The Impact of E-Consults During COVID-19 & Beyond

Nacinovich:
One of the many impacts of COVID-19 pandemic has been an accelerated transition from in-person visits to virtual ones. But some recent findings are now suggesting that electronic consultations may not only be appropriate, but perhaps even preferred over face-to-face appointments, in some cases, after the pandemic is over. More about these findings to come on today’s program.
For ReachMD, this is COVID-19: On the Frontlines, and I’m Mario Nacinovich. Joining me today is Dr. Salman Ahmed, staff nephrologist in the Renal Division at the Brigham and Women’s Hospital of Harvard Medical School in Boston, Massachusetts. Dr. Ahmed, welcome to you.

Dr. Ahmed:
Thank you so much, Mario. Pleasure to be here.

Nacinovich:
To start us off, in terms of the current COVID-19 pandemic, what’s the impact on your nephrology practice, and patients that are suffering various diseases and conditions renally?

Dr. Ahmed:
Yeah, that’s a great question. So I think that me being part of a large group in an academic medical center, I personally feel the great benefit of the infrastructure support that is in place and is constantly adapting to allow me to care for my patients. I can only sympathize with groups who may not have that support who are community providers, for example, who may have their own challenges in arranging for that care. That is one point that I would like to get across, and the second thing is with regards to my own patients, what I have noticed is that overlaying the conversation that I have with my patients is a risk-benefit evaluation that is ongoing about having patients come in for the labs and other studies, like kidney ultrasounds, which before would just be something that is matter-of-fact and routine. But now, every lab test and every visit to the ultrasound department comes with it a risk benefit calculation of a patient acquiring COVID iatrogenically or from being in that health care setting. And that has led to a bit of a challenge in terms of monitoring my patients’ lab tests and is requiring a bit more vigilance on my part.

Nacinovich:
So Dr. Ahmed, can you share with us your experience with telemedicine and your personal viewpoint on the value of electronic consultations, or E-consults?

Dr. Ahmed:
Sure, absolutely. I have, just like many other providers nationwide and perhaps globally, been seeing many of my patients in the renal clinic virtually the past few weeks, and it’s been a blessing in many ways, for the patients especially who are saved from a trip into a place where there is a lot of anxiety about exposure to coronavirus and it allows me to continue to provide high quality care and address my patients’ needs. With regards to the E-consults, that is a different platform that I have not had personal experience with in the sense of responding to or placing E-consults, but certainly I’ve been involved on the research side, looking at the potential benefits across different specialties and for different providers.

Nacinovich:
So with that background in mind, Dr. Ahmed, let’s look at the recent data you gathered. First off, how did this study come about in the setting of COVID-19 pandemic, and what were you investigating specifically?

Dr. Ahmed:
So the interesting thing about this study is when we first initiated the data extraction and analysis, COVID-19 didn’t exist. This was a already-in-place, full-fledged program throughout Partners Health System, allowing physician-to-physician communication to answer essentially specialist consultation. As from the paper, the actual consultations happened in 2017 and 2018. So really the purpose of this paper was to assess what types of questions were being asked by frontline providers to specialists and also to get a sense of what made for an appropriate E-consult, as opposed to a consult that deserved an in-person encounter.

Nacinovich:
And how did you obtain the data?

Dr. Ahmed:
So, the data was obtained with assistance from our Partners’ E-care team, now known as the Enterprise Data and Digital Health, or EDDH team. They basically had a team of analysts acquire the data.

Nacinovich:
And which specialties were involved?

Dr. Ahmed:
The study looked initially at multiple specialties. Over 20 specialties were involved in the process of doing consults. In the end, we decided to focus on five specialties that were relatively high volume so those are the ones that we mentioned, that are kind of more in-depth in the paper, which were psychiatry, infectious disease, hematology, dermatology, and rheumatology.

Nacinovich:
Were the settings academic or community hospitals?

Dr. Ahmed:
Partners Health System includes both. So the consultants were primarily affiliated with their two academic medical centers, Brigham and Women’s Hospital and Massachusetts General, but the questions were being asked by providers throughout the system in multiple community settings throughout the northeast.

