James D. Harrison, PhD

The discharge process is a critical bottleneck for efficient patient flow through the hospital. Delayed discharges translate into delays in admissions and other patient transitions, often leading to excess costs, patient dissatisfaction, and even patient harm.^1-3 The emergency department is particularly impacted by these delays; bottlenecks there lead to overcrowding, increased overall hospital length of stay, and increased risks for bad outcomes during hospitalization.²

Academic medical centers in particular may struggle with delayed discharges. In a typical teaching hospital, a team composed of an attending physician and housestaff share responsibility for determining the discharge plan. Additionally, clinical teaching activities may affect the process and quality of discharge.^4-6

The prevalence and causes of delayed discharges vary greatly.^7-9 To improve efficiency around discharge, many hospitals have launched initiatives designed to discharge patients earlier in the day, including goal setting (“discharge by noon”), scheduling discharge appointments, and using quality-improvement methods, such as Lean Methodology (LEAN), to remove inefficiencies within discharge processes.^10-12 However, there are few data on the prevalence and effectiveness of different strategies.

The aim of this study was to survey academic hospitalist and general internal medicine physician leaders to elicit their perspectives on the factors contributing to discharge timing and the relative importance and effectiveness of early-discharge initiatives.

Study Design, Participants, and Oversight

We obtained a list of 115 university-affiliated hospitals associated with a residency program and, in most cases, a medical school from Vizient Inc. (formerly University HealthSystem Consortium), an alliance of academic medical centers and affiliated hospitals. Each member institution submits clinical data to allow for the benchmarking of outcomes to drive transparency and quality improvement.¹³ More than 95% of the nation’s academic medical centers and affiliated hospitals participate in this collaborative. Vizient works with members but does not set nor promote quality metrics, such as discharge timeliness. E-mail addresses for hospital medicine physician leaders (eg, division chief) of major academic medical centers were obtained from each institution via publicly available data (eg, the institution’s website). When an institution did not have a hospital medicine section, we identified the division chief of general internal medicine. The University of California, San Francisco Institutional Review Board approved this study.

Survey Development and Domains

We developed a 30-item survey to evaluate 5 main domains of interest: current discharge practices, degree of prioritization of early discharge on the inpatient service, barriers to timely discharge, prevalence and perceived effectiveness of implemented early-discharge initiatives, and barriers to implementation of early-discharge initiatives.

Respondents were first asked to identify their institutions’ goals for discharge time. They were then asked to compare the priority of early-discharge initiatives to other departmental quality-improvement initiatives, such as reducing 30-day readmissions, improving interpreter use, and improving patient satisfaction. Next, respondents were asked to estimate the degree to which clinical or patient factors contributed to delays in discharge. Respondents were then asked whether specific early-discharge initiatives, such as changes to rounding practices or communication interventions, were implemented at their institutions and, if so, the perceived effectiveness of these initiatives at meeting discharge targets. We piloted the questions locally with physicians and researchers prior to finalizing the survey.

Data Collection

We sent surveys via an online platform (Research Electronic Data Capture).¹⁴ Nonresponders were sent 2 e-mail reminders and then a follow-up telephone call asking them to complete the survey. Only 1 survey per academic medical center was collected. Any respondent who completed the survey within 2 weeks of receiving it was entered to win a Kindle Fire.

Data Analysis

We summarized survey responses using descriptive statistics. Analysis was completed in IBM SPSS version 22 (Armonk, NY).

Survey Respondent and Institutional Characteristics

Of the 115 institutions surveyed, we received 61 responses (response rate of 53%), with 39 (64%) respondents from divisions of hospital medicine and 22 (36%) from divisions of general internal medicine. A majority (n = 53; 87%) stated their medicine services have a combination of teaching (with residents) and nonteaching (without residents) teams. Thirty-nine (64%) reported having daily multidisciplinary rounds.

Early Discharge as a Priority

Forty-seven (77%) institutional representatives strongly agreed or agreed that early discharge was a priority, with discharge by noon being the most common target time (n = 23; 38%). Thirty (50%) respondents rated early discharge as more important than improving interpreter use for non-English-speaking patients and equally important as reducing 30-day readmissions (n = 29; 48%) and improving patient satisfaction (n = 27; 44%).

Factors Delaying Discharge

The most common factors perceived as delaying discharge were considered external to the hospital, such as postacute care bed availability or scheduled (eg, ambulance) transport delays (n = 48; 79%), followed by patient factors such as patient transport issues (n = 44; 72%). Less commonly reported were workflow issues, such as competing primary team priorities or case manager bandwidth (n = 38; 62%; Table 1).

Initiatives to Improve Discharge

The most commonly implemented initiatives perceived as effective at improving discharge times were the preemptive identification of early discharges to plan discharge paperwork (n = 34; 56%), communication with patients about anticipated discharge time on the day prior to discharge (n = 29; 48%), and the implementation of additional rounds between physician teams and case managers specifically around discharge planning (n = 28; 46%). Initiatives not commonly implemented included regular audit of and feedback on discharge times to providers and teams (n = 21; 34%), the use of a discharge readiness checklist (n = 26; 43%), incentives such as bonuses or penalties (n = 37; 61%), the use of a whiteboard to indicate discharge times (n = 23; 38%), and dedicated quality-improvement approaches such as LEAN (n = 37; 61%; Table 2).

Our study suggests early discharge for medicine patients is a priority among academic institutions. Hospitalist and general internal medicine physician leaders in our study generally attributed delayed discharges to external factors, particularly unavailability of postacute care facilities and transportation delays. Having issues with finding postacute care placements is consistent with previous findings by Selker et al.¹⁵ and Carey et al.⁸ This is despite the 20-year difference between Selker et al.’s study and the current study, reflecting a continued opportunity for improvement, including stronger partnerships with local and regional postacute care facilities to expedite care transition and stronger discharge-planning efforts early in the admission process. Efforts in postacute care placement may be particularly important for Medicaid-insured and uninsured patients.

Our responders, hospitalist and internal medicine physician leaders, did not perceive the additional responsibilities of teaching and supervising trainees to be factors that significantly delayed patient discharge. This is in contrast to previous studies, which attributed delays in discharge to prolonged clinical decision-making related to teaching and supervision.^4-6,8 This discrepancy may be due to the fact that we only surveyed single physician leaders at each institution and not residents. Our finding warrants further investigation to understand the degree to which resident skills may impact discharge planning and processes.

