1140 — Evaluation of Electronic Consultations in the VHA: The Providers' Perspectives

Battaglia C, VA Eastern Colorado Health Care System; Lambert-Kerzner A, VA Eastern Colorado Health Care System; Aron AC, VA Louis Stokes Cleveland Medical Center; Sayre G, VA Puget Sound Health Care System; Ho PM, VA Eastern Colorado Health Care System; Haverhals LM, VA Eastern Colorado Health Care System; Stevenson L, VA Louis Stokes Cleveland Medical Center; Kirsh S, VA Louis Stokes Cleveland Medical Center; Au DH, VA Puget Sound Health Care System; Helfrich CD, VA Puget Sound Health Care System

Objectives:
U.S. Veterans face barriers accessing specialty services. In 2011, Veterans Health Administration (VHA) began a national electronic consultation (E-Consults) pilot in 15 medical centers. E-Consults allow primary care providers (PCPs) to obtain specialist advice via the VHA's electronic medical record, and represent a departure from the conventional in-person consultation visit. We describe how E-Consults achieved programmatic objectives and how implementation affected PCPs, specialists, and staff.

Methods:
We conducted a key informant analysis, with two waves of telephone interviews a year apart, at eight E-Consult pilot sites purposefully selected for variation in early implementation progress. Data were analyzed using an iterative, inductive content analysis methodology. Emergent codes were added throughout analysis. A multidisciplinary team of clinicians, implementation scientists, and mixed methodologists reviewed findings.

Results:
We completed 37 interviews at baseline and 21 interviews at follow-up (one-year later). PCPs reported that E-Consults were an effective means of consultation and contained information needed to provide high quality care and increased communication between PCPs and specialists. At baseline, some specialists described E-consults as akin to administrative work, not patient care. Specialists also reported the work necessary to complete E-Consults often exceeded newly established workload credits they received, which were equivalent to brief in-person visits. Consult templates were sometimes developed without primary care input, and as a result some were too onerous. During the follow-up interviews, workload credits had expanded and specialists no longer identified E-Consults as not patient care. Participants reported that E-Consults had reduced the time to obtain feedback from specialists while maintaining high-quality care.

Implications:
Participants were supportive of E-Consults and credited this program with increasing Veterans' access to specialty care by improving local care delivery. Specialists were more reliant on the PCP to describe the problem and provide adequate information in the E-Consult request and PCPs needed to know that E-Consults were available and when appropriate to use. Challenges included lack of standardized procedures and confusion related to roles and responsibilities.

Impacts:
E-Consults can provide a valuable alternative to in-person specialty consultations, but take time to implement. Effective implementation may depend on local VHA leadership taking action based on early evaluation of challenges.