Kevin O'Leary
eConsults: A Market Deep Dive
We’re working on a new series with HTN diving into various health tech spaces and sharing what we know about the current state of the space. Our goal here is to provide a starting point for us all to learn from including a buyer’s perspective if you are evaluating these. If you are reading this and have feedback / things to add - please feel free to reach out to us here with suggestions and we’ll follow-up.
- What are eConsults?
- Who plays in this space? (we’ve focused on the the four companies below)
- Key questions in evaluating vendors
eConsults Defined
We thought we’d start off the article by taking a look at two definitions of what eConsults are and aren’t for context, as it’s not entirely black and white from our perspective:
Definition 1:
Clinicians use the electronic health record to send an asynchronous message about a particular patient problem. A specialist reviews the message and relevant clinical information and either answers the question, requests additional information, or suggests an in-person consult. By reducing unnecessary consults, eConsults improve specialty access, enhance patient and clinical experiences, decrease total costs, and free-up specialists to evaluate patients with more complicated conditions and perform procedures.
https://hbr.org/2022/06/4-ways-to-improve-specialty-health-care-in-the-u-s?ab=hero-subleft-1
Definition 2:
Electronic consultations (eConsults) are an emerging strategy to reduce the need for face-to-face specialty consultation. While no standard definition for eConsults has been established, most existing systems feature a secure, asynchronous, electronic exchange of clinical information between a primary care provider and a specialist resulting in a consult note or document that becomes a part of the patient’s permanent record.
https://www.healthaffairs.org/doi/10.1377/hlthaff.2018.05124
These provide good context for what an eConsult is: a way for a provider (generally a PCP) to exchange clinical information with a specialist who provides an opinion on the case without needing to see a patient in-person. As the second definition notes, it’s primarily a strategy to reduce the need for a face-to-face patient visit with a specialist.
Conceptually, that strategy of reducing face-to-face specialists visits makes eConsults seem very similar to other adjacent spaces, including Second Opinions, which also entails a specialist giving a virtual opinion on a patient case. Second Opinions services generally seem to be differentiated from an eConsult in terms of who initiates the specialist giving the opinion - a patient or a PCP. As a result, Second Opinion services tend to have a different business model. Many Second Opinion services are sold to employees on behalf of their employers.
Further confusing this, the same specialist might actually work for both an eConsult and a Second Opinion vendor, among other digital health platforms. Check out the LinkedIn profile of a provider who happens to work with Sitka, a eConsults vendor, and 2nd.MD, a Second Opinions vendor. It highlights the overlap in capabilities between these types of companies, with the main difference being who is paying.
Strategic Rationale
eConsults are gaining popularity as a concept particularly in two use cases:
- PCP groups looking to manage risk. eConsults are gaining adoption particularly in the Medicare Advantage primary care segment, with organizations like ChenMed, Iora, and Oak Street all heavy users of eConsults.
- Underserved models. The other place we are seeing adoption of eConsults is with FQHCs. Any model where it is hard to gain access to a provider (i.e. rural care, Medicaid patients), eConsults should be able to solve a needed access issue.
Given how eConsults are designed to reduce the need for in-person visits with specialists, it makes all the sense in the world that they’d be a core component of those models. In many ways, eConsults are a good example of an intervention that should have a positive effect across quadruple-aim-y outcomes:
A Sample Use Case
This Health Affairs article provides a great sample use case for rolling eConsults out within a Medicaid population. An FQHC in Connecticut partnered with a hospital initially to provide cardiology eConsults. Four years later, based on the success of that initiative, they expanded the relationship to provide eConsults for dermatology, endocrinology, orthopedics, and gastroenterology. As the article notes, those specialties were picked because they were in highest demand and had the longest wait times. The article does a nice job describing how the workflow was implemented - including staffing to help limit the amount of additional work required of clinicians. eConsults were made a default part of care, with clinicians needing to opt out. Patients who received eConsults cost $84 PMPM less to Medicaid than patients who didn’t.
The logic here is straightforward. If you’re a PCP trying to manage an entire population, if you can have access to specialists in a low cost frictionless manner, that theoretically should help improve quality of care, improve patient experience, and reduce overall costs. The challenges with implementing eConsults come in the practical implementation - i.e. how does it fit into a clinician’s workflow? What specialties is it for? The example above provides for a relatively concrete answer to some of those questions.
This BI article on how VBC primary care players like ChenMed are managing specialty costs, and it highlights how ChenMed is working with Sitka as its partner of choice to implement. The article notes that ChenMed has actually hired its own internal staff of 10 physicians for the highest cost specialties, and then is working with Sitka’s virtual provider network for the remaining specialties. Again, this approach hints at some of the operational complexity with implementing eConsults, and how for high volume procedures it can actually make sense to insource it if an organization can afford it. ChenMed appears to be doing a logical financial calculus to figure out how and where they implement eConsults.
Success Metrics
Not surprisingly, the primary success metric is the number of referrals that are avoided once an eConsult program is implemented. This in many ways is the whole point of implementing eConsults. There are of course other metrics that vendors will highlight, and these metrics roughly align to the quadruple aim goals discussed above.
Whether, and how much, eConsults reduce referrals from PCPs to specialists depends on who you listen to. The various startups in the space all cite relatively high rates of referral avoidance: 70% for AristaMD (website), 80% for Sitka (website), 69% for ConferMED (website), and 40% for RubiconMD (Oak Street acquisition slides).
