Experience with Pediatric Neurology e-Consults from a Specialist Perspective at an Academic Center

Introduction

Electronic consultations (e-consults) are asynchronous interactions between medical providers. They are becoming more widespread as health care systems seek ways to limit cost and improve specialty access. One form of e-consult involves an inquiry from a primary care provider (PCP) to a specialist in the outpatient setting. Prior studies have reported feedback from patients and from PCPs. Liddy et al. examined access to specialists in a remote community and reported reduced cost to health care systems, ¹ improved specialty access, and enhanced patient and PCP satisfaction. Ackerman et al. examined patient acceptance of e-consults in an academic medical center. Patients raised concerns over potential copays, and loss of the opportunity to communicate their concerns directly to the specialist. ² PCPs reported improved knowledge through case-based learning but raised concern over the additional workload.^3,4 Few studies examined e-consults from a specialist perspective^5–8 including rheumatology, cardiology, and adult neurology. Pediatric neurology may be perceived as a complex specialty that is less suitable for e-consults, especially for younger patients. We aim to describe our experience in implementing this service at a large academic medical center (AMC) with affiliated PCPs who shared the same electronic medical record.

Methods

Study Setting

In 2014, the Association of American Medical Colleges (AAMC) through the CORE program (Coordinating Optimal Referral Experiences) implemented the e-consult model in 7 AMCs in the US, including the University of Virginia (UVA). ³

The e-consult service for adult subspecialties was launched at UVA in March 2015 and was made available to UVA-affiliated PCPs only. Pediatric subspecialties were added in 2019, and Pediatric Neurology was one of the first to pilot the service. As of August 2021, there have been 917 e-consults to 14 participating pediatric subspecialties. Of these, 309 (33.7%) were to Sleep Medicine, 196 (21.4%) to Endocrinology, 166 (18.1%) to Gastroenterology, and Pediatric Neurology was the 4th most common with 68 (7.4%).

When Pediatric Neurology joined the e-consults service, we assigned two pediatric neurologists as the “champions” responsible for managing this service (authors AA and KH). We created templates for what we anticipated would be the most common consult questions, including: tics, febrile seizures, headache, spells, concussion, and “other”. The templates included guidance for consulting PCPs regarding relevant information to include in the e-consult and indications for when a traditional referral should be considered instead (Figure 1). PCPs were encouraged to include all relevant information in the e-consult order using the appropriate template, but the neurologists had access to the patient's electronic medical record (EMR) and could review additional notes, images, and labs as needed. Specialists used a template to respond to the e-consult, including recommendations and contingency plans (Figure 2). Specialists had the choice to decline the e-consult while providing alternative options to address the question. These included forwarding the question to the patient's current neurologist or arranging for FTF visit. The expectation was that the e-consults would be addressed within three business days. The specialist's response could be communicated to the PCP electronically, through a phone call, or both. Initially, both the PCP and the specialist received an internal work Relative Value Unit (wRVU)-based credit for the e-consults. With the onset of the COVID-19 pandemic in 2020 we started billing e-consults for the specialist who received 0.7wRVU for each e-consult over 5 minutes if the communication was only through EMR (CPT 99451), and 0.5–2.0 wRVU for each e-consult over 20 minutes if the communication was through both EMR and verbal discussion (CPT 99446-99449). PCPs continued to receive 0.5 wRVU credit per consult towards their wRVU targets.

OPEN IN VIEWER

Figure 3.

Number of e-consults received per month. Arrow denotes when the limitations due to the COVID19 pandemic began.

Unlike many other states, Virginia Medicaid does not cover e-consults, given that the service in e-consult is not directly provided to patients. The exception is that e-consults were covered during the period of Public Health Emergency state (PHE) which started at the start of the COVID pandemic in March of 2020 and ended in June 2021. Private insurances are starting to cover e-consults more broadly.

Results

We received 58 Pediatric Neurology e-consults in the period from 4/17/2019 to 4/29/2021. We received 2.7 consults/month before the limitations imposed by the COVID-19 pandemic began in March 2020, and 2 consults/month after these limitations began. (Figure 3)

OPEN IN VIEWER

Figure 4.

Age distribution of patients at the time of e-consults.

Patient Characteristics

Patient ages varied from neonates to 19 years old with a mean age of 8.7 years (SD = 6.0) and a median age [IQR] = 9 (3-14). Of these, 20.6% (N = 12) were ≤ age 1 year. (Figure 4). Thirty-two (55.2%) of the patients were females, and 26 (44.8%) were males.

OPEN IN VIEWER

Figure 1.

Example of an e-consult template (headache).

E-Consult Content

The chief complaints included spells (N = 17, 29.3%), headaches (N = 13, 22.4%), tremor (N = 4, 6.9%), concussion (N = 3, 5.2%), abnormal head circumference (N = 3, 5.2%), limb pain (N = 3, 5.2%), abnormal physical exam (N = 3, 5.2%: abnormal Moro reflex, abnormal muscle tone, abnormal eye movements), abnormal EEG (N = 2, 3.4%), abnormal imaging (1, 1.7%), and other (N = 4, 6.9%: speech regression, anosmia, restless sleep, recurrent facial palsy). (Table 1)

OPEN IN VIEWER

Table 1.