Nacinovich:
For those just tuning in, this is COVID-19: On the Frontlines. I’m Mario Nacinovich, and today I’m speaking with Dr. Salman Ahmed from Harvard Medical School about his research on electronic consultations and their impacts on patient care. So, Dr. Ahmed, let’s jump right over to the results of your study. What were the overall findings?

Dr. Ahmed:
So the overall findings were that70% of consults were deemed to be appropriate in all categories, which included several different sub-criterion. And we also found 80%visit avoidance rate, which we defined as a person undergoing an E-consult and then within 120 days, not requiring a subsequent inpatient consultation for the same question.

Nacinovich:
Were there any key differences among the specialties that were studied?

Dr. Ahmed: Yes, we found that there was variation in rate of visit avoidance. Some specialties tended to be on the higher end of that spectrum, such as psychiatry, while others tended to be on the lower end of the range, such as dermatology.

Nacinovich:
And if we apply these findings to the COVID-19 pandemic, how can clinicians find better success with these kinds of virtual approaches to care?

Dr. Ahmed:
Yeah, as has been mentioned so often, the practice changes we’re seeing now may have permanent implications for the practice of medicine. I think what E-consults, in particular, show us is that physician-to-physician communication can be enhanced through streamlining the process. So if you consider everything that goes into a patient being referred to a specialist, that referral actually being noted by that specialist’s office, scheduled, and the patient actually making it into that consultant’s office sometimes weeks or months later, there’s a lot of room for slippage or for a failure for that consultation to eventually happen. One of the key findings of our study was that most of the electronic consults were being answered within a matter of 1-2 days. So while E-consults don’t necessarily solve every problem, I think that’s one of the key points of our study, is that sometimes really an in-person consult is necessary. There are a lot of questions that we feel could be appropriately answered by specialists through an E-consult platform.

Nacinovich:
Given that E-consults have become the new normal due to COVID-19, do you think their applications will continue or even expand after the pandemic is over?

Dr. Ahmed:
I think that’s a great question, and I think one of the reasons we did this study was to understand the nature of the questions being asked. We found that questions were primarily about diagnosis and therapy, but there were also questions that were being asked of specialists just because the patient wanted to know something, or because the front line provider felt that they needed additional education about something. And these latter two were much less common than diagnosis and therapy questions and could potentially be interesting avenues for growth into the future.

Nacinovich:
Any additional key takeaways or lessons learned that you want to pass on to fellow nephrologists or those on the front lines in primary care that are dealing with patients with these acute disorders or some longer standing kidney diseases?

Dr. Ahmed:
Yes if there is one thing I could suggest, it’s that patients coming in with COVID may be volume-depleted or have other symptoms and signs of poor oral intake of food and fluids for some time, because of the nature of the illness. And so I would just urge caution with regards to volume management or fluid management in these patients. I know there’s generally been guidance towards being conservative with fluids given to these patients, and for the most part, I agree with that, but I think we should also apply our good clinical judgment when the patients are especially first coming in to the ER, or to the hospital floor and judiciously give a small amount of IV fluids, say, in patients who have been not eating for several days, or up to a week sometimes. A lot of these patients may also have the additional risk factor of having treated their fevers with non-steroidal anti-inflammatories, or NSAIDs, at home, which is another risk factor for acute kidney injury, so doing what we can to judiciously give fluids just as much as we are withholding them is something to consider.

Nacinovich:
Well that’s all the time we have for today, but I want to thank Dr. Salman Ahmed for sharing this virtual interview in lockstep with the topic, but more importantly for providing new insights on this rapidly changing practice environment for clinicians. It was great speaking with you today, Dr. Ahmed.

Dr. Ahmed:
Mario, thank you for the opportunity.

Nacinovich:
For ReachMD, I’m Mario Nacinovich. To access this episode, and others from COVID-19: On the Frontlines, visit reachmd.com/covid-19, where you can be part of the knowledge. Thank you for listening.