Virtual Interconsultations for Primary Care Referrals to Rheumatology: Real-World Implementation and Societal Cost-Avoidance Analysis in a Public Health System

Aznar, Antonio; Hernández-Díaz, Marta; Ferraz-Amaro, Iván; Flores-Rodríguez, Miguel; Viotti, Jose María; Hernández-Hernández, María Vanesa; Delgado-Frias, Esmeralda; García-Dorta, Alicia; Bethencourt Baute, Juan José; Sánchez-Pérez, Hiurma; Trujillo, Elisa; García-González, María; Gonzalez-Dávila, Enrique; Díaz-González, Federico

Virtual Interconsultations for Primary Care Referrals to Rheumatology: Real-World Implementation and Societal Cost-Avoidance Analysis in a Public Health System

Articles in Press

Document Type : Original Article

Authors

Antonio Aznar ¹

Marta Hernández-Díaz ¹

Iván Ferraz-Amaro ¹^{, 2}

Miguel Flores-Rodríguez ¹

Jose María Viotti ¹

María Vanesa Hernández-Hernández ¹

Esmeralda Delgado-Frias ¹

Alicia García-Dorta ¹

Juan José Bethencourt Baute ¹

Hiurma Sánchez-Pérez ¹

Elisa Trujillo ¹^{, 2}

María García-González ¹

Enrique Gonzalez-Dávila ³

Federico Díaz-González ¹^{, 2}

¹ Servicio de Reumatología, Hospital Universitario de Canarias, La Laguna, Spain

² Departamento de Medicina Interna, Dermatología y Psiquiatría de la Universidad de La Laguna, La Laguna, Spain

³ Departamento de Matemáticas, Estadística eInvestigación Operativa, IMAULL, Universidad de La Laguna, La Laguna, Spain

Abstract

Background
Rising demand for rheumatology care strains referral pathways between primary care and specialist services. We evaluated whether a virtual interconsultation (VIC) program, an asynchronous e-consult system integrated into the electronic health record (EHR), improved referral efficiency for new patients and generated net societal cost savings in a public health system.

Methods
We conducted a retrospective study of 12 213 VICs (10 181 patients) submitted from primary care to a tertiary rheumatology service between January 2021 and June 2022. Extracted EHR data included demographics, referral reason, delay time (submission to specialist response), resolution time (minutes per case), and outcomes (virtual resolution vs. in-person referral). Referral efficiency was assessed by the proportion of referrals resolved without an in-person visit and time to specialist response. Descriptive and comparative analyses used Mann–Whitney U, chi-square, and student’s t tests. The economic evaluation used a cost-avoidance micro costing approach from a societal perspective. Robustness of the economic evaluation was assessed through one-way sensitivity analyses, probabilistic Monte Carlo simulations (>100 000 iterations), and threshold analysis (ie, the minimum virtual resolution rate at which the program achieves breakeven).

Results
Patients were predominantly female (69%), mean age 54.8 years. Median specialist response time was 53.5 hours (interquartile range [IQR]: 20.6–122.3) and median resolution time 3.2 minutes (IQR: 1.6–8.6). Overall, 41.4% of referrals were resolved without an in-person visit. The program generated net societal savings of €206 280 over 18 months in the deterministic base case; the probabilistic analysis yielded a mean of €200 540 (95% credible interval: €142 289–€261 316) and a 100% probability of net savings. Absenteeism was the principal economic driver (highest Spearman correlation with net savings in Monte Carlo simulation, r = 0.92). The breakeven virtual resolution rate was 5.6%.

Conclusion
Integrating VICs into routine rheumatology referral pathways improved referral efficiency and produced substantial societal cost savings. These findings support scaling EHR-integrated VIC programs across publicly funded health systems to optimize specialist resources and enhance access to care.

Keywords

E-Consultation

Rheumatology

Primary Care

Cost-Avoidance

Referral Management

Spain

1. Fuchs F, Morf H, Mohn J, et al. Diagnostic delay stages and pre-diagnostic treatment in patients with suspected rheumatic diseases before special care consultation: results of a multicenter-based study. Rheumatol Int. 2023;43(3):495-502. doi:10.1007/s00296-022-05223-z

2. Kernder A, Thiele K, Chehab G, Schneider M, Callhoff J. Time interval between the onset of connective tissue disease symptoms and first contact with a rheumatologist: results from the German National Database of collaborative arthritis centers. Rheumatol Int. 2023;43(8):1453-1458. doi:10.1007/s00296-023-05335-0

3. Ahmed S, Kelly YP, Behera TR, et al. Utility, appropriateness, and content of electronic consultations across medical subspecialties. Ann Intern Med. 2020;172(10):641-647. doi:10.7326/M19-3852

4. Liddy C, Joschko J, Guglani S, Afkham A, Keely E. Improving equity of access through electronic consultation: a case study of an econsult service. Front Public Health. 2019;7:279. doi:10.3389/fpubh.2019.00279

5. Anderson E, Vimalananda VG, Orlander JD, et al. Implications of electronic consultations for clinician communication and relationships: a qualitative study. Med Care. 2021;59(9):808-815. doi:10.1097/mlr.0000000000001575