These rates don’t necessarily jive with some of the literature that has been published on the subject, however. This study looking at a group of Montefiore primary care practices actually found that implementing an eConsult program actually increased the total number of referral rates for those primary care practices.
This shouldn’t exactly be surprising that marketing materials highlight what is possible, not necessarily what is actually achieved in various implementations. The difference in actual experience with the marketing numbers highlights how important it is to evaluate workflows when considering implementing eConsults.
With that, let’s now take a look at four of the key vendors in the eConsults space:
The Players
AristaMD
ConferMED
RubiconMD
Sitka
Evaluating eConsults
From our conversations with folks who have been evaluating e-consults players, here’s a list of key questions that frame up the decision making criteria when thinking about how to implement e-consults in an organization. For each question, we offer some thoughts and relevant info on the various eConsults vendors.
Clinical Considerations
Which specialties does my organization need eConsults from?
Depending on the patient population that your practice serves, it will likely influence what specialties you need to prioritize eConsults from. For instance, a senior care model that has the highest needs in cardiology, kidney care, infectious diseases, and orthopedics, will likely end up focusing eConsults on those conditions.
As these vendors grow, they are expanding their networks and introducing new specialities over time. Whether your organization wants a partner that has any specialty, or just a handful of specialties like ChenMed, becomes a big question of consideration in evaluating vendors.
Would my organization prefer eConsults with a local or national network of specialists?
Referral patterns can be important in selecting an eConsult vendor. If your organization is looking to refer to a local specialist who can also see the patient in-person if necessary, you’ll want to prioritize vendors with local relationships, versus vendors that will send your eConsult for national review.
For instance, RubiconMD is known for partnering with leading academic institutions with anonymity of physicians. Yet, if you’re a local FQHC that values local referrals, RubiconMD might not be a good partner. Instead, you might look to an organization like ConferMED building a local network of referral partners.
Does my organization want providers exclusively working with one platform?
It’s not uncommon in digital health land for specialist providers to be working with multiple companies, see the LinkedIn page referenced above as a good example. This dynamic is indicative of the type of relationship this provider has with all of these digital health vendors – appearing to be a side hustle to earn more income in their free time. We’d expect providers in situations like this to not be particularly loyal to these digital health brands, prioritizing how much they’re paid for their time. Thus, considering the stickiness and quality of a vendor’s eConsult network relationships becomes an important question to evaluate. RubiconMD having an exclusive partnership with Cleveland Clinic is different from Sitka having a provider who moonlights with them and a number of other digital health vendors.
Operational Considerations
How do providers in my organization want to communicate with specialists?
The different eConsult players leverage different methods to communicate with providers. Sitka, for instance, uses video consults with specialists. This is very different from RubiconMD, which uses anonymous messages with providers.
How does my organization’s investment in an EMR impact this?
Our understanding is that many larger health systems are choosing to build eConsults capability in house, in part because of the investment most have already made in their EMR platform.
How do providers in my organization view the usability of the eConsult platform?
For many primary care organizations, there won’t be an option to seamlessly integrate the eConsult vendor into your EMR and your clinicians will be left using the eConsult vendor’s portal to do the work. This is one of the single largest barriers to eConsults being done given the implications it has for workflow.
What is the turnaround time for receiving an eConsult?
It’s not uncommon for an eConsult vendor to commit to specific turnaround times(i.e. 24 hour turnaround for an eConsult). If this is important to your organization, it’s worth confirming with a vendor that they can meet your needs.
How will an eConsult vendor support my organization in achieving provider buy-in to use eConsults?
It is one thing to offer an eConsult to your providers, but it is another thing entirely to actually get those providers to use it. The studies referenced in the use cases described earlier in the article provide good examples for how much change management is required to change the behavior of clinicians.
Financial Considerations
Revenue model
This is a lower tier consideration as it sounds like eConsults vendors are still largely figuring out how to build a scalable business model and willing to discuss pricing strategies in order to win business. Some organizations reported that vendors are doing per consult pricing, while others were charging membership fees. It is worth thinking through what makes the most sense for your organization and asking vendors what they’re willing to support.
Do I want an eConsult vendor that primarily supports VBC or not?
Some eConsults startups – such as Sitka and RubiconMD – primarily target value-based care primary care models. These startups generally have a fairly unique operating model when compared to other care delivery companies, as they are built around the needs of VBC primary care models. These vendors will diverge from the needs of other models, such as FQHCs. For instance, those two customers likely have different desires of having a local versus national referral.
Our overall view of the space
There is an obvious benefit that eConsults can play, particularly in rural and safety net settings where access to high quality providers is challenging. Assuming that your organization can manage the workflow and has providers who will leverage eConsults, it can be a powerful tool in a toolkit to help manage overall spend and clinical care. It is not surprising to see Oak Street choose to acquire RubiconMD for this exact reason.
For primary care organizations looking to manage risk, or any other organizations looking to provide access to specialties, eConsults are a logical choice. Whether you choose to work with a startup in the space or build a home grown tool likely seems to hinge on your EMR platform and the relationships you already have with specialists.
We’d expect that as digital health startups continue to mature that we’ll see eConsults naturally be a piece of broader platforms - either they’ll be vertically integrated into care delivery organizations looking to build out more capabilities (i.e. Oak Street) or horizontally integrated into tech platforms looking to support care delivery.
Things to Add?
This document is intended to be a living document evaluating the eConsults space. If you’re reading it and have things to add / edit / amend, please email us at hello@healthtechnerds.com describing what you’d like to change and we’ll follow-up.