Institutions represented in our study have attempted a variety of initiatives promoting earlier discharge, with varying levels of perceived success. Initiatives perceived to be the most effective by hospital leaders centered on 2 main areas: (1) changing individual provider practice and (2) anticipatory discharge preparation. Interestingly, this is in discordance with the main factors labeled as causing delays in discharges, such as obtaining postacute care beds, busy case managers, and competing demands on primary teams. We hypothesize this may be because such changes require organization- or system-level changes and are perceived as more arduous than changes at the individual level. In addition, changes to individual provider behavior may be more cost- and time-effective than more systemic initiatives.

Our findings are consistent with the work published by Wertheimer and colleagues,¹¹ who show that additional afternoon interdisciplinary rounds can help identify patients who may be discharged before noon the next day. In their study, identifying such patients in advance improved the overall early-discharge rate the following day.

Our findings should be interpreted in light of several limitations. Our survey only considers the perspectives of hospitalist and general internal medicine physician leaders at academic medical centers that are part of the Vizient Inc. collaborative. They do not represent all academic or community-based medical centers. Although the perceived effectiveness of some initiatives was high, we did not collect empirical data to support these claims or to determine which initiative had the greatest relative impact on discharge timeliness. Lastly, we did not obtain resident, nursing, or case manager perspectives on discharge practices. Given their roles as frontline providers, we may have missed these alternative perspectives.

Our study shows there is a strong interest in increasing early discharges in an effort to improve hospital throughput and patient flow.

Acknowledgments

The authors thank all participants who completed the survey and Danielle Carrier at Vizient Inc. (formally University HealthSystem Consortium) for her assistance in obtaining data.

Disclosures

Hemali Patel, Margaret Fang, Michelle Mourad, Adrienne Green, Ryan Murphy, and James Harrison report no conflicts of interest. At the time the research was conducted, Robert Wachter reported that he is a member of the Lucian Leape Institute at the National Patient Safety Foundation (no compensation except travel expenses); recently chaired an advisory board to England’s National Health Service (NHS) reviewing the NHS’s digital health strategy (no compensation except travel expenses); has a contract with UCSF from the Agency for Healthcare Research and Quality to edit a patient-safety website; receives compensation from John Wiley & Sons for writing a blog; receives royalties from Lippincott Williams & Wilkins and McGraw-Hill Education for writing and/or editing several books; receives stock options for serving on the board of Acuity Medical Management Systems; receives a yearly stipend for serving on the board of The Doctors Company; serves on the scientific advisory boards for amino.com, PatientSafe Solutions Inc., Twine, and EarlySense (for which he receives stock options); has a small royalty stake in CareWeb, a hospital communication tool developed at UCSF; and holds the Marc and Lynne Benioff Endowed Chair in Hospital Medicine and the Holly Smith Distinguished Professorship in Science and Medicine at UCSF.

The discharge process is a critical bottleneck for efficient patient flow through the hospital. Delayed discharges translate into delays in admissions and other patient transitions, often leading to excess costs, patient dissatisfaction, and even patient harm.^1-3 The emergency department is particularly impacted by these delays; bottlenecks there lead to overcrowding, increased overall hospital length of stay, and increased risks for bad outcomes during hospitalization.²

Academic medical centers in particular may struggle with delayed discharges. In a typical teaching hospital, a team composed of an attending physician and housestaff share responsibility for determining the discharge plan. Additionally, clinical teaching activities may affect the process and quality of discharge.^4-6

The prevalence and causes of delayed discharges vary greatly.^7-9 To improve efficiency around discharge, many hospitals have launched initiatives designed to discharge patients earlier in the day, including goal setting (“discharge by noon”), scheduling discharge appointments, and using quality-improvement methods, such as Lean Methodology (LEAN), to remove inefficiencies within discharge processes.^10-12 However, there are few data on the prevalence and effectiveness of different strategies.

The aim of this study was to survey academic hospitalist and general internal medicine physician leaders to elicit their perspectives on the factors contributing to discharge timing and the relative importance and effectiveness of early-discharge initiatives.

Study Design, Participants, and Oversight

We obtained a list of 115 university-affiliated hospitals associated with a residency program and, in most cases, a medical school from Vizient Inc. (formerly University HealthSystem Consortium), an alliance of academic medical centers and affiliated hospitals. Each member institution submits clinical data to allow for the benchmarking of outcomes to drive transparency and quality improvement.¹³ More than 95% of the nation’s academic medical centers and affiliated hospitals participate in this collaborative. Vizient works with members but does not set nor promote quality metrics, such as discharge timeliness. E-mail addresses for hospital medicine physician leaders (eg, division chief) of major academic medical centers were obtained from each institution via publicly available data (eg, the institution’s website). When an institution did not have a hospital medicine section, we identified the division chief of general internal medicine. The University of California, San Francisco Institutional Review Board approved this study.

Survey Development and Domains

We developed a 30-item survey to evaluate 5 main domains of interest: current discharge practices, degree of prioritization of early discharge on the inpatient service, barriers to timely discharge, prevalence and perceived effectiveness of implemented early-discharge initiatives, and barriers to implementation of early-discharge initiatives.

Respondents were first asked to identify their institutions’ goals for discharge time. They were then asked to compare the priority of early-discharge initiatives to other departmental quality-improvement initiatives, such as reducing 30-day readmissions, improving interpreter use, and improving patient satisfaction. Next, respondents were asked to estimate the degree to which clinical or patient factors contributed to delays in discharge. Respondents were then asked whether specific early-discharge initiatives, such as changes to rounding practices or communication interventions, were implemented at their institutions and, if so, the perceived effectiveness of these initiatives at meeting discharge targets. We piloted the questions locally with physicians and researchers prior to finalizing the survey.

Data Collection

We sent surveys via an online platform (Research Electronic Data Capture).¹⁴ Nonresponders were sent 2 e-mail reminders and then a follow-up telephone call asking them to complete the survey. Only 1 survey per academic medical center was collected. Any respondent who completed the survey within 2 weeks of receiving it was entered to win a Kindle Fire.

Data Analysis

We summarized survey responses using descriptive statistics. Analysis was completed in IBM SPSS version 22 (Armonk, NY).

Survey Respondent and Institutional Characteristics

Of the 115 institutions surveyed, we received 61 responses (response rate of 53%), with 39 (64%) respondents from divisions of hospital medicine and 22 (36%) from divisions of general internal medicine. A majority (n = 53; 87%) stated their medicine services have a combination of teaching (with residents) and nonteaching (without residents) teams. Thirty-nine (64%) reported having daily multidisciplinary rounds.