Distribution of e-Consults Based on Indication, and the Need for FTF Visit.

Indication	FTF visit recommended	FTF visit not recommended
Spells	10	7
Headache	8	5
Tremor	1	3
Concussion	3	-
Breakthrough seizures	-	5
Abnormal physical examination	1	2
Abnormal head circumference	3	-
Abnormal EEG	-	2
Abnormal imaging	1	-
Limb pain	2	1
Other	4	-
Total	33	25

Most of the e-consults were ordered following a PCP clinic visit (N = 53, 91.4%). A few were initiated following a telephone call (N = 3, 5.2%) or a MyChart message (N = 2, 3.5%).

Five (8.6%) of the e-consults were declined, because the patients were already known to Pediatric Neurology. All 5 patients had epilepsy, and all had breakthrough seizures for which the PCP requested recommendations for anti-seizure medication adjustment.

Other than these 5 epilepsy patients, only 9 other e-consults asked about management options (5 patients with headache, 2 patients with concussion, 1 with restless sleep, and 1 with arm pain). The remaining e-consults requested guidance regarding possible diagnosis, additional workup (mainly magnetic resonance imaging (MRI) or electroencephalogram (EEG)), or whether a referral to Pediatric Neurology was warranted.

Thirty-three, (56.9%) of the questions were answered without recommending an FTF appointment. Of these, one patient was subsequently referred and seen in clinic. For 17 (29.3%) of the e-consults, initial recommendations regarding workup or management were made, while recommending an FTF visit with Pediatric Neurology. Of these, 14 were already seen at the time of this study. For 3 (5.1%) e-consults, the specialist recommended referral for an FTF appointment without additional recommendations. Of these, two were already seen at the time of this study. (Table 1)

Of the 17 patients who were seen by Pediatric Neurology, 71% (12) were seen in less than 1 month, and the rest were seen in less than 2 months of the e-consult. The average time from the e-consult request to the FTF visit was 27.4 days (SD = 17.2).

Of the patients seen in an FTF consultation, 64.7% (N = 11) had a workup initiated, 43.8% (N = 7) were prescribed treatment, and 94.1% (N = 16) required follow up visits in the Pediatric Neurology clinic.

PCPs documented the outcome of the e-consult in 72.4% (N = 42), and they documented specifically discussing the outcome of the e-consult with the patient's family in 55,2% (N = 32).

Of the 17 e-consults that were for spells, 58.8% (N = 10) were answered without the need for an FTF visit. Of the 13 e-consults for headache, 61.5% (N = 8) were answered without the need for an FTF visit. Of the 4 e-consults related to tremor, 3 required an FTF evaluation. In 2 patients (one with speech regression, another with abnormal imaging), a referral to a different specialty was recommended.

Discussion

E-consult is an established method of communication between providers in many centers in the US and around the world. ⁴ Few studies have reported the specialists’ perspective of the e-consults, and these showed that the e-consults were used appropriately, reduced the need for FTF visits, and improved specialists’ efficiency.^6–8

There is a shortage of child neurologists in the United States, and the wait time for an FTF visit can be several months. ⁹ Referrals to pediatric neurology vary in their relevance and their urgency and may not contain enough information to triage properly. In practice, many PCPs use “curbside” consults to seek guidance from specialists, but these may not provide all the needed information, are not always documented in the patient's chart, and are not reimbursed. E-consults are covered under the malpractice insurance policy. There is a concern from specialists that e-consults might put them at increased liability; however, the documentation of the question and rationale behind the recommendation are often considered more protective to the specialist over the traditional “curbside” consults which occur outside of the EMR (Figure 2).

OPEN IN VIEWER

Figure 2.

Example of e-consult response template.

Alternative methods to improve specialty access include telehealth visits, though many neurologists are hesitant to conduct telehealth visits on patients they have not seen FTF before. At our center, pediatric neurologists performed some initial visits via telehealth after restrictions related to the COVID-19 pandemic began, which may in part explain why the number of Pediatric Neurology e-consults per month did not increase after March of 2020.

There are no clear practice guidelines for e-consults, including what problems can be addressed by an e-consult alone and at what point to recommend a referral for an FTF visit. For Pediatric Neurology, we opted to use e-consults to address neurological issues in patients not known to our service. Patients who already have established care with a pediatric neurologist are typically instructed to contact their neurologist's office directly if questions or concerns arise. Our nurse coordinators are trained to address such issues with guidance from specialists, and we did not feel comfortable delegating that responsibility to PCPs.

