Patel M, Gadzinski AJ, Bell AM et al: Interprofessional consultations (eConsults) in urology. Urol Pract 2021; doi: 10.1097/UPJ.0000000000000209

Within the specialty of urology, there has been an increasingly greater need to expand the delivery of health care services while still preserving quality of care.¹ Telehealth has emerged as a key mechanism to help meet this challenge. While the video visit is a familiar service among both providers and patients, a lesser known modality of telehealth is the eConsult (interprofessional consultation).

An eConsult is an asynchronous electronic or telephone interaction, whereby a primary care physician reaches out to a consulting physician (such as a urologist) for advice regarding patient care.² Without seeing the patient, the consulting physician reviews patient electronic medical records and provides written recommendations for evaluation and management.² This interaction is now reimbursable through the Medicare program and many commercial insurance payers.

The use of eConsults is a slight departure from the traditional interaction between primary care providers and specialists. Most commonly, a primary care provider who has a question regarding a patient with a kidney cyst found on imaging, for example, would request a formal consultation with a urologist. In this scenario, the urologist would perform a full evaluation of the patient. However, a full evaluation may have been unnecessary as the urologist may have been able to provide a recommendation solely after reviewing the patient’s chart and imaging. Alternatively, the primary care provider may contact a urologist with whom he or she already has a collegial relationship for an informal consultation, such as by text message or email. Although a full urological visit is avoided in this scenario, there are multiple drawbacks including a lack of reimbursement for urological services and a lack of documentation of the consultation from a legal perspective.

Numerous eConsult programs have been developed across the nation, including those centered on connecting primary care providers with urologists.^3–5 Nevertheless, the extent to which an eConsult could be useful in the management of urological conditions had remained a mystery. In our new study, we answered this question by examining the utilization of urological eConsult programs at 4 major academic health centers.⁶ We focused our analysis on 3 objectives. First, we sought to determine if an eConsult did in fact eliminate the need for a traditional in-person urological evaluation. Next, we hoped to understand the set of urological conditions for which eConsults were both most often requested and most often effective. Finally, our last objective was to gain an appreciation for the logistics and operation of eConsults, specifically in terms of the time required to respond to and complete an eConsult by urologists.

After reviewing the nearly 500 eConsults from our collective databases, we discovered that approximately 2 out of every 3 eConsults were successful, meaning the urologist was able to provide a recommendation without the need to see the patient thereafter in clinic. In terms of the urological diagnoses that were covered by eConsults, there was a broad distribution including renal cyst, dysuria, and pelvic pain. The urological diagnosis that was most often the subject of a requested eConsult was andrology/infertility. Andrology/infertility eConsult requests were also the most likely to be successfully resolved with an eConsult. Other top diagnoses that were completed without escalation to in-person services included a renal mass or cyst and benign prostatic hyperplasia. As may be expected, hematuria and elevated prostate specific antigen/cancer were the top two diagnoses for which eConsults were not sufficient and required an ensuing in-person urological visit. In regards to the logistics of an eConsult, over 50% of these interactions were responded to in less than a day by a urologist and required less than 10 minutes of time by the urologist to complete.

Based on our findings, eConsults are beneficial in the management of a range of low-complexity urological issues. Moreover, the potential benefits in efficiency of health care delivery are quite clear. When considering that an average in-person patient consultation requires at least 15 or more minutes compared to the less than 10 minutes required of eConsults, the latter certainly allows urologists to save time that may then be used to see additional patients or patients with higher complexity issues.⁷ From the patient standpoint, eConsults are perhaps even more convenient. Delays in care due to urologist access/availability or patient transportation are bypassed and medical recommendations are provided rapidly with minimal additional action necessary from the patient.

Despite the efficacy of eConsults, overall utilization of eConsults within urology is currently low. Even during the height of the COVID-19 pandemic, the number of eConsults requested at the 4 institutions included in our study was comparable to pre-pandemic counts. One plausible explanation for the lack of eConsult expansion is the business aspect of eConsults. Although eConsults are reimbursed by insurance payers, the rate of reimbursement is lower than the rate for an in-person consultation. This creates a more difficult cost-benefit analysis for the individual urologist, especially one who may not have the immediate clinic volume to replace the additional capacity created by eConsults. Another potential barrier is simply the combination of technological resources, coordination, and commitment that is required from both primary care providers and urologists to switch to the eConsult platform.

In our view, eConsults are a practical and effective option for urological care. However, further adoption of eConsults by both primary care providers and urologists is necessary if we hope to truly improve health care access and efficiency.