Early Discharge as a Priority

Forty-seven (77%) institutional representatives strongly agreed or agreed that early discharge was a priority, with discharge by noon being the most common target time (n = 23; 38%). Thirty (50%) respondents rated early discharge as more important than improving interpreter use for non-English-speaking patients and equally important as reducing 30-day readmissions (n = 29; 48%) and improving patient satisfaction (n = 27; 44%).

Factors Delaying Discharge

The most common factors perceived as delaying discharge were considered external to the hospital, such as postacute care bed availability or scheduled (eg, ambulance) transport delays (n = 48; 79%), followed by patient factors such as patient transport issues (n = 44; 72%). Less commonly reported were workflow issues, such as competing primary team priorities or case manager bandwidth (n = 38; 62%; Table 1).

Initiatives to Improve Discharge

The most commonly implemented initiatives perceived as effective at improving discharge times were the preemptive identification of early discharges to plan discharge paperwork (n = 34; 56%), communication with patients about anticipated discharge time on the day prior to discharge (n = 29; 48%), and the implementation of additional rounds between physician teams and case managers specifically around discharge planning (n = 28; 46%). Initiatives not commonly implemented included regular audit of and feedback on discharge times to providers and teams (n = 21; 34%), the use of a discharge readiness checklist (n = 26; 43%), incentives such as bonuses or penalties (n = 37; 61%), the use of a whiteboard to indicate discharge times (n = 23; 38%), and dedicated quality-improvement approaches such as LEAN (n = 37; 61%; Table 2).

Our study suggests early discharge for medicine patients is a priority among academic institutions. Hospitalist and general internal medicine physician leaders in our study generally attributed delayed discharges to external factors, particularly unavailability of postacute care facilities and transportation delays. Having issues with finding postacute care placements is consistent with previous findings by Selker et al.¹⁵ and Carey et al.⁸ This is despite the 20-year difference between Selker et al.’s study and the current study, reflecting a continued opportunity for improvement, including stronger partnerships with local and regional postacute care facilities to expedite care transition and stronger discharge-planning efforts early in the admission process. Efforts in postacute care placement may be particularly important for Medicaid-insured and uninsured patients.

Our responders, hospitalist and internal medicine physician leaders, did not perceive the additional responsibilities of teaching and supervising trainees to be factors that significantly delayed patient discharge. This is in contrast to previous studies, which attributed delays in discharge to prolonged clinical decision-making related to teaching and supervision.^4-6,8 This discrepancy may be due to the fact that we only surveyed single physician leaders at each institution and not residents. Our finding warrants further investigation to understand the degree to which resident skills may impact discharge planning and processes.

Institutions represented in our study have attempted a variety of initiatives promoting earlier discharge, with varying levels of perceived success. Initiatives perceived to be the most effective by hospital leaders centered on 2 main areas: (1) changing individual provider practice and (2) anticipatory discharge preparation. Interestingly, this is in discordance with the main factors labeled as causing delays in discharges, such as obtaining postacute care beds, busy case managers, and competing demands on primary teams. We hypothesize this may be because such changes require organization- or system-level changes and are perceived as more arduous than changes at the individual level. In addition, changes to individual provider behavior may be more cost- and time-effective than more systemic initiatives.

Our findings are consistent with the work published by Wertheimer and colleagues,¹¹ who show that additional afternoon interdisciplinary rounds can help identify patients who may be discharged before noon the next day. In their study, identifying such patients in advance improved the overall early-discharge rate the following day.

Our findings should be interpreted in light of several limitations. Our survey only considers the perspectives of hospitalist and general internal medicine physician leaders at academic medical centers that are part of the Vizient Inc. collaborative. They do not represent all academic or community-based medical centers. Although the perceived effectiveness of some initiatives was high, we did not collect empirical data to support these claims or to determine which initiative had the greatest relative impact on discharge timeliness. Lastly, we did not obtain resident, nursing, or case manager perspectives on discharge practices. Given their roles as frontline providers, we may have missed these alternative perspectives.

Our study shows there is a strong interest in increasing early discharges in an effort to improve hospital throughput and patient flow.

Acknowledgments

The authors thank all participants who completed the survey and Danielle Carrier at Vizient Inc. (formally University HealthSystem Consortium) for her assistance in obtaining data.

Disclosures

Hemali Patel, Margaret Fang, Michelle Mourad, Adrienne Green, Ryan Murphy, and James Harrison report no conflicts of interest. At the time the research was conducted, Robert Wachter reported that he is a member of the Lucian Leape Institute at the National Patient Safety Foundation (no compensation except travel expenses); recently chaired an advisory board to England’s National Health Service (NHS) reviewing the NHS’s digital health strategy (no compensation except travel expenses); has a contract with UCSF from the Agency for Healthcare Research and Quality to edit a patient-safety website; receives compensation from John Wiley & Sons for writing a blog; receives royalties from Lippincott Williams & Wilkins and McGraw-Hill Education for writing and/or editing several books; receives stock options for serving on the board of Acuity Medical Management Systems; receives a yearly stipend for serving on the board of The Doctors Company; serves on the scientific advisory boards for amino.com, PatientSafe Solutions Inc., Twine, and EarlySense (for which he receives stock options); has a small royalty stake in CareWeb, a hospital communication tool developed at UCSF; and holds the Marc and Lynne Benioff Endowed Chair in Hospital Medicine and the Holly Smith Distinguished Professorship in Science and Medicine at UCSF.

The discharge process is a critical bottleneck for efficient patient flow through the hospital. Delayed discharges translate into delays in admissions and other patient transitions, often leading to excess costs, patient dissatisfaction, and even patient harm.^1-3 The emergency department is particularly impacted by these delays; bottlenecks there lead to overcrowding, increased overall hospital length of stay, and increased risks for bad outcomes during hospitalization.²

Academic medical centers in particular may struggle with delayed discharges. In a typical teaching hospital, a team composed of an attending physician and housestaff share responsibility for determining the discharge plan. Additionally, clinical teaching activities may affect the process and quality of discharge.^4-6

The prevalence and causes of delayed discharges vary greatly.^7-9 To improve efficiency around discharge, many hospitals have launched initiatives designed to discharge patients earlier in the day, including goal setting (“discharge by noon”), scheduling discharge appointments, and using quality-improvement methods, such as Lean Methodology (LEAN), to remove inefficiencies within discharge processes.^10-12 However, there are few data on the prevalence and effectiveness of different strategies.

The aim of this study was to survey academic hospitalist and general internal medicine physician leaders to elicit their perspectives on the factors contributing to discharge timing and the relative importance and effectiveness of early-discharge initiatives.

