Historically, a specialty consult occurred when a physician desired input and would request a specialist examine the patient either in the hospital or as a referral in the outpatient setting. Frequently, as a primary care physician, I would ask a specialist to opine on a particular patient’s situation or diagnosis. Invariably, this request would generate a discussion regarding the necessity of the specialist first seeing the patient before uttering an opinion. Hence, avoiding the “curbside consult”- a rendering of advice without having seen the patient and potentially not having all the facts.
This ultimately can create inefficiencies in the delivery of care. Although it is comprehensive as it relates to a specific person and situation, it is both resource-intensive and requires the referring physician to see the need for consultation, and thus possibly not consulting a specialist when their input will enhance care. Electronic consults (E-Consults) are growing in popularity and aid with access to consultations. However, they still require the sending physician to recognize the need as well as an available resource.
But technology can help. We can design models that create automatic consultations and provide consultants the opportunity to monitor a higher number of patients simultaneously. Examples include a consult triggered by a diagnosis or an abnormal laboratory or x-ray finding. However, the downside to this model is the consultant only receives a single piece of information. Therefore, they must rely on initiating a conversation with the primary physician and acquire the appropriate clinical information to render an opinion. Keeping this same example in mind, if we instead utilize the data within the electronic health record, we can progress to a model where the abnormality has accompanying information “packaged” in a manner that will enable the specialist a more in-depth understanding of the issue at hand. Ultimately this will allow a set of data elements to “trigger” a consultation rather than just a referral request and the trigger is accompanied by all the necessary information for the specialist or physician to make an informed decision.
Another model for e-consults involves a specialist monitoring a cohort of patients, such as all those in a hospital. For example, a nephrologist may be responsible for all hospitalized patients and is “consulted” when worsening renal function occurs, or conditions that are associated with renal failure arise. They then become a part of the care team and deliver needed inputs in a timely and effective manner. One can use this same premise for nutritional needs as well as physical therapy.
As we continue to delve into how to improve the logistics of care delivery, focusing on specialty consultations in new and creative ways will enhance the quality of care delivered. With access to an ever-growing body of electronic data and information, coupled with technology, we can improve the use of our resources while avoiding the pitfalls of our present models.