An Electronic Consult, also known as an eConsult, is an asynchronous, store and forward mechanism for a primary care physician to request advice from a specialist. EConsults use a structured consult template developed by the specialist specific to each disease process or category of clinical question for which an eConsult is appropriate. The template ensures that the information needed by the consultant (whether medical history, symptomatology, or laboratory results) is obtained by the primary care provider prior to the consultation. The consultant's response typically contains a restatement of the clinical question, recommendations, rationale for those recommendations and a contingency plan. The eConsult is placed as an order in an EHR, often in the room with the patient to enable the primary care provider to gather information requested by the consult template. The response is documented in the EHR as an encounter.
Benefits of eConsults
The eConsult process essentially represents a formalization of the tradition of the curbside consult, in which a provider would call, email, or stop a specialist in the hallway to ask a question about a patient. The curbside is often not documented in the chart, does not involve a formal physician-patient relationship between the specialist and the patient, and can be a burden on the specialist's time without any way of accounting for the time spent. The eConsult offers the advantages of documentation in the patient's chart, formalized advice for which the consultant is responsible, and a guaranteed turnaround time. It also provides a mechanism to account for time spent, and may be reimbursed with Relative Value Unit (RVU) credit or monetary reimbursement depending on the specialist's institution. In many models, the PCP also receives reimbursement because the PCP contributes to the work of the consult by gathering further information from the patient and is expected to continue management of the patient depending on consult results.
For the patient, the eConsult provides answers to questions that may have previously necessitated a referral, with answers received much more quickly than a referral appointment. It strengthens the patient/PCP relationship, with the added benefit of avoiding travel time and lost work hours for the patient if a referral is not necessary. If a referral is necessary, it can dramatically reduce the wait time for a specialist visit.
History of eConsults
eConsults in Canada
In 2009 – 2010, an eConsult service was developed in the Champlain region of Ontario in partnership with Winchester Memorial Hospital and the Champlain Local Health Integration Network. After successful grant-funded proof of concept and pilot programs, the service has expanded to include all PCPs in the region. In the Champlain BASE (Building Access to Specialists through eConsultation) model, primary care providers fill out a secure online template that is then reviewed by a central manager and assigned to an appropriate specialist based on availability and expertise. Responses are required within 7 days. Specialists are reimbursed based on time spent at a rate of $200 per hour, while PCPs receive a flat rate $16 per eConsult ordered. As of the end of 2017, more than 30,000 eConsults have been completed, and the model is being expanded to other provinces. 
eConsults in the United States
eConsults in the United States developed out of an enhanced referral (eReferral) system at San Francisco General Hospital developed in 2005. The eReferral system utilized structured consult templates to improve the information provided to specialists in referrals. Each eReferral was reviewed for appropriateness and triaged for urgency of scheduling. Those referrals that could be managed by the PCP with specialist input were not scheduled to see a specialist but sent back with recommendations for management. The program spread in 2010 to the University of California San Francisco Medical Center, where the latter result of eReferral was formalized into an eConsult program in mid-2012 using similar templates. . .
The Los Angeles County Department of Health Services (DHS) (a 670,000 patient public health system for uninsured patients) went live with an eConsult program in 2012 to address the inability of their uninsured patients to get specialist input. As the program expanded, DHS required all primary care providers in its system to use the eConsult format when requesting specialty input. eConsult requests were triaged by specialists into those patients needing face to face visits and those who could be managed by PCPs with specialist input. eConsult volume has increased from < 100 consults per month at the start of the program to > 12,000 consults per month at the end of 2015. PCPs and specialists were not provided reimbursement for eConsults as all participants were salaried employees of the DHS. 
In 2014, the American Association of Medical Colleges (AAMC) received a grant from the Center for Medicare and Medicaid Innovation to test the scalability of the UCSF eConsult model to other academic medical centers. An initial cohort of five medical centers began implementation in 2015 using grant funds to cover start-up costs and reimburse physicians. Under this model, consults were limited to adult specialties, with a required turn-around time of three business days. The AAMC is now on its third cohort of academic medical centers, with the eConsult program underway at eighteen institutions. At the start of 2018, the eConsult model was being expanded to include pediatric primary care providers and specialists.
Reimbursement for eConsults
In the United States, as eConsults are being developed, most reimbursement for physician time has come from grant funding. As initial grants end, different institutions have funded eConsults in a number of ways. Some have reimbursed providers with credit towards RVU targets, some health systems have set aside dedicated funds for eConsults as a way to increase access to specialists. The Medicaid programs in some states (most notably MediCal in California, as well as Colorado and Washington) have begun to develop rate plans for reimbursement. Few private insurers are paying for this service. This has been hampered by the lack of CPT codes specific to eConsults.
Research on eConsults
Both PCP and specialist response to eConsults has been overwhelmingly positive in multiple different survey studies. At UCSF, for example, upwards of 91% of PCPs agreed that the response received from an eConsult was helpful. This study also showed a decrease in health care costs during the 120 days following a referral or eConsult of 7.2% and an absolute decline in ED visits of 1%.  The Champlain BASE program found a reduction of total societal costs of $11 per eConsult 
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Submitted by Bryan Thorne