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Despite an aging population and increasing burden of musculoskeletal disease, the United States faces a shortage of rheumatologists (1). To increase access and efficiency, new models of care may be needed, including greater pre-visit collaborations between referring and specialty care physicians. Pre-consultation exchange is a novel model proposed by the American College of Physicians (ACP) to facilitate effective, patient-centered communication between primary and specialty care providers (2, 3, 4). Pre-consultation exchange is a process that facilitates communication among providers during the primary care to specialty care referral process. The goal of pre-consultation exchange is to maximize the efficiency of specialty visits both by answering clinical questions that may not require a formal patient visit and streamlining the pre-specialty visit workup (2,5). While studies regarding pre-consultation exchange and health information technology (HIT) exist for other medical subspecialties such as hepatology (3), to our knowledge, there are no studies examining HIT solutions for pre-consultation exchange in rheumatology. It therefore remains unknown whether this tool would be acceptable or useful in ambulatory rheumatology care. Two studies from the early 2000s have examined the use of pre-appointment management in rheumatology. In the first study, which involved review of paper-based referrals, only 59% of 279 referred patients actually required a rheumatology consultation (6). In the second, a multi-faceted strategy that aimed to eliminate appointment backlogs using interventions such as redesigning appointment scheduling processes and creating pre-appointment templates for osteoarthritis referrals reduced wait times for the third available rheumatology appointment from about 60 days to less than 2 days (7). However, these studies did not incorporate the use of HIT-enabled electronic iterative communication between the specialist and referring provider. The safety net health system at San Francisco General Hospital (SFGH) was an early adopter of HIT to facilitate specialty care referrals in order to maximize the scarce resource of specialty providers (5, 8). In this study, we aimed to describe the nature and quality of iterative pre-consultation exchanges with rheumatology between 2008 and 2012, and to determine the impact and appropriateness of pre-consultation exchange in rheumatology ambulatory care. |
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