title: Impact of a national specialty e-consultation implementation project on access.
abstract: To assess the early impact of implementation of the electronic consults (e-consults) initiative by the Veterans Health Administration (VHA), designed to improve specialty care access.
  
  
  
  Observational cohort study exploiting a natural experiment begun in May 2011 at 12 VHA medical centers and expanded to 122 medical centers by December 2013.
  
  
  
  The following were assessed: 1) growth of e-consults by VHA regional networks, medical centers, and specialty; 2) location of patient's primary care provider (medical center vs community-based outpatient clinic [CBOC]); 3) potential patient miles needed to travel for a specialty care face-to-face consult in place of the observed e-consults using estimated geodesic distance; 4) use of specialty care subsequent to the e-consult.
  
  
  
  Of 11,270,638 consults completed in 13 clinics of interest, 217,014 were e-consults (adjusted rate, 1.93 e-consults per 100 consults). The e-consult rate was highest in endocrinology (5.0 per 100), hematology (3.0 per 100), and gastroenterology (3.0 per 100). The percentage of e-consult patients with CBOC-based primary care grew from 28.5% to 44.4% in the first year of implementation and to 45.6% at year 3. Of those e-consult patients from community clinics, the average potential miles needed to travel was 72.1 miles per patient (SD = 72.6; median = 54.6; interquartile range = 17.1-108), translating to a potential savings of 6,875,631 total miles and travel reimbursement costs of $2,853,387.
  
  
  
  E-consult volume increased significantly since inception within many medical and surgical specialties. For patients receiving primary care at one of more than 800 CBOCs, e-consults may decrease travel burden and direct travel costs for patients.
authors.affiliation: Case Western Reserve University School of Medicine, 10701 East Blvd, Cleveland, OH 44106. E-mail: susan.kirsh@va.gov.
authors.forename: Susan
authors.initials: S
authors.lastname: Kirsh
authors.forename: Evan
authors.initials: E
authors.lastname: Carey
authors.forename: David C
authors.initials: DC
authors.lastname: Aron
authors.forename: Omar
authors.initials: O
authors.lastname: Cardenas
authors.forename: Glenn
authors.initials: G
authors.lastname: Graham
authors.forename: Rajiv
authors.initials: R
authors.lastname: Jain
authors.forename: David H
authors.initials: DH
authors.lastname: Au
authors.forename: Chin-Lin
authors.initials: CL
authors.lastname: Tseng
authors.forename: Heather
authors.initials: H
authors.lastname: Franklin
authors.forename: P Michael
authors.initials: PM
authors.lastname: Ho
mesh_terms: D015331:Cohort Studies; D017046:Cost Savings; D006297:Health Services Accessibility; D006787:Hospitals, Veterans; D006801:Humans; D008511:Medicine / Q000706:statistics & numerical data*; D010044:Outpatient Clinics, Hospital; D019114:Remote Consultation / Q000706:statistics & numerical data*; D013043:Specialties, Surgical / Q000706:statistics & numerical data*; D014195:Travel / Q000191:economics; D014481:United States; D014493:United States Department of Veterans Affairs