A study from Massachusetts General Hospital (MGH) researchers finds 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, which has been published online in the Journal of Allergy and Clinical Immunology: In Practice, reports on the first two years of the MGH program and finds a significant reduction in the time needed to access specialist guidance.

“We found that e-consults expedite care for all patients with allergy/immunology conditions,” says senior author Kimberly Blumenthal, MD, MSc, MGH Division of Rheumatology, Allergy and Immunology. “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. 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 non-urgent questions specific to the care of an individual patient. The MGH 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 MGH e-consult program involves 47 specialty areas, and almost 10,000 e-consults were provided during 2018.

The current study, led by first author Neelam Phadke, MD, MGH Division of Rheumatology, Allergy and Immunology, 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 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.

Study co-author Jason H. Wasfy, MD, MPhil, MGH Cardiology – who founded the MGH e-consult program in 2013 and now directs population health management at MGH – says, “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. 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.”

Lead author Phadke notes 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 says, “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.”

Blumenthal and Wasfy are both assistant professors of Medicine, and Phadke is a research fellow in Allergy/Immunology at MGH. Additional co-authors are Susan Goldstein, MsIE, and Jacqueline Ngo, MPH, MGH Performance Analysis and Improvement Unit; and Anna Wolfson, MD, Christian Mancini, Xiaoqing Fu, MS, Aidan Long, MD, Aleena Banerji, MD, MGH Rheumatology, Allergy and Immunology.

Massachusetts General Hospital, founded in 1811, is the original and largest teaching hospital of Harvard Medical School. The MGH Research Institute conducts the largest hospital-based research program in the nation, with an annual research budget of more than $925 million and major research centers in HIV/AIDS, cardiovascular research, cancer, computational and integrative biology, cutaneous biology, genomic medicine, medical imaging, neurodegenerative disorders, regenerative medicine, reproductive biology, systems biology, photomedicine and transplantation biology. The MGH topped the 2015 Nature Index list of health care organizations publishing in leading scientific journals and earned the prestigious 2015 Foster G. McGaw Prize for Excellence in Community Service. In August 2018 the MGH was once again named to the Honor Roll in the U.S. News & World Report list of "America's Best Hospitals."