Matthew Press, MD
Marcie Ordowich, MPH, MBA
Jonathan Glick, MD
Primary care providers (PCPs) help patients access specialty services when necessary.
However, traditional methods for obtaining specialist input are suboptimal. PCPs often pursue "curbside consults" with specialists – reaching out via email or phone for advice. This outreach can feel disjointed as the PCP may not have an established relationship with the specialist. Additionally, specialists don't always have all the information they need to weigh in. Finally, when feedback is obtained, it is not accounted for in the electronic health record (EHR) as part of formal patient care.
Without a standardized and reliable approach to gain specialist input, many patients who could be managed in primary care with specialist input end up getting referred for new patient visits with specialists. Wait times for such appointments can be lengthy due to high demand.
These obstacles delay treatment for sick patients and burden already busy providers.
E-consults streamline communication between PCPs and specialty providers by enabling providers to request specialist feedback through the EHR. PCPs placing E-consult orders are prompted to ask a specific clinical question and detail key background information for the specialist to reference. Specialists are alerted in their In basket when a request comes through, and the entire exchange is captured in the patient's chart as a telephone encounter.
E-consults enable PCPs to quickly obtain specialist input so that timely, high-value care can be provided to patients in the appropriate care setting.
In the initial one-month pilot, E-consults reduced unnecessary specialist visits, enhanced access for the sickest patients, improved satisfaction among patients and providers, and increased downstream revenue to the health system. With E-consults, the wait time for specialist input dropped dramatically – from a three- to six-month wait for an in-person visit to less than seven days.
Based on these results and accelerated by the need for virtual care options during the COVID-19 pandemic, E-consults for diabetes, endocrine, cardiology, rheumatology, renal, genetics, sleep, gastroenterology, and other specialties were implemented in early 2020. Providers at Penn Medicine conducted more than 150 E-consults in the first two months of adoption at scale, and approximately 30 to 40 percent of cases prevented unnecessary specialist visits.
Further work by the Penn Center for Cancer Care Innovation found that E-consults for non-malignant hematology allowed patients to receive a medical intervention 13 times faster.
In 2022, when E-consults were implemented in Penn Medicine’s Division of Infectious Diseases, they quickly became the largest receiver of requests.
Fake back end
Fake back end
Fake back end
It is essential to validate feasibility and understand user needs before investing in the design and development of a product or service.
A fake back end is a temporary, usually unsustainable, structure that presents as a real service to users but is not fully developed on the back end.
Fake back ends can help you answer the questions, "What happens if people use this?" and "Does this move the needle?"
As opposed to fake front ends, fake back ends can produce a real outcome for target users on a small scale. For example, suppose you pretend to be the automated back end of a two-way texting service during a pilot. In that case, the user will receive answers from the service, just ones generated by you instead of automation.
Fake back end
In the first iteration of E-consults, we used existing In basket functionality to streamline clinician workflows and simulate a future, chart-based billable encounter flow.
Piloting the first iteration as a fake back end allowed us to quickly test various approaches to templated questions and menu options without requiring an Epic build. It also revealed provider best practices and enabled us to measure satisfaction and identify critical use case scenarios for optimal consults.