Similar to other studies looking at adult subspecialties, we found that most of the questions were appropriate for an e-consult and were used for cases with appropriate patient complexity and clinical urgency.^6,8 When the e-consult was used for patients known to us (N = 5, 8.6%), we provided some education in our response to the PCP, but we did not bill for the e-consult and asked that the patient directly contacts our office. We also sent a direct message to their primary neurologist to make them aware of the contact.

Providing PCPs with a template for each chief complaint provided us with relevant details that may not be included in traditional referrals (Figure 1). This allowed for more efficient triage of patients who needed FTF appointment. This significantly reduced the wait time, and 76% of patients were seen in less than a month from the e-consult date compared to the usual wait time of 3–4 months. On some occasions, we were able to direct the referring PCP to another appropriate specialty (eg, Neurosurgery, Developmental Pediatrics), saving time and unnecessary visits. The nature of evaluation and/or management recommendations of our specialists, including possible multi-step and contingency plans (eg, refer only if imaging is abnormal or refer if no improvement on the proposed treatment), seems similar to other institutions. ¹⁰

Satisfaction with e-consults may be influenced by the specialty. Some specialties (eg, Hematology, Endocrinology) rely more heavily on laboratory tests compared to neurologists who rely on history and physical examination in addition to specialized tests such as EEG. Neurologists may be uncomfortable giving clinical input provided by non-neurologists. However, 56.7% of the e-consults in this study were answered without a need for an FTF visit, and specific recommendations were given while awaiting the FTF visit in an additional 29.3%.

Spells are a common indication for an FTF visit with a neurologist, but in 58.8% (N = 10) of these e-consults, the question was answered without the need for such a visit. This was facilitated when enough details were included in the e-consult, and especially when a video was attached. Examples of diagnoses made through the e-consult included shuddering spells, stereotypies, jitteriness, behavioral staring spells, and vasovagal syncope. The 7 patients who had to be seen in our clinic had a history that was suspicious for seizures, or the history was not complete. For these patients, the e-consultant often requested placement of an order for an EEG that was completed on or before the day of appointment.

Of the 13 e-consults for headache, 8 were answered without needing an FTF visit. For the other 5 e-consults, an FTF visit was recommended due to red flags on history or examination, incomplete history or examination, or continued worsening of symptoms despite the PCP's management. For these, the e-consultants recommended getting head imaging ahead of the appointment if needed. Of the 4 e-consults related to tremor, 3 needed FTF evaluation due to red flags reported on history or examination (eg, rapid worsening, positive Romberg sign, ataxia), and workup was recommended ahead of time in 2 of these patients.

Prior studies showed that that PCPs tend to adhere to recommendations provided by specialists through e-consults. ¹¹ In this study, 72.4% of the charts showed documentation by the PCPs of the recommendations provided by the e-consult. One drawback from e-consults is that patients are unable to directly communicate with the specialist. One study showed that in 87% of the charts reviewed, patients were informed of the recommendations. ¹⁰ In our study, only 52.2% of the charts showed documentation of the PCP specifically discussing the outcome of the e-consult with the patient. This raises concern that patients may not appreciate/recognize the role of e-consults in their care.

We anticipated a higher percentage of e-consults for complaints such as tics, tremor, and headache, as we consider these to be suitable indications for an e-consult. We continue to get these consult requests through traditional clinic referrals. In many cases, these patients do not require any additional workup or treatment, raising concern that PCPs are uncertain about diagnosis or management even in these less acute common conditions. Studies in other specialties have shown that many of traditional referrals can be converted to e-consults,^5,12 which is also true for pediatric neurology. Further discussion and targeted education with PCPs may lead to changes in practice regarding which clinical problems are appropriate for e-consults. Wrenn et al. reviewed the content of e-consults across internal medicine subspecialties and found that questions were related to treatment in 46%. ¹¹ In our cohort, only 24% of the e-consults asked about treatment options, and that may be driven by the PCP's unease in diagnosing neurological conditions, or parental anxiety associated with these conditions.

Limitations

This is a single center experience, within a single specialty. Specific findings are in part influenced by the practice structure at our medical center, as well as by insurance and patient demographics. Getting the feedback from PCPs and from patients would be beneficial in refining the process and improve efficiency.

Conclusions

At our institution, we found that e-consults are beneficial for pediatric neurology specialists, as they facilitate collaboration with PCPs and provide detailed information helpful for patient triage. For patients who did not need FTF visits, e-consults provided timely access to specialists and helped document what otherwise might have been “curb-side” discussions. We found most questions sent to be appropriate for e-consults, though further education would be useful to manage expectations and to further guide the e-consult mechanism at our institution. FTF visits were recommended when the question could not be answered without seeing the patient, or because of concerning history or examination findings. For patients who required FTF evaluation, e-consults helped reduce the wait time and facilitated the visits by providing initial steps of workup or treatment ahead of time. Even though this service was added to Pediatrics in 2019, e-consults continue to be underutilized in our center, and we continue to receive emails, phone calls, or texts asking for “curb side” consults. This retrospective study provided ideas for helpful strategies, including targeted education on specific topics and an open discussion regarding any perceived barriers.