Rheumatologist
E-Consult Guide
An e-consult is a written, provider-to-provider question answered from the chart. Used well, it helps decide whether a patient needs to be seen, how urgently, and what workup to send first, so clinic slots go to the patients who need an examination. It is not a substitute for an in-person examination when one is needed.
Principles
A triage decision, not a remote diagnosis
The most useful output is a clear disposition: needs a visit (and how soon), can be managed locally with advice, or doesn't need rheumatology input.
Examination findings decide many questions
Possible synovitis, a new rash, weakness or skin thickening usually need hands-on assessment. When the answer depends on an examination, the right response is a visit.
Safety first
Organ-threatening or sight-threatening features belong on the phone, not in an e-consult queue. Make the escalation route obvious on the request form.
Close the loop
Every response should say what would change the plan and how to re-refer, so the requesting clinician isn't left guessing.
Which questions suit an e-consult?
Good fit
- Interpreting a result in context (for example, a positive ANA with few symptoms, an isolated raised CK, a low-titer RF)
- Whether a patient needs to be seen, and how soon
- What to check before a visit so it is most useful
- Starting or adjusting treatment while the patient waits (gout, osteoporosis, OA)
- DMARD monitoring questions in a stable patient on a shared-care plan
- Vaccine, perioperative or pregnancy medication questions for an established patient
Usually better as a referral or a call
- Suspected new inflammatory arthritis, lupus, myositis, vasculitis or systemic sclerosis, which usually need an examination (refer)
- Anything organ-threatening: suspected GCA, kidney or lung involvement, swallowing or breathing weakness, a threatened digit (call)
- Complex multi-system problems needing a full history and examination
- Questions that can't be answered without information the chart doesn't contain
A response structure that works
| Answer to your question | One or two sentences, directly answering what was asked. |
|---|---|
| Does the patient need to be seen? | Yes, urgently (within days); yes, soon (2–4 weeks); yes, routinely; or no. Give the reason in one line. |
| Before the visit | Specific tests or imaging that will make the first visit count (or 'none needed'). |
| Meanwhile | Interim management that is safe to start now, with doses where relevant. |
| Re-refer or call if | The findings that would change the plan, and how to reach rheumatology quickly. |
Setting up or improving a service
- Agree the scope. Decide which questions the service answers, which need a referral, and which need a phone call. Publish this on the request form.
- Design the workflow. Who answers, how requests are assigned, and a turnaround target (many services aim for a few business days). Include a route for urgent questions that bypasses the queue.
- Use a structured request. Ask for the question, the working diagnosis, duration, key examination findings, recent results and treatments. The How to Refer checklists on this site are a starting point.
- Make dispositions explicit. Track whether each e-consult resulted in a visit (and at what urgency), local management, or no further input.
- Check billing locally. In the US, interprofessional consultation codes (CPT 99446–99449, 99451, and 99452 for the requesting clinician) exist, but payer rules vary, and Medicare requires documented patient consent and applies cost-sharing. Check current local and payer policies.
- Measure and adjust. Volume, turnaround, the proportion converted to visits, time to visit for those converted, requester satisfaction, and any safety events. Refine the request form around the most common questions.