We aim to describe our practice’s use of electronic consultations (e-consults) and assess safety and risk factors for subsequent face-to-face consultations (FTF-consults).

The application of e-consults is a growing practice utilized to improve access to neurological expertise. Safety and outcomes of e-consults have not been well studied.

A retrospective cohort study of all e-consults completed in a community neurology practice between May 5, 2018 to June 31, 2019, was completed. Clinical and demographic variables were compared between the successful and unsuccessful (defined by presence of subsequent FTF-consult) cohorts. Hazard ratios (HR) were calculated using Cox regression model. Kaplan-Meier probability analysis (with 95% confidence interval) of subsequent FTF-consult was performed. Case examples highlighting potential harm were summarized.

302 e-consults were reviewed. The median time from e-consult order to completion was 3 days. The median age was 53 years and 68.5% were female. Most referring providers were attending physicians (51.3%), followed by advanced practice providers (34.1%) and resident trainees (14.6%). The most frequent referrals were for headache (n=125, 41.4%), dysesthesia (n=40, 13.2%), and abnormal imaging finding (n=27, 8.9%). The most common e-consult questions were for treatment (57.6%) and diagnostic evaluation (48.0%) recommendations. 24.8% of e-consults were followed by FTF-consults. Primary risk factors associated with subsequent FTF-consult included female sex (HR=1.9), referral for headache (HR=1.7), and final diagnosis of migraine (HR=2.0) or chronic migraine (HR 5.0). Potential harm related to delayed diagnosis/treatment was identified in 6 (2.0%) patients with migraine and 4 (1.3%) without migraine presenting to emergency department.

Utilization of e-consults may safely improve access to neurological expertise. In patients with chronic migraine, e-consults should be considered short-term and followed by FTF-consult as soon as access allows. Neurologists performing e-consults should be able to triage patients to FTF-consults, particularly when diagnosis is uncertain or the neurological examination may help guide appropriate testing.