Study Design, Participants, and Oversight

We obtained a list of 115 university-affiliated hospitals associated with a residency program and, in most cases, a medical school from Vizient Inc. (formerly University HealthSystem Consortium), an alliance of academic medical centers and affiliated hospitals. Each member institution submits clinical data to allow for the benchmarking of outcomes to drive transparency and quality improvement.¹³ More than 95% of the nation’s academic medical centers and affiliated hospitals participate in this collaborative. Vizient works with members but does not set nor promote quality metrics, such as discharge timeliness. E-mail addresses for hospital medicine physician leaders (eg, division chief) of major academic medical centers were obtained from each institution via publicly available data (eg, the institution’s website). When an institution did not have a hospital medicine section, we identified the division chief of general internal medicine. The University of California, San Francisco Institutional Review Board approved this study.

Survey Development and Domains

We developed a 30-item survey to evaluate 5 main domains of interest: current discharge practices, degree of prioritization of early discharge on the inpatient service, barriers to timely discharge, prevalence and perceived effectiveness of implemented early-discharge initiatives, and barriers to implementation of early-discharge initiatives.

Respondents were first asked to identify their institutions’ goals for discharge time. They were then asked to compare the priority of early-discharge initiatives to other departmental quality-improvement initiatives, such as reducing 30-day readmissions, improving interpreter use, and improving patient satisfaction. Next, respondents were asked to estimate the degree to which clinical or patient factors contributed to delays in discharge. Respondents were then asked whether specific early-discharge initiatives, such as changes to rounding practices or communication interventions, were implemented at their institutions and, if so, the perceived effectiveness of these initiatives at meeting discharge targets. We piloted the questions locally with physicians and researchers prior to finalizing the survey.

Data Collection

We sent surveys via an online platform (Research Electronic Data Capture).¹⁴ Nonresponders were sent 2 e-mail reminders and then a follow-up telephone call asking them to complete the survey. Only 1 survey per academic medical center was collected. Any respondent who completed the survey within 2 weeks of receiving it was entered to win a Kindle Fire.

Data Analysis

We summarized survey responses using descriptive statistics. Analysis was completed in IBM SPSS version 22 (Armonk, NY).

Survey Respondent and Institutional Characteristics

Of the 115 institutions surveyed, we received 61 responses (response rate of 53%), with 39 (64%) respondents from divisions of hospital medicine and 22 (36%) from divisions of general internal medicine. A majority (n = 53; 87%) stated their medicine services have a combination of teaching (with residents) and nonteaching (without residents) teams. Thirty-nine (64%) reported having daily multidisciplinary rounds.

Early Discharge as a Priority

Forty-seven (77%) institutional representatives strongly agreed or agreed that early discharge was a priority, with discharge by noon being the most common target time (n = 23; 38%). Thirty (50%) respondents rated early discharge as more important than improving interpreter use for non-English-speaking patients and equally important as reducing 30-day readmissions (n = 29; 48%) and improving patient satisfaction (n = 27; 44%).

Factors Delaying Discharge

The most common factors perceived as delaying discharge were considered external to the hospital, such as postacute care bed availability or scheduled (eg, ambulance) transport delays (n = 48; 79%), followed by patient factors such as patient transport issues (n = 44; 72%). Less commonly reported were workflow issues, such as competing primary team priorities or case manager bandwidth (n = 38; 62%; Table 1).

Initiatives to Improve Discharge

The most commonly implemented initiatives perceived as effective at improving discharge times were the preemptive identification of early discharges to plan discharge paperwork (n = 34; 56%), communication with patients about anticipated discharge time on the day prior to discharge (n = 29; 48%), and the implementation of additional rounds between physician teams and case managers specifically around discharge planning (n = 28; 46%). Initiatives not commonly implemented included regular audit of and feedback on discharge times to providers and teams (n = 21; 34%), the use of a discharge readiness checklist (n = 26; 43%), incentives such as bonuses or penalties (n = 37; 61%), the use of a whiteboard to indicate discharge times (n = 23; 38%), and dedicated quality-improvement approaches such as LEAN (n = 37; 61%; Table 2).

Our study suggests early discharge for medicine patients is a priority among academic institutions. Hospitalist and general internal medicine physician leaders in our study generally attributed delayed discharges to external factors, particularly unavailability of postacute care facilities and transportation delays. Having issues with finding postacute care placements is consistent with previous findings by Selker et al.¹⁵ and Carey et al.⁸ This is despite the 20-year difference between Selker et al.’s study and the current study, reflecting a continued opportunity for improvement, including stronger partnerships with local and regional postacute care facilities to expedite care transition and stronger discharge-planning efforts early in the admission process. Efforts in postacute care placement may be particularly important for Medicaid-insured and uninsured patients.

Our responders, hospitalist and internal medicine physician leaders, did not perceive the additional responsibilities of teaching and supervising trainees to be factors that significantly delayed patient discharge. This is in contrast to previous studies, which attributed delays in discharge to prolonged clinical decision-making related to teaching and supervision.^4-6,8 This discrepancy may be due to the fact that we only surveyed single physician leaders at each institution and not residents. Our finding warrants further investigation to understand the degree to which resident skills may impact discharge planning and processes.

Institutions represented in our study have attempted a variety of initiatives promoting earlier discharge, with varying levels of perceived success. Initiatives perceived to be the most effective by hospital leaders centered on 2 main areas: (1) changing individual provider practice and (2) anticipatory discharge preparation. Interestingly, this is in discordance with the main factors labeled as causing delays in discharges, such as obtaining postacute care beds, busy case managers, and competing demands on primary teams. We hypothesize this may be because such changes require organization- or system-level changes and are perceived as more arduous than changes at the individual level. In addition, changes to individual provider behavior may be more cost- and time-effective than more systemic initiatives.

Our findings are consistent with the work published by Wertheimer and colleagues,¹¹ who show that additional afternoon interdisciplinary rounds can help identify patients who may be discharged before noon the next day. In their study, identifying such patients in advance improved the overall early-discharge rate the following day.

Our findings should be interpreted in light of several limitations. Our survey only considers the perspectives of hospitalist and general internal medicine physician leaders at academic medical centers that are part of the Vizient Inc. collaborative. They do not represent all academic or community-based medical centers. Although the perceived effectiveness of some initiatives was high, we did not collect empirical data to support these claims or to determine which initiative had the greatest relative impact on discharge timeliness. Lastly, we did not obtain resident, nursing, or case manager perspectives on discharge practices. Given their roles as frontline providers, we may have missed these alternative perspectives.

Our study shows there is a strong interest in increasing early discharges in an effort to improve hospital throughput and patient flow.

