Why This Topic Matters Now
Telemedicine has moved from a pandemic-era workaround to a permanent part of modern healthcare. One of the most promising tools is the electronic consultation, or e-consult: a secure digital exchange in which a primary care clinician asks a specialist for advice without sending the patient for a full in-person hospital visit.
The idea is simple and appealing. If a family doctor can quickly get input from a cardiologist, neurologist, dermatologist, or internist, maybe some patients can be treated safely in primary care. That could mean fewer unnecessary referrals, shorter waits for specialty clinics, lower costs, and less hassle for patients.
But does it actually work that way in the real world?
A newly published interrupted time-series study from the Netherlands offers a timely reality check. The study, published in 2026 in the Journal of General Internal Medicine, examined whether a multi-specialty e-consultation service changed hospital referral rates over time. Its answer was more cautious than many digital-health enthusiasts might expect: overall, the effect on referrals was limited.
That does not mean e-consults have failed. It means their value may be more nuanced than the usual technology narrative suggests.
The New Study: What Researchers Looked At
The Dutch study by Peeters and colleagues evaluated a regional e-consultation service linking family physicians with hospital specialists across 11 specialties between 2015 and 2023. The researchers compared referral trends in practices using the service with trends in a national control sample drawn from the Nivel Primary Care Database.
This is an important design choice. Referral patterns can change over time for many reasons unrelated to e-consults: aging populations, staffing shortages, new guidelines, pandemic disruptions, and public awareness of disease. To address that, the investigators used interrupted time-series analysis with seasonal autoregressive integrated moving average models, along with difference-in-differences analyses. In plain English, they tried to separate the effect of the new e-consult service from background changes happening anyway.
Their main finding was striking in its restraint: there was no clinically meaningful overall reduction in referrals across specialties.
Some specialty-specific signals emerged. Internal medicine showed a regional decline in referrals, but that reduction was not significant compared with national trends. Surgery and neurology, surprisingly, showed increases in referrals compared with broader trends.
The authors concluded that the overall effect was likely modest because e-consults made up a relatively small share of total referral activity. In other words, even if e-consults help in some cases, they may not be used often enough to move system-wide referral numbers very much.
Why the Findings Are So Important
This study matters because e-consults are often promoted as a near-automatic solution to specialist bottlenecks. Policymakers, health systems, and insurers frequently hope that digital advice will shift care away from hospitals and into the community. That may still happen in certain settings, but this study suggests we should not assume referral reduction is guaranteed.
There are several reasons why an e-consult might not reduce referrals.
First, the specialist may advise an in-person visit after reviewing the case. In that sense, an e-consult does not replace referral; it may simply refine it.
Second, digital access to specialist input may uncover problems that deserve more workup, actually increasing appropriate referrals.
Third, clinicians may use e-consults for borderline or complex cases, meaning the patients are already more likely to need specialty care.
Fourth, implementation matