the question and then to engage in an iterative dialogue with the specialist.  This “pre-referral” conversation has substantial clinical value and can be greatly beneficial in improving the patient’s experience with their health care.

Consider the typical, non-eConsult scenario where the patient sees their PCP for a medical problem.  The PCP sends a “referral” to the specialist.  A few weeks go by for referral approval and after the visit is scheduled, the inconvenience to the patient begins.  The patient has to take a day off of work (or arrange childcare), drive (or take buses) to the specialist’s office, find parking (and sometimes pay for it), navigate the registration process and sit (at times for hours) in a waiting room with other sick patients.  Often, that first specialist visit is begun with questions like “why are you here” and ends with “get a bunch of tests to come back and see me again in a few weeks for the results.”  A few weeks later, the hassle repeats itself for the patient as they return for follow up care. The medical system in the United States has largely stuck with this approach to care with little change over the past six decades.

“Electronic consultation or “eConsult” is a secure, HIPAA-compliant, web-based or EMR-integrated communication technology that connects a Primary Care Provider (PCP), like myself, with a specialist expert"

In contrast, let me share the patient experience in my practice, where we have eConsult.  I see the patient and have a question about their care.  I send an eConsult to the specialist and, in a median time of 24 hours, receive a response back.  For a significant percentage of the questions, I receive specific enough advice back from the specialist that the patient never needs to see the specialist.  My nurse or I call the patient with the updated plan of care.  The patient has not been asked to go through the inconvenience of waiting for the approval, taking the time off of work or away from family, arranging the transportation, finding the parking and sitting in the waiting room.  However, there is still patient value If, after the eConsult conversation, the specialist wants to see the patient in-person.  In such cases, I can, at the direction of the specialist, order in advance, all the “pre-visit” labs and testing, so that the first specialist encounter is a definitive one and the patient does not have to waste their time attending low-value specialty visits. 

We have deployed eConsult in all our specialties and, after the first million eConsults, have seen patient experience improve without noting any concerns with regards to patient outcomes.  In all aspects of society, communication has improved efficiency and safety.  We need to do the same in medicine.  Our patients are expecting their providers to have discussed their care and determined a care plan that includes, among other things, a high level of respect for their time and effort.  With the reduction in low-value visits and the improved communication between providers – all while keeping the patient’s desires at the center of care, our experience has convinced me that sometimes the best option for the patient is not a face-to-face visit but instead is an eConsult.