Acknowledgments

The authors thank all participants who completed the survey and Danielle Carrier at Vizient Inc. (formally University HealthSystem Consortium) for her assistance in obtaining data.

Disclosures

Hemali Patel, Margaret Fang, Michelle Mourad, Adrienne Green, Ryan Murphy, and James Harrison report no conflicts of interest. At the time the research was conducted, Robert Wachter reported that he is a member of the Lucian Leape Institute at the National Patient Safety Foundation (no compensation except travel expenses); recently chaired an advisory board to England’s National Health Service (NHS) reviewing the NHS’s digital health strategy (no compensation except travel expenses); has a contract with UCSF from the Agency for Healthcare Research and Quality to edit a patient-safety website; receives compensation from John Wiley & Sons for writing a blog; receives royalties from Lippincott Williams & Wilkins and McGraw-Hill Education for writing and/or editing several books; receives stock options for serving on the board of Acuity Medical Management Systems; receives a yearly stipend for serving on the board of The Doctors Company; serves on the scientific advisory boards for amino.com, PatientSafe Solutions Inc., Twine, and EarlySense (for which he receives stock options); has a small royalty stake in CareWeb, a hospital communication tool developed at UCSF; and holds the Marc and Lynne Benioff Endowed Chair in Hospital Medicine and the Holly Smith Distinguished Professorship in Science and Medicine at UCSF.

Electronic consultation (e-consult) in the outpatient setting allows subspecialists to provide assessment and recommendations for patients without in-person visits.¹ An e-consult is an asynchronous communication that uses the electronic medical record (EMR) and typically involves an electronic order from a requesting provider and an electronic note from a consulting provider. The initial motivation for developing this consultation modality was to improve access to subspecialty care for patients in the primary care setting, and findings of studies at several sites support this claim.^1-4 In addition, e-consult may also reduce cost because converting unnecessary face-to-face encounters into e-consults reduces patients’ travel costs and healthcare organizations’ expensive subspecialty clinic time.^3,5 Moreover, instead of addressing less complex clinical questions in informal, undocumented face-to-face or telephone “curbside” consultations with specialists, providers can instead ask for e-consults and thereby ensure thorough chart review and proper documentation.⁶

Use of e-consults in the inpatient setting is relatively novel.⁷ In addition to having the advantages already mentioned, e-consults are faster than in-person bedside consultations and may be beneficial in the fast-moving inpatient care setting. Finally, healthcare systems with multiple hospital sites may not have the capacity to physically locate subspecialists at each site, which makes e-consults attractive for avoiding unnecessary travel time.

In this article, we describe how we developed an inpatient e-consult protocol for a new, remote hospital within our healthcare system and explore data on safety and physician attitudes after e-consult implementation.

The Institutional Review Board of the University of California San Francisco (UCSF) approved this study.

Setting

In February 2015, UCSF opened a new hospital in the Mission Bay neighborhood of San Francisco, 4 miles from the existing hospital. The new hospital is home to several adult inpatient services: urology, otolaryngology, colorectal surgery, obstetrics, and gynecologic surgery. A hospitalist is on-site 24 hours a day to provide consultation for these services around issues that relate to internal medicine. A hospitalist who requires subspecialty expertise to answer a clinical question can request a consultation by in-person visit, video telemedicine, or e-consult, each of which is available 24/7. Almost all of the medicine subspecialists work on the existing campus, not in Mission Bay.

Protocol Development and Implementation

The protocol for the e-consult program was developed over several months by an interdisciplinary group that included 3 hospitalists, 1 obstetrician, 1 project manager, and 1 informaticist. The group outlined the process for requesting and completing an e-consult (Figure), designed a note template for consultants to use for EMR documentation, conducted outreach with subspecialty groups to discuss the protocol, and developed an EMR report to track e-consult use and content over time. As our medical center does not bill payers for inpatient e-consults, e-consult note tracking is used to provide reimbursement internally, from the medical center to the respective departments of the consultants. Reimbursement is made at a set rate per e-consult note, with the rate set to approximate the reimbursement of a low-acuity in-person consult on the main campus.

The workflow of an e-consult is as follows: (1) When a primary team requires a consultation on an issue that falls within the purview of internal medicine, it pages the on-site hospitalist. (2) The hospitalist accepts the consultation by phone, reviews the chart, and examines the patient. (3) If the hospitalist requires subspecialty assistance to answer a clinical question, he or she contacts the appropriate subspecialty service by pager. (4) The subspecialist speaks with the hospitalist about the consultation question, and together they decide if an e-consult is appropriate, based on the complexity of the clinical scenario. (5) The subspecialist reviews the patient’s chart and documents their care plan recommendations in an e-consult note. Consultants can use e-consult for both initial and follow-up assessment, and there is no strict requirement that they also contact the hospitalist or the primary team by phone in addition to consultation note. Given their novelty, almost all e-consults are performed by subspecialist attendings, not residents or fellows.

Evaluation

Each month, we tracked e-consult use using an EMR report built as part of the implementation of the program. For the first four months of implementation, every patient who received an e-consult also had a manual chart review of the period around the e-consult, performed by a hospitalist, in order to audit for any potential safety issues. These issues included, for example, an e-consult performed for a patient whose complexity or severity of illness was felt to be too great to defer an in-person visit, or a patient who received e-consult recommendations that were significantly retracted in a follow-up in-person note.

Eight months after the program started, we assessed experience by electronically surveying the 9 hospitalists and 11 consultants who had requested or performed at least 2 e-consults.⁸ Survey items were measured on a 5-point Likert scale: strongly disagree to strongly agree. The items, which related to ease of calling for a consultation, quality of e-consults, impact on clinical care, safety concerns, and satisfaction, were inspired by themes identified in a systematic review of the literature on e-consults in the outpatient setting.² We sent 2 reminders to responders. Data were summarized using descriptive statistics. Analysis was performed in SPSS version 22.0 (IBM).

There were 143 initial subspecialty consultations by e-consult between program launch in February 2015 and manuscript preparation in February 2016, an average of 11 e-consults per month. There were 313 total e-consult notes (these included both initial and follow-up e-consult notes). By comparison, 240 initial in-person consultations occurred during the same period, and there were 435 total in-person consultation notes (46% new or initial notes, 54% follow-up notes). The top 5 subspecialties by volume of e-consults were infectious disease (35%), hematology (20%), endocrinology (14%), nephrology (13%), and cardiology (8%). For reference, e-consults are also available from psychiatry, neurology, oncology, gastroenterology, pulmonology, and rheumatology. Percentage of consultations performed during daytime hours (defined as 8 a.m. to 5 p.m.) was 92% for e-consults and 96% for in-person consultations.

