The use of e-consultation as an alternative to in-person medical consultations, or as a means of assessing the referral of patients from primary care to specialized care has been studied from various points of view. At first glance, e-consultation, which is more economical than in-person interviews, appears to reduce outpatient clinic costs,1 although not all authors have found this to be true2; moreover, e-consultations may facilitate and simplify faster access to a specialist,3 and allow medical care to be provided in areas where the population is widely dispersed,4 without compromising quality of care.5 However, the impact of e-consultation on efficacy in specialist outpatient clinics has not been studied to date.

In May 2006, we began to occasionally use clinician–clinician e-consultation to discuss NSCLC cases with different hospitals within our referral area. Our sporadic experience over a 5-year period was positive, so in 2011 we initiated a program of weekly clinician–clinician e-consultations with 2 hospitals within the referral area. In these multidisciplinary e-consultations,6 members of the departments of respiratory medicine, medical oncology and radiotherapy, radiology, and pathology presented the clinical features and radiological images of certain patients to the group and discussed the most suitable treatment.

The aim of this study was to evaluate if systematic clinician–clinician e-consultation versus occasional e-consultation for complicated cases improved efficiency (see definition below in the methods section) in the outpatient clinics of the thoracic surgery department.

The study was designed as a retrospective, comparative analysis of newly-evaluated NSCLC patients in the outpatient clinics of the department of thoracic surgery over the 6-year study period. Between 2008 and 2010, the department held e-consultations with any departments that requested our opinion on complicated cases. In 2011, we systematized procedures by setting up weekly e-consultations with the respiratory medicine departments of the Hospital Nuestra Señora de Sonsoles de Ávila and the Healthcare Complex of the University of León. These units were selected because they had reliable access to the necessary technical equipment.

Two study groups were established, according to the frequency of the discussions, each comprising a 3-year period: Group A, 2008–2010, years during which occasional discussions were held, and Group B, 2011–2013, years during which regular weekly discussions were held.

Between 2008 and 2013, a total of 3027 patients were evaluated in a preliminary in-person visit to the outpatient clinic of our department. During this same period, 553 cases were discussed using the clinician–clinician e-consultation system.

The mean number of cases seen in a first visit between 2008 and 2010 was 563/year (range: 518–565). During this period, the ratio of operated cases to new cases/year seen in the outpatient clinic was 0.69, 0.71, and 0.71, respectively (mean: 0.70). The mean number of cases discussed by e-consultation was 42/year (range: 36–60) during these 3 years.

In the period 2011–2013, the mean number of new cases seen in the outpatient clinic was 464/year (range: 442–475). The ratio of operated cases to new cases/year seen in the outpatient clinic during this period was 0.84, 0.89, and 0.87 respectively (mean: 0.87). The mean number of cases evaluated by e-consultation was 136/year (range: 132–147) during these 3 years.

Differences in the mean ratio of operated cases to new cases seen in the outpatient clinic in each period were statistically significant (Wilcoxon P=0.04). Fig. 1 shows the number of cases evaluated by e-consultation and the ratio of operated cases to new cases/year seen in the outpatient clinic multiplied by 100 for the purposes of obtaining data that can be reproduced on the same graph.

Fig. 1.

Number of cases discussed and ratio of operated cases to new cases × 100 by year of study.

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Our results indicate that regular clinician–clinician e-consultation had a significant impact on the management of the in-person outpatient clinic. Our results show that e-consultation improves the yield of thoracic surgery outpatient clinics, increasing the ratio of operated cases to new cases seen in this setting from 0.70 to 0.87. As the overall number of patients evaluated in first visits fell, the yield increased: 87% of patients seen in first visits during the second study period (2011–2013) underwent scheduled surgery, and possibly of more interest, the percentage of patients in whom surgery was not advised after the first visit fell from 30% to 13%.