6. Kirsh SR, Ho PM, Aron DC. Providing specialty consultant expertise to primary care: an expanding spectrum of modalities. Mayo Clin Proc. 2014;89(10):1416-1426. doi:10.1016/j.mayocp.2014.04.016

7. Lee MS, Ray KN, Mehrotra A, Giboney P, Yee HF Jr, Barnett ML. Primary care practitioners' perceptions of electronic consult systems: a qualitative analysis. JAMA Intern Med. 2018;178(6):782-789. doi:10.1001/jamainternmed.2018.0738

8. Palen TE, Price D, Shetterly S, Wallace KB. Comparing virtual consults to traditional consults using an electronic health record: an observational case-control study. BMC Med Inform Decis Mak. 2012;12:65. doi:10.1186/1472-6947-12-65

9. Lopez-Liria R, Valverde-Martinez MA, Lopez-Villegas A, et al. Teledermatology versus face-to-face dermatology: an analysis of cost-effectiveness from eight studies from Europe and the United States. Int J Environ Res Public Health. 2022;19(5):2534. doi:10.3390/ijerph19052534

10. Nguyen OT, Alishahi Tabriz A, Huo J, Hanna K, Shea CM, Turner K. Impact of asynchronous electronic communication-based visits on clinical outcomes and health care delivery: systematic review. J Med Internet Res. 2021;23(5):e27531. doi:10.2196/27531

11. Peeters KMM, Reichel LAM, Muris DMJ, Cals JWL. Family physician-to-hospital specialist electronic consultation and access to hospital care: a systematic review. JAMA Netw Open. 2024;7(1):e2351623. doi:10.1001/jamanetworkopen.2023.51623

12. Tejera Segura B, Bustabad S. A new form of communication between rheumatology and primary care: The virtual consultation. Reumatol Clin. 2016;12(1):11-14. doi:10.1016/j.reuma.2015.01.003

13. Rostom K, Smith CD, Liddy C, Afkham A, Keely E. Improving access to rheumatologists: use and benefits of an electronic consultation service. J Rheumatol. 2018;45(1):137-140. doi:10.3899/jrheum.161529

14. Liddy C, Moroz I, Mihan A, Nawar N, Keely E. A systematic review of asynchronous, provider-to-provider, electronic consultation services to improve access to specialty care available worldwide. Telemed J E Health. 2019;25(3):184-198. doi:10.1089/tmj.2018.0005

15. Williams S, Barnard A, Collis P, et al. Remote consultations in primary care across low-, middle- and high-income countries: implications for policy and care delivery. J Health Serv Res Policy. 2023;28(3):181-189. doi:10.1177/13558196221140318

16. Memoria del Complejo Hospitalario Universitario de Canarias. 2022; https://www3.gobiernodecanarias.org/sanidad/scs/scs/as/tfe/28/memorias/2022/index.html. Accessed December 26, 2025.

17. Husereau D, Drummond M, Augustovski F, et al. Consolidated Health Economic Evaluation Reporting Standards (CHEERS) 2022 explanation and elaboration: a report of the ISPOR CHEERS II Good Practices Task Force. Value Health. 2022;25(1):10-31. doi:10.1016/j.jval.2021.10.008

18. INSTRUCCIÓN NÚM. 2/25 DE LA DIRECCIÓN DEL SERVICIO CANARIO DE LA SALUD, SOBRE EL RÉGIMEN Y CUANTÍA DE LAS RETRIBUCIONES DEL PERSONAL ADSCRITO A LOS ÓRGANOS DE PRESTACIÓN DE SERVICIOS SANITARIOS DEL SERVICIO CANARIO DE LA SALUD PARA EL EJERCICIO 2025. . 2025; https://www3.gobiernodecanarias.org/sanidad/scs/content/bae3b961-ef90-11ef-84fa-6b9dc09d4fa1/2025-02-20_Instruccion_2_2025_retribuciones.pdf. Accessed December 26, 2025.

19. Cómo llegar desde Puerto de la Cruz a Hospital Universitario en autobús, coche o taxi 2025; https://www.rome2rio.com/es/s/Puerto-de-la-Cruz-Islas-Canarias-Espa%C3%B1a/Hospital-Universitario. Accessed December 26, 2025.

20. EPA Canarias 2021; https://datosmacro.expansion.com/paro-epa/espana-comunidades-autonomas/canarias?anio=2021. Accessed December 26, 2025.

21. Instituto Nacional de Estadística (INE). Encuesta Trimestral de Coste Laboral (ETCL): Coste laboral por hora efectiva — últimos datos 2025. 2025; https://www.ine.es/dyngs/INEbase/es/operacion.htm?c=Estadistica_C&cid=1254736045053&menu=ultiDatos&idp=1254735976596. Accessed December 26, 2025.

