Simplifying Care

Study shows e-consults streamline allergy, immunology care

Photo of a doctor administering an allergy test on someone's arm

A study by Harvard Medical School researchers at Massachusetts General Hospital has found that electronic consultations (e-consults) in allergy and immunology can simplify the process of providing the most appropriate care, often reducing the need for in-person specialist visits. 

The paper, published online in the Journal of Allergy and Clinical Immunology: In Practice, reported on the first two years of the program and found a significant reduction in the time needed to access specialist guidance.

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“We found that e-consults expedite care for all patients with allergy/immunology conditions,” said senior author Kimberly Blumenthal, an HMS assistant professor of medicine in the Division of Rheumatology, Allergy and Immunologyat Mass General.

“Whereas wait times for an in-person patient visit with an allergist often exceed three weeks, e-consults can provide allergist guidance to referring physicians within 72 business hours,” she said. “For many patients, e-consults avert the need for an in-person visit entirely; and even when an in-person consult is required, the initial e-consult provides valuable information—including additional patient history, previous diagnostic testing and treatment trials—that can make the in-person consult more productive and valuable for the allergist, the referring provider and the patient.”

Electronic, clinician-to-clinician consultations based on data in the electronic health record do not require real-time communication and are designed to address nonurgent questions specific to the care of an individual patient. 

Mass General began offering e-consults in cardiology and dermatology in late 2013 and extended the program to Allergy/Immunology in August 2016.

As of January 2019, the e-consult program involved 47 specialty areas and almost 10,000 e-consults were provided during 2018.

Wait times reduced

The current study, led by first author Neelam Phadke, HMS research fellow in medicine at Mass General, looked at data regarding allergy/immunology e-consults provided from August 2016 through July 2018, as well as in-person consults beginning in August 2014.

Of approximately 300 e-consults completed during the study period, around 60 percent led to recommendations for in-person specialty visits, while 27 percent provided only advice and education to the referring practitioner.

When the e-consult led to a recommendation for an in-person specialty visit, information from the e-consult made visits more productive by allowing the allergist to be better prepared. 

Educational information provided via e-consults benefited both referring physicians and the patients, often providing reassurance on the appropriateness of a planned course of action.

Two-thirds of e-consults related to patients with histories of potentially allergic reactions to drugs, primarily antibiotics like penicillin, many in conjunction with a program to evaluate pregnant patients with a history of penicillin allergy. Immunology e-consults could result from patient or provider concerns about frequent infections or abnormal antibody levels. 

While the average wait time for an in-person allergist visit before institution of the e-consult program was 22.5 days, the wait time was reduced to 21.0 days after the program began. 

Allergists completed e-consults in an average of 11 minutes, and the average turnaround time for the referring provider to receive allergy specialist guidance was less than 24 hours. 

Critical tool

“E-consults have become a critical tool in our efforts to innovate in outpatient care delivery. We believe they can increase patient satisfaction, since we always give patients the choice between e-consults and regular in-person consults, and they reduce the burden for primary care providers,” said study co-author Jason Wasfy, an HMS assistant professor of medicine who founded the Mass General e-consult program in 2013 and now directs population health management at Mass General. 

“We also believe they can improve the quality of care and reduce costs, since electronic consults can substitute for in-person consults that are billed to insurance companies and to patients themselves,” he said.

 Lead author Phadke noted that a key limitation to broader use of e-consults is the reliance on electronic medical records systems that may not be shared between specialists and referring physicians, a problem that could disproportionately affect smaller hospitals that already lack access to subspecialists like allergists.

But when the required systems are in place, she said, “E-consults can allow primary care physicians to receive guidance from one or more subspecialists, synthesize messages that may have been conveyed from multiple providers and delivery neatly packaged recommendations to the patient.”

 Additional co-authors are Susan Goldstein and Jacqueline Ngo in the Mass General Performance Analysis and Improvement Unit and Anna Wolfson, Christian Mancini, Xiaoqing Fu, Aidan Long and Aleena Banerji in Mass General’s Division of Rheumatology, Allergy and Immunology.