A novel aspect of this study was the creation of a ratio to measure efficiency in the management of a specialized surgical clinic. In our opinion, a surgery department should dedicate all or most of its time to managing patients who require a surgical procedure. Time in the outpatient clinic should be spent preparing patients for surgery and taking definitive decisions on difficult cases, for example, patients with borderline lung function in previous evaluations, such as those discussed in the multidisciplinary e-consultation setting. The novelty of this ratio is that it provides a calculable, objective quality criterion to evaluate the work carried out in the outpatient clinic of a surgery department. Outpatient clinics are mainly managed in terms of numbers: the number of patients seen in first or subsequent visits, waiting times to receive an appointment, etc. Other quality parameters can also be obtained, for example the extent to which the portfolio of specialty services offered meets demand, or the extent to which cases are resolved in the outpatient clinics of each department, but none of these parameters measure the efficiency of experts in the specialized outpatient clinic in terms of time management. The ratio of operated cases to new cases seen in the outpatient clinic clearly reflects this aspect of outpatient clinic activity.

A comprehensive search of the literature leads us to conclude that this is the first time such a ratio has been presented and discussed. Other studies have shown how the use of e-consultation changes and improves the selection of patients seen in nursing outpatient clinics.7 The impact of prospective patient–clinician e-consultation on the time spent on each in-person visit has also been analyzed, showing that this can be significantly reduced8 without compromising quality of care. In this respect, in our department, prospective e-consultations reduced the number of overall clinic visits (from 563 to 464 cases/year), leaving more time available for each patient eventually seen, although this parameter was not measured. The time thus gained was used to gather more detailed, better quality information, prepare surgical cases, and improve the evaluation of the cases that had previously been classified as difficult.

Since it was introduced in the 1970s,9 the utility of e-consultation has been widely demonstrated. The use of technological resources has optimized healthcare by saving both time and money and has also overcome geographical barriers to healthcare,10 an aspect of great importance in our autonomous community. Clinician–clinician e-consultation has been shown to maximize the use of healthcare resources, improve inter-departmental and inter-hospital communications, and reduce patients’ transport costs.11 Moreover, most e-consultation applications have been shown to provide clinicians with the same clinical data as that obtained during an in-person consultation, enabling them to reach accurate diagnoses that can be used to design effective treatment plans.12 We believe, then, that this project has significant socioeconomic advantages for patients, families, healthcare professionals, and the healthcare system.

Very little investment is needed to set up an e-consultation system, since the communication tools are already included in the applications created by the health agencies of the different autonomous communities (e.g., eSalud in Catalonia, cges in the Andalusian Health Service, etc.). The advantages, moreover, far outweigh the cost, since these multidisciplinary meetings give patients faster and more accurate diagnoses and treatments, and reduce the number of duplicate tests and the expense of traveling to see the specialist.3,11 According to a study conducted by Freeman et al.,13 prospective multidisciplinary meetings benefit non-small cell lung cancer patients by promoting adherence to clinical practice guidelines, increasing the percentage of patients who receive full staging and a multidisciplinary evaluation, and significantly reducing the period of time between diagnosis and starting treatment. Stevenson et al.14 analyzed the use of this tool in the evaluation of complex lung cancer patients and suggested that these meetings are easily incorporated into routine practice and do not require any substantial timetable modification. In our case, we opted for a real-time system with both sound and image in which the same group of specialists met to discuss cases.6 Dedicating 1–2h a week to these regular e-consultations did not affect our surgery timetable.

This study has the limitations of retrospective studies, although our data were extracted from prospective databases with 2 consecutive quality control procedures. The main limitation, however, is the absence of evidence to show that all candidates for thoracic interventions seen in outpatient clinic were discussed by e-consultation methods.

In conclusion, in our experience, the implementation of a systematic clinician–clinician e-consultation program improved the overall efficiency of the chest surgery outpatient clinic in our hospital.

This project was funded in part by a SOCALPAR grant.

None of the authors has any conflict of interests to disclose associated with this study.