title: Electronic Consultations to Improve the Primary Care-Specialty Care Interface for Cardiology in the Medically Underserved: A Cluster-Randomized Controlled Trial.
abstract: OBJECTIVE
  Communication between specialists and primary care clinicians is suboptimal, and access to referrals is often limited, which can lead to lower quality, inefficiency, and errors. An electronic consultation (e-consultation) is an asynchronous, non-face-to-face consultation between a primary care clinician and a specialist using a secure electronic communication platform. The purpose of this study was to conduct a randomized controlled trial of e-consultations to test its efficacy and effectiveness in reducing wait times and improving access to specialty care.
  
  
  METHODS
  Primary care clinicians were randomized into a control (9 traditional) or an intervention (17 e-consultation) arm for referrals to cardiologists. Primary care clinicians were recruited from 12 practice sites in a community health center in Connecticut with mainly medically underserved patients. Two end points were analyzed with a Cox proportional hazards model where the hazard of either a visit or an e-consultation was linked to study arm, sex, race, and age.
  
  
  RESULTS
  Thirty-six primary care clinicians participated in the study, referring 590 patients. In total, 69% of e-consultations were resolved without a visit to a cardiologist. After adjusting for covariates, median days to a review for an electronic consultation vs a visit for control patients were 5 and 24, respectively. A review of 6-month follow-up data found fewer cardiac-related emergency department visits for the intervention group.
  
  
  CONCLUSIONS
  E-consultation referrals improved access to and timeliness of care for an underserved population, reduced overall specialty utilization, and streamlined specialty referrals without any increase in adverse cardiovascular outcomes. e-consultations are a potential solution for improving access to specialty care.
authors.affiliation: Center for Excellence in Primary Care, San Francisco General Hospital, San Francisco, California Department of Family and Community Medicine, University of California San Francisco, San Francisco, California OlayiwolaJ@fcm.ucsf.edu.
authors.forename: J Nwando
authors.initials: JN
authors.lastname: Olayiwola
authors.affiliation: Weitzman Institute, Community Health Center, Inc, Middletown, Connecticut.
authors.forename: Daren
authors.initials: D
authors.lastname: Anderson
authors.affiliation: Rollins School of Public Health, Emory University, Atlanta, Georgia.
authors.forename: Nicole
authors.initials: N
authors.lastname: Jepeal
authors.affiliation: Division of Behavioral Sciences and Community Health, University of Connecticut Health Center, Farmington, Connecticut.
authors.forename: Robert
authors.initials: R
authors.lastname: Aseltine
authors.affiliation: Pat and Jim Calhoun Cardiology Center, University of Connecticut Health Center, Farmington, Connecticut.
authors.forename: Christopher
authors.initials: C
authors.lastname: Pickett
authors.affiliation: Department of Statistics, University of Connecticut, Storrs, Connecticut.
authors.forename: Jun
authors.initials: J
authors.lastname: Yan
authors.affiliation: Weitzman Institute, Community Health Center, Inc, Middletown, Connecticut.
authors.forename: Ianita
authors.initials: I
authors.lastname: Zlateva
mesh_terms: D000328:Adult; D002309:Cardiology; D003142:Communication; D003237:Connecticut; D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D008297:Male; D008507:Medically Underserved Area; D008875:Middle Aged; D011320:Primary Health Care / Q000458:organization & administration*; D016016:Proportional Hazards Models; D019114:Remote Consultation; D016037:Single-Blind Method; D013038:Specialization