eConsults' Impact on Care Access and Wait Times in Rheumatology.



A growing number of health systems have implemented eConsults to improve access to specialty advice, but few studies have described their use in rheumatology or impact on visit wait times. We evaluated the uptake of an eConsult program and its impact on wait times for in-person rheumatology visits.


In this quality improvement project, we analyzed electronic health record data from 4 intervention clinics and 4 comparison clinics, 12 months before and after implementation of an eConsult program. We compared median wait time for rheumatology appointments using a pre-post difference-in-differences analysis and quantile regression, adjusting for patient age, race, sex, clinic pair, and primary insurance payer. We also interviewed 11 primary care providers from the intervention clinics and conducted a rheumatology provider focus group (n = 4) to elucidate experiences with the program.


Rheumatologists recommended management in primary care or referral to another specialty for 41% of eConsults, reducing initial demand for in-person visits. The median wait times dropped in the intervention and the comparison clinics (42 and 25 days, respectively). Intervention clinic median wait time dropped 17 days more than comparison clinics, and this was nonstatistically significant (p = 0.089). eConsults fit provider care tasks best for triage or initial workup for diagnosis, and less well when tests required interpretation, or when back and forth communication was needed to manage the patient's condition.


Implementation of eConsults for rheumatology was associated with reduced wait times for rheumatology appointments and supported primary care providers in the triage and workup for a substantial portion of patients.





Published Version (Please cite this version)


Publication Info

Malcolm, Elizabeth J, Zachary Brandon, Lauren E Wilson, John Paul Shoup, Heather A King, Allison Lewinski, Melissa A Greiner, Shauna Malone, et al. (2022). eConsults' Impact on Care Access and Wait Times in Rheumatology. Journal of clinical rheumatology : practical reports on rheumatic & musculoskeletal diseases, 28(3). pp. 147–154. 10.1097/rhu.0000000000001825 Retrieved from

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Elizabeth Jane Malcolm

Assistant Professor of Medicine

Heather Alyse King

Assistant Professor in Population Health Sciences

Areas of expertise: Implementation Science, Health Services Research, and Health Measurement


Allison A. Lewinski

Assistant Research Professor in the School of Nursing

As a nurse scientist and health services researcher, with a joint appointment between the Duke University School of Nursing (DUSON) and the Durham Veterans Affairs Health Care System (VHA), I have acquired expertise in the areas of diabetes distress, qualitative research methods, and virtual care (e.g., telehealth, digital health) as a method of care delivery. My research focuses on the current and potential ability of virtual care interventions to reduce distress, improve self-management, increase access to evidence-based care delivery, and improve patient and population health outcomes. My collaborative and interdisciplinary research focuses on how patient-, provider-, and system-level factors influence virtual care use and outcomes. As evidence of its growing significance and impact at DUSON and the VHA, my work has been well funded, published in high-impact journals, presented at select conferences, and used to guide health system decision-making. I am a sought-after teacher and mentor because I connect my research interests to teaching students and mentees rigorous and systematic research approaches. I am frequently asked by local and national colleagues to provide guidance on distress, qualitative research methods, and virtual care approaches used in grants, projects, and manuscripts.  

My research contributions have focused on alleviating psychosocial distress, developing and implementing multi-level virtual care interventions, and enhancing qualitative methods. As a staff nurse, I witnessed the psychosocial distress of patients who experience challenges in obtaining care which led to my interest in diabetes distress. I aspire and work to improve health outcomes for individuals with chronic illness by developing equitable and sustainable multi-level virtual care interventions and assessing their implementation and adaptation. Virtual care describes any remote interaction between a patient and/or members of their care team. To achieve these goals, I use qualitative methods and implementation science approaches to enhance alignment between patient, modality, disease state, and social and environmental context; my collective assessments address for whom and what purposes, in what situations and contexts, when in a disease course or clinical activity, and in what specific ways such interventions are effective. My focus on the uptake and adoption of virtual care to address psychosocial distress considers interactions with patients, between patients and clinicians, and within health care systems and the larger population.


Teresa Kathleen Tarrant

Associate Professor of Medicine

I first became interested in clinical immunology as a medical student studying autoimmune inflammatory eye disease at the National Institutes of Health.  Since then, I have been inspired to understand what causes autoimmunity and immune deficiency disorders in order to improve the quality of life for my patients.  I see patients with multiple complex immune disorders with particular expertise in autoimmune and Rheumatoid arthritis, primary Sjogren's syndrome, and the immunodeficiency disorders Common Variable Immunodeficiency (CVID), Adenosine Deaminase Deficiency (ADA) disorders, and WHIM (Warts, Hypogammaglobulinemia, Infections, and Myelokathexis). My research investigates immune targets that may impact either the development of immune disease or identify new therapies for patients.  The goal is to help us understand why and how immunologic diseases develop so that we may better treat them.

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