Citations

E-consultations are being offered within clinic walls as an option for specialist advice without a face-to-face consultation appointment. In a six month time frame, nearly 100% of primary care internists and family medicine providers in a multispecialty practice had used an e-consultation at least once. Specialists also used e-consultations for advice from other specialists. E-consultations were often questions about interpreting images or laboratory tests, or questions about management of chronic conditions such as osteoporosis, hypertension, or headaches. Although e-consultations were offered as an alternative to face-to-face specialty consultations, 1,111 of 5,334 e-consultations eventually did receive face-to-face appointments in the same specialty. Within 30 days of the e-consultation 11.5% had a specialty face-to-face visit and 17.7% had seen a specialist face-to-face within 90 days of the e-consultation. The conversions of e-consultations to face-to-face consultations depended on the specialty providing the e-consultation (fewer for gastroenterology and infectious disease), patient distance from the clinic (fewer for international patients and those living greater than 800 kilometers from the clinic), and experience of specialist responding to the e-consultation (lower conversions for specialists providing 15 or more e-consultations).

An e-consultation is an asynchronous consultation performed by a specialist without a face-to-face patient visit. E-consultations have been available to primary care providers at the Mayo Clinic for several years. We reviewed e-consultations performed by specialists at the Mayo Clinic for the first six months of 2013. We included only “internal” e-consultations, originating from within the Rochester practice. During the study period a total of 3242 e-consultations were completed at the Mayo Clinic. After excluding those relating to patients who did not give research consent, 3008 e-consultations remained. We categorized our internal e-consultations into eight types. The most frequently used types were the first e-consultation processes to be implemented: the primary care to specialist e-consultation and the specialist to specialist e-consultation, accounting for 74% of the total. As these two types of e-consultation became widely used, the staff discovered that the e-consultation process could be adapted to meet specific practice needs and six more e-consultation types emerged. For example, intra-specialty e-consultations and surgical e-consultations accounted for 16% of the total. E-consultations appear to have improved access to specialists, and they are integrated into care processes when timely expert opinions are needed. As e-consultations evolve, it will be important to develop a standard, well-defined terminology to compare outcomes of these processes across practices.

Introduction: Secure messages and electronic visits (“e-visits”) through patient portals provide patients with alternatives to face-to-face appointments, telephone contact, letters, and e-mails. Limited information exists on how portal messaging impacts face-to-face visits in primary care. Materials and Methods: We conducted a retrospective cohort study of 2,357 primary care patients who used electronic messaging (both secure messages and e-visits) on a patient portal. Face-to-face appointment frequencies (visits/year) of each patient were calculated before and after the first message in a matched-pairs analysis. We analyzed visit frequencies with and without adjustments for a first message surge in visits, and we examined subgroups of high message utilizers and long-term users. Results: Primary care patients who sent at least one message (secure message or e-visit) had a mean of 2.43 (standard deviation [SD] 2.3) annual face-to-face visits before the first message and 2.47 (SD 2.8) after, a nonsignificant difference ( p =0.45). After adjustment for a first message surge in visits, no significant visit frequency differences were observed (mean, 2.35 annual visits per patient both before and after first message; p =0.93). Subgroup analysis also showed no significant change in visit frequency for patients with higher message utilization or for those who had used the messaging feature longer. Conclusions: No significant change in face-to-face visit frequency was observed following implementation of portal messaging. Secure messaging and e-visits through a patient portal may not result in a change of adult primary care face-to-face visits.

Telemedicine practitioners are familiar with multiple barriers to delivering care at a distance. Licensing and reimbursement barriers are well known and are being addressed at national and state levels by the American Telemedicine Association. Another telemedicine barrier comes in the form of quality measures for diabetes. Minnesota medical practices are currently being compared on the proportion of their patients with diabetes who have attained goals for blood pressure, low-density lipoprotein cholesterol, and hemoglobin A1C. The quality measure for blood pressure specifically excludes measurements taken by the patient, thus precluding blood pressure telemonitoring as a way to meet the blood pressure goal. To counter this barrier, advocacy in telemedicine is needed so that telemonitoring as a data collection tool is included in quality measures.

Although it has been assumed that telephone triage can directly benefit patients by facilitating early diagnosis and treatment, this potential benefit has not been well documented. Using appendicitis cases ascertained from claims data, we compared telephone triage recommendations with what the callers originally intended to do. Over a two-year period, there were 20,230 calls to a telephone triage centre in the US where insurance information was available. Of these, 12,709 calls (63%) had insurance claims made within seven days of the call. Among these calls, 46 had a diagnosis of appendicitis. In 72% of calls concerning appendicitis, the telephone triage recommendation was for a more rapid evaluation than the caller originally intended ( P < 0.0001). In 91% of the appendicitis cases, triage nurses directed callers to care within 8 h, but without triage advice, only 39% of callers stated they would have sought care within 8 h ( P < 0.0001). Telephone triage significantly reduced the delay in care for appendicitis in comparison with what the caller would have done. This suggests that telephone triage potentially reduces the morbidity associated with appendicitis.

We reviewed surrogate calls (i.e. those made on behalf of the patient) to a national triage call centre to determine whether there were differences between calls made by surrogates and self calls. During a three-year period there were 14,646 calls (14% of the total) made by a surrogate on behalf of the patient. Surrogate calls, as a percentage of total calls, increased with the age of the patient from 12% in the 18–34 year age group to 43% in the 80 and over age group ( P < 0.0001). The symptoms of vomiting or nausea and dizziness or light-headedness were significantly more likely to be reported by surrogate callers than self callers. Surrogates reported a higher original intention of taking patients to the hospital emergency department (ED) compared with self callers across all adult age groups (OR 1.64; 95% CI 1.57 to 1.71). A higher proportion (38%) of surrogate calls ended with the nurse recommending an ED visit compared with only 26% of self calls (OR 1.72; 95% CI 1.66 to 1.79). Calls about men accounted for 54% of surrogate calls but only 26% of self calls (OR 3.3; 95% CI 3.2 to 3.4), suggesting that surrogate calls may be a way of increasing medical access for men.

Introduction: Telemedicine options for symptom assessment include both telephonic means (call centers) and Internet sites. Although symptom assessment call centers have been available for decades, symptom assessment over the Internet is relatively new. It is not well known what types of symptoms Internet users are seeking assessment for and whether extant telephone triage algorithms would be applicable to Internet users. Methods: Symptom assessments on a heavily used Internet site ( MayoClinic.com ) were compared with symptom calls to a U.S. call center (Ask Mayo Clinic). Results: Internet users sought symptom assessments about adult symptoms 13 times more often than children's symptoms. In contrast, over the telephone, adult symptoms were addressed 2.1 times more frequently than children's symptoms. Despite the differences in frequencies of adult and child symptom assessments, users of the Internet and telephone callers asked about specific symptoms with similar relative frequencies. Analysis of 20 adult symptom types shared by the Web and call center revealed that by excluding only 2 assessments (nasal symptoms and leg pain) the remaining 18 showed a significant correlation in counts of use ( r 2 = 0.68, p < 0.001 for linear trend). Conclusions: Internet users have symptoms assessed in similar proportions to callers, with a few exceptions. Compared with callers, Web users are much more likely looking for information about adult symptoms. Callers are proportionally asking more about acute symptoms, whereas Internet users appear more interested in symptom assessment of chronic conditions.