There were no e-consult–related patient safety issues reported through the medical center’s incident reporting system during the study period. There were also no patient safety issues identified in the manual audits of 80 charts during the first 4 months of the program.

Seven (78%) of 9 hospitalists and 7 (64%) of 11 consultants completed the survey. Both groups agreed that e-consults were easy to use and efficient (Table). All hospitalists were satisfied with the quality of e-consult recommendations, but only 3 (43%) of the 7 consultants agreed they could provide high-quality consultation by e-consult. In their comments, 2 consultants expressed concerns. One concern was about missing crucial information by performing only a chart review, and the other was about being tempted to perform an e-consult simply because it is expedient.

Although use of e-consults in the outpatient setting is relatively commonplace, our program represents a novel use of e-consults in safely and efficiently providing subspecialty consultation to inpatients at a remote hospital.

For hospitalists, an e-consult system offers numerous benefits. Clinical questions beyond an internists’ scope of practice come up often, and simple questions might traditionally result in an informal curbside consult. While a curbside consult provides answers faster than an in-person visit, it creates risks for the requesting hospitalists: the consultants only know what they are told, whether the information is incomplete or erroneous; their opinions are given without documentation or compensation, which reduces a sense of accountability; and the lack of documentation does not allow their advice to persist in the chart as a reference for future providers.⁹ Our e-consult program solves these problems by requiring that consultants perform chart review and provide documentation as well as obligating the medical center to pay a small compensation to consultants for their time. We hope this lowers the bar to requesting consultation for remote sites, where the alternative would be burdensome travel time to do an in-person visit.

In our study, hospitalists were universally pleased with the quality of e-consult recommendations, but only 43% of consultants agreed. These findings correlate with the literature on e-consults in the outpatient setting.² Unfortunately, our survey comments did not shed further light on this sentiment. In the outpatient literature, consultants were most concerned with having a clear clinical question, facing the liability of providing recommendations without performing an examination, and receiving appropriate compensation for answering e-consults.

The generalizability of our program findings is limited most significantly by the particular arrangement of our clinical services: Our remote site is home to a select group of adult inpatient services, a hospitalist is available on-site for these services 24 hours a day, and the distance to the remote site can be overcome with modest effort should a patient require an in-person visit in the initial or follow-up period. The generalizability of our safety findings is limited by the use of a single reviewer for chart auditing.

Given the rise of accountable care organizations and the prevalence of hospital mergers in the healthcare landscape, we believe that healthcare systems that operate remote sites under constrained budgets could look to e-consults to more cost-effectively extend subspecialty expertise across the inpatient enterprise. With improvements in health information exchange, it may also become feasible for consultants to offer e-consults to hospitals outside a medical center’s network. Our study showed that inpatient e-consult programs can be developed and implemented, that they appear not to pose any significant safety issues, and that they can facilitate delivery of timely clinical care.

Acknowledgment

The authors thank Raphaela Levy-Moore for creating and implementing the e-consult note template for our electronic medical record.

Disclosure

Nothing to report.

Electronic consultation (e-consult) in the outpatient setting allows subspecialists to provide assessment and recommendations for patients without in-person visits.¹ An e-consult is an asynchronous communication that uses the electronic medical record (EMR) and typically involves an electronic order from a requesting provider and an electronic note from a consulting provider. The initial motivation for developing this consultation modality was to improve access to subspecialty care for patients in the primary care setting, and findings of studies at several sites support this claim.^1-4 In addition, e-consult may also reduce cost because converting unnecessary face-to-face encounters into e-consults reduces patients’ travel costs and healthcare organizations’ expensive subspecialty clinic time.^3,5 Moreover, instead of addressing less complex clinical questions in informal, undocumented face-to-face or telephone “curbside” consultations with specialists, providers can instead ask for e-consults and thereby ensure thorough chart review and proper documentation.⁶

Use of e-consults in the inpatient setting is relatively novel.⁷ In addition to having the advantages already mentioned, e-consults are faster than in-person bedside consultations and may be beneficial in the fast-moving inpatient care setting. Finally, healthcare systems with multiple hospital sites may not have the capacity to physically locate subspecialists at each site, which makes e-consults attractive for avoiding unnecessary travel time.

In this article, we describe how we developed an inpatient e-consult protocol for a new, remote hospital within our healthcare system and explore data on safety and physician attitudes after e-consult implementation.

The Institutional Review Board of the University of California San Francisco (UCSF) approved this study.

Setting

In February 2015, UCSF opened a new hospital in the Mission Bay neighborhood of San Francisco, 4 miles from the existing hospital. The new hospital is home to several adult inpatient services: urology, otolaryngology, colorectal surgery, obstetrics, and gynecologic surgery. A hospitalist is on-site 24 hours a day to provide consultation for these services around issues that relate to internal medicine. A hospitalist who requires subspecialty expertise to answer a clinical question can request a consultation by in-person visit, video telemedicine, or e-consult, each of which is available 24/7. Almost all of the medicine subspecialists work on the existing campus, not in Mission Bay.

Protocol Development and Implementation

The protocol for the e-consult program was developed over several months by an interdisciplinary group that included 3 hospitalists, 1 obstetrician, 1 project manager, and 1 informaticist. The group outlined the process for requesting and completing an e-consult (Figure), designed a note template for consultants to use for EMR documentation, conducted outreach with subspecialty groups to discuss the protocol, and developed an EMR report to track e-consult use and content over time. As our medical center does not bill payers for inpatient e-consults, e-consult note tracking is used to provide reimbursement internally, from the medical center to the respective departments of the consultants. Reimbursement is made at a set rate per e-consult note, with the rate set to approximate the reimbursement of a low-acuity in-person consult on the main campus.

The workflow of an e-consult is as follows: (1) When a primary team requires a consultation on an issue that falls within the purview of internal medicine, it pages the on-site hospitalist. (2) The hospitalist accepts the consultation by phone, reviews the chart, and examines the patient. (3) If the hospitalist requires subspecialty assistance to answer a clinical question, he or she contacts the appropriate subspecialty service by pager. (4) The subspecialist speaks with the hospitalist about the consultation question, and together they decide if an e-consult is appropriate, based on the complexity of the clinical scenario. (5) The subspecialist reviews the patient’s chart and documents their care plan recommendations in an e-consult note. Consultants can use e-consult for both initial and follow-up assessment, and there is no strict requirement that they also contact the hospitalist or the primary team by phone in addition to consultation note. Given their novelty, almost all e-consults are performed by subspecialist attendings, not residents or fellows.