22. Bartz D, Chitnis T, Kaiser UB, et al. Clinical advances in sex- and gender-informed medicine to improve the health of all: a review. JAMA Intern Med. 2020;180(4):574-583. doi:10.1001/jamainternmed.2019.7194

23. Chen N, Fong DYT, Wong JYH. Secular trends in musculoskeletal rehabilitation needs in 191 countries and territories from 1990 to 2019. JAMA Netw Open. 2022;5(1):e2144198. doi:10.1001/jamanetworkopen.2021.44198

24. Jin Z, Feng X, Wang D, et al. Global, regional and national trends in sex- and age-specific disability-adjusted life years of musculoskeletal disorders, 1990-2019. Rheumatology (Oxford). 2022;61(7):2978-2986. doi:10.1093/rheumatology/keab804

25. Haas R, Gorelik A, Busija L, et al. Prevalence and characteristics of musculoskeletal complaints in primary care: an analysis from the population level and analysis reporting (POLAR) database. BMC Prim Care. 2023;24(1):40. doi:10.1186/s12875-023-01976-z

26. Hagen KB, Bjørndal A, Uhlig T, Kvien TK. A population study of factors associated with general practitioner consultation for non-inflammatory musculoskeletal pain. Ann Rheum Dis. 2000;59(10):788-793. doi:10.1136/ard.59.10.788

27. Chiarotto A, Koes BW. Nonspecific low back pain. N Engl J Med. 2022;386(18):1732-1740. doi:10.1056/NEJMcp2032396

28. Gendelman O, Amital H, Bar-On Y, et al. Time to diagnosis of fibromyalgia and factors associated with delayed diagnosis in primary care. Best Pract Res Clin Rheumatol. 2018;32(4):489-499. doi:10.1016/j.berh.2019.01.019

29. Goldblatt F, O'Neill SG. Clinical aspects of autoimmune rheumatic diseases. Lancet. 2013;382(9894):797-808. doi:10.1016/s0140-6736(13)61499-3

30. Scheibe MM, Imboden JB, Schmajuk G, et al. Efficiency gains for rheumatology consultation using a novel electronic referral system in a safety-net health setting. Arthritis Care Res (Hoboken). 2015;67(8):1158-1163. doi:10.1002/acr.22559

31. de la Torre Rubio N, Pavía Pascual M, Campos Esteban J, Godoy Tundidor H, Fernández Castro M, Andréu Sánchez JL. Usefulness of an electronic consultation system between primary care health centres and the rheumatology department of a tertiary hospital. Reumatol Clin (Engl Ed). 2023;19(9):512-514. doi:10.1016/j.reumae.2022.12.008

32. Avouac J, Marotte H, Balsa A, et al. Teleconsultation in rheumatology: A literature review and opinion paper. Semin Arthritis Rheum. 2023;63:152271. doi:10.1016/j.semarthrit.2023.152271

33. Zickuhr L, Albert DA, Herndon C, et al. Addressing Competency in Rheumatology Telehealth Care Delivery. Arthritis Care Res (Hoboken). 2023;75(6):1213-1219. doi:10.1002/acr.25023

34. Borges do Nascimento IJ, Abdulazeem H, Vasanthan LT, et al. Barriers and facilitators to utilizing digital health technologies by healthcare professionals. NPJ Digit Med. 2023;6(1):161. doi:10.1038/s41746-023-00899-4

35. Marco Ibáñez A, Aguilar Palacio I, Aibar Remón C. Evaluation of virtual consultation by primary care professionals: quality dimensions and opportunities for improvement. Aten Primaria. 2024;56(4):102818. doi:10.1016/j.aprim.2023.102818

36. Nguyen MT, Honcharov V, Ballard D, Satterwhite S, McDermott AM, Sarkar U. Primary care physicians' experiences with and adaptations to time constraints. JAMA Netw Open. 2024;7(4):e248827. doi:10.1001/jamanetworkopen.2024.8827

37. Oudbier SJ, Souget-Ruff SP, Chen BSJ, Ziesemer KA, Meij HJ, Smets EMA. Implementation barriers and facilitators of remote monitoring, remote consultation and digital care platforms through the eyes of healthcare professionals: a review of reviews. BMJ Open. 2024;14(6):e075833. doi:10.1136/bmjopen-2023-075833

38. Biln NK, Bansback N, Shojania K, Puil L, Harrison M. A scoping review of triage approaches for the referral of patients with suspected inflammatory arthritis, from primary to rheumatology care. Rheumatol Int. 2024;44(11):2279-2292. doi:10.1007/s00296-024-05575-8

39. Parsons J, Salman B, Leach H, Watson E, Atherton H. Training primary care staff in delivering the primary care consultation remotely: a systematic review. BJGP Open. 2023;7(4):BJGPO.2023.0110. doi:10.3399/bjgpo.2023.0110

40. Rohweder CL, Morrison A, Mottus K, et al. Virtual quality improvement collaborative with primary care practices during COVID-19: a case study within a clinically integrated network. BMJ Open Qual. 2024;13(1):e002400. doi:10.1136/bmjoq-2023-002400

41. Shephard E, Stockdale C, May F, et al. E-referrals: improving the routine interspecialty inpatient referral system. BMJ Open Qual. 2018;7(3):e000249. doi:10.1136/bmjoq-2017-000249