Evaluation

Each month, we tracked e-consult use using an EMR report built as part of the implementation of the program. For the first four months of implementation, every patient who received an e-consult also had a manual chart review of the period around the e-consult, performed by a hospitalist, in order to audit for any potential safety issues. These issues included, for example, an e-consult performed for a patient whose complexity or severity of illness was felt to be too great to defer an in-person visit, or a patient who received e-consult recommendations that were significantly retracted in a follow-up in-person note.

Eight months after the program started, we assessed experience by electronically surveying the 9 hospitalists and 11 consultants who had requested or performed at least 2 e-consults.⁸ Survey items were measured on a 5-point Likert scale: strongly disagree to strongly agree. The items, which related to ease of calling for a consultation, quality of e-consults, impact on clinical care, safety concerns, and satisfaction, were inspired by themes identified in a systematic review of the literature on e-consults in the outpatient setting.² We sent 2 reminders to responders. Data were summarized using descriptive statistics. Analysis was performed in SPSS version 22.0 (IBM).

There were 143 initial subspecialty consultations by e-consult between program launch in February 2015 and manuscript preparation in February 2016, an average of 11 e-consults per month. There were 313 total e-consult notes (these included both initial and follow-up e-consult notes). By comparison, 240 initial in-person consultations occurred during the same period, and there were 435 total in-person consultation notes (46% new or initial notes, 54% follow-up notes). The top 5 subspecialties by volume of e-consults were infectious disease (35%), hematology (20%), endocrinology (14%), nephrology (13%), and cardiology (8%). For reference, e-consults are also available from psychiatry, neurology, oncology, gastroenterology, pulmonology, and rheumatology. Percentage of consultations performed during daytime hours (defined as 8 a.m. to 5 p.m.) was 92% for e-consults and 96% for in-person consultations.

There were no e-consult–related patient safety issues reported through the medical center’s incident reporting system during the study period. There were also no patient safety issues identified in the manual audits of 80 charts during the first 4 months of the program.

Seven (78%) of 9 hospitalists and 7 (64%) of 11 consultants completed the survey. Both groups agreed that e-consults were easy to use and efficient (Table). All hospitalists were satisfied with the quality of e-consult recommendations, but only 3 (43%) of the 7 consultants agreed they could provide high-quality consultation by e-consult. In their comments, 2 consultants expressed concerns. One concern was about missing crucial information by performing only a chart review, and the other was about being tempted to perform an e-consult simply because it is expedient.

Although use of e-consults in the outpatient setting is relatively commonplace, our program represents a novel use of e-consults in safely and efficiently providing subspecialty consultation to inpatients at a remote hospital.

For hospitalists, an e-consult system offers numerous benefits. Clinical questions beyond an internists’ scope of practice come up often, and simple questions might traditionally result in an informal curbside consult. While a curbside consult provides answers faster than an in-person visit, it creates risks for the requesting hospitalists: the consultants only know what they are told, whether the information is incomplete or erroneous; their opinions are given without documentation or compensation, which reduces a sense of accountability; and the lack of documentation does not allow their advice to persist in the chart as a reference for future providers.⁹ Our e-consult program solves these problems by requiring that consultants perform chart review and provide documentation as well as obligating the medical center to pay a small compensation to consultants for their time. We hope this lowers the bar to requesting consultation for remote sites, where the alternative would be burdensome travel time to do an in-person visit.

In our study, hospitalists were universally pleased with the quality of e-consult recommendations, but only 43% of consultants agreed. These findings correlate with the literature on e-consults in the outpatient setting.² Unfortunately, our survey comments did not shed further light on this sentiment. In the outpatient literature, consultants were most concerned with having a clear clinical question, facing the liability of providing recommendations without performing an examination, and receiving appropriate compensation for answering e-consults.

The generalizability of our program findings is limited most significantly by the particular arrangement of our clinical services: Our remote site is home to a select group of adult inpatient services, a hospitalist is available on-site for these services 24 hours a day, and the distance to the remote site can be overcome with modest effort should a patient require an in-person visit in the initial or follow-up period. The generalizability of our safety findings is limited by the use of a single reviewer for chart auditing.

Given the rise of accountable care organizations and the prevalence of hospital mergers in the healthcare landscape, we believe that healthcare systems that operate remote sites under constrained budgets could look to e-consults to more cost-effectively extend subspecialty expertise across the inpatient enterprise. With improvements in health information exchange, it may also become feasible for consultants to offer e-consults to hospitals outside a medical center’s network. Our study showed that inpatient e-consult programs can be developed and implemented, that they appear not to pose any significant safety issues, and that they can facilitate delivery of timely clinical care.

Acknowledgment

The authors thank Raphaela Levy-Moore for creating and implementing the e-consult note template for our electronic medical record.

Disclosure

Nothing to report.

Electronic consultation (e-consult) in the outpatient setting allows subspecialists to provide assessment and recommendations for patients without in-person visits.¹ An e-consult is an asynchronous communication that uses the electronic medical record (EMR) and typically involves an electronic order from a requesting provider and an electronic note from a consulting provider. The initial motivation for developing this consultation modality was to improve access to subspecialty care for patients in the primary care setting, and findings of studies at several sites support this claim.^1-4 In addition, e-consult may also reduce cost because converting unnecessary face-to-face encounters into e-consults reduces patients’ travel costs and healthcare organizations’ expensive subspecialty clinic time.^3,5 Moreover, instead of addressing less complex clinical questions in informal, undocumented face-to-face or telephone “curbside” consultations with specialists, providers can instead ask for e-consults and thereby ensure thorough chart review and proper documentation.⁶

Use of e-consults in the inpatient setting is relatively novel.⁷ In addition to having the advantages already mentioned, e-consults are faster than in-person bedside consultations and may be beneficial in the fast-moving inpatient care setting. Finally, healthcare systems with multiple hospital sites may not have the capacity to physically locate subspecialists at each site, which makes e-consults attractive for avoiding unnecessary travel time.

In this article, we describe how we developed an inpatient e-consult protocol for a new, remote hospital within our healthcare system and explore data on safety and physician attitudes after e-consult implementation.

The Institutional Review Board of the University of California San Francisco (UCSF) approved this study.

Setting

In February 2015, UCSF opened a new hospital in the Mission Bay neighborhood of San Francisco, 4 miles from the existing hospital. The new hospital is home to several adult inpatient services: urology, otolaryngology, colorectal surgery, obstetrics, and gynecologic surgery. A hospitalist is on-site 24 hours a day to provide consultation for these services around issues that relate to internal medicine. A hospitalist who requires subspecialty expertise to answer a clinical question can request a consultation by in-person visit, video telemedicine, or e-consult, each of which is available 24/7. Almost all of the medicine subspecialists work on the existing campus, not in Mission Bay.

Protocol Development and Implementation

The protocol for the e-consult program was developed over several months by an interdisciplinary group that included 3 hospitalists, 1 obstetrician, 1 project manager, and 1 informaticist. The group outlined the process for requesting and completing an e-consult (Figure), designed a note template for consultants to use for EMR documentation, conducted outreach with subspecialty groups to discuss the protocol, and developed an EMR report to track e-consult use and content over time. As our medical center does not bill payers for inpatient e-consults, e-consult note tracking is used to provide reimbursement internally, from the medical center to the respective departments of the consultants. Reimbursement is made at a set rate per e-consult note, with the rate set to approximate the reimbursement of a low-acuity in-person consult on the main campus.

The workflow of an e-consult is as follows: (1) When a primary team requires a consultation on an issue that falls within the purview of internal medicine, it pages the on-site hospitalist. (2) The hospitalist accepts the consultation by phone, reviews the chart, and examines the patient. (3) If the hospitalist requires subspecialty assistance to answer a clinical question, he or she contacts the appropriate subspecialty service by pager. (4) The subspecialist speaks with the hospitalist about the consultation question, and together they decide if an e-consult is appropriate, based on the complexity of the clinical scenario. (5) The subspecialist reviews the patient’s chart and documents their care plan recommendations in an e-consult note. Consultants can use e-consult for both initial and follow-up assessment, and there is no strict requirement that they also contact the hospitalist or the primary team by phone in addition to consultation note. Given their novelty, almost all e-consults are performed by subspecialist attendings, not residents or fellows.

Evaluation

Each month, we tracked e-consult use using an EMR report built as part of the implementation of the program. For the first four months of implementation, every patient who received an e-consult also had a manual chart review of the period around the e-consult, performed by a hospitalist, in order to audit for any potential safety issues. These issues included, for example, an e-consult performed for a patient whose complexity or severity of illness was felt to be too great to defer an in-person visit, or a patient who received e-consult recommendations that were significantly retracted in a follow-up in-person note.

Eight months after the program started, we assessed experience by electronically surveying the 9 hospitalists and 11 consultants who had requested or performed at least 2 e-consults.⁸ Survey items were measured on a 5-point Likert scale: strongly disagree to strongly agree. The items, which related to ease of calling for a consultation, quality of e-consults, impact on clinical care, safety concerns, and satisfaction, were inspired by themes identified in a systematic review of the literature on e-consults in the outpatient setting.² We sent 2 reminders to responders. Data were summarized using descriptive statistics. Analysis was performed in SPSS version 22.0 (IBM).

There were 143 initial subspecialty consultations by e-consult between program launch in February 2015 and manuscript preparation in February 2016, an average of 11 e-consults per month. There were 313 total e-consult notes (these included both initial and follow-up e-consult notes). By comparison, 240 initial in-person consultations occurred during the same period, and there were 435 total in-person consultation notes (46% new or initial notes, 54% follow-up notes). The top 5 subspecialties by volume of e-consults were infectious disease (35%), hematology (20%), endocrinology (14%), nephrology (13%), and cardiology (8%). For reference, e-consults are also available from psychiatry, neurology, oncology, gastroenterology, pulmonology, and rheumatology. Percentage of consultations performed during daytime hours (defined as 8 a.m. to 5 p.m.) was 92% for e-consults and 96% for in-person consultations.

There were no e-consult–related patient safety issues reported through the medical center’s incident reporting system during the study period. There were also no patient safety issues identified in the manual audits of 80 charts during the first 4 months of the program.

Seven (78%) of 9 hospitalists and 7 (64%) of 11 consultants completed the survey. Both groups agreed that e-consults were easy to use and efficient (Table). All hospitalists were satisfied with the quality of e-consult recommendations, but only 3 (43%) of the 7 consultants agreed they could provide high-quality consultation by e-consult. In their comments, 2 consultants expressed concerns. One concern was about missing crucial information by performing only a chart review, and the other was about being tempted to perform an e-consult simply because it is expedient.

Although use of e-consults in the outpatient setting is relatively commonplace, our program represents a novel use of e-consults in safely and efficiently providing subspecialty consultation to inpatients at a remote hospital.

For hospitalists, an e-consult system offers numerous benefits. Clinical questions beyond an internists’ scope of practice come up often, and simple questions might traditionally result in an informal curbside consult. While a curbside consult provides answers faster than an in-person visit, it creates risks for the requesting hospitalists: the consultants only know what they are told, whether the information is incomplete or erroneous; their opinions are given without documentation or compensation, which reduces a sense of accountability; and the lack of documentation does not allow their advice to persist in the chart as a reference for future providers.⁹ Our e-consult program solves these problems by requiring that consultants perform chart review and provide documentation as well as obligating the medical center to pay a small compensation to consultants for their time. We hope this lowers the bar to requesting consultation for remote sites, where the alternative would be burdensome travel time to do an in-person visit.

In our study, hospitalists were universally pleased with the quality of e-consult recommendations, but only 43% of consultants agreed. These findings correlate with the literature on e-consults in the outpatient setting.² Unfortunately, our survey comments did not shed further light on this sentiment. In the outpatient literature, consultants were most concerned with having a clear clinical question, facing the liability of providing recommendations without performing an examination, and receiving appropriate compensation for answering e-consults.

The generalizability of our program findings is limited most significantly by the particular arrangement of our clinical services: Our remote site is home to a select group of adult inpatient services, a hospitalist is available on-site for these services 24 hours a day, and the distance to the remote site can be overcome with modest effort should a patient require an in-person visit in the initial or follow-up period. The generalizability of our safety findings is limited by the use of a single reviewer for chart auditing.

Given the rise of accountable care organizations and the prevalence of hospital mergers in the healthcare landscape, we believe that healthcare systems that operate remote sites under constrained budgets could look to e-consults to more cost-effectively extend subspecialty expertise across the inpatient enterprise. With improvements in health information exchange, it may also become feasible for consultants to offer e-consults to hospitals outside a medical center’s network. Our study showed that inpatient e-consult programs can be developed and implemented, that they appear not to pose any significant safety issues, and that they can facilitate delivery of timely clinical care.

Acknowledgment

The authors thank Raphaela Levy-Moore for creating and implementing the e-consult note template for our electronic medical record.

Disclosure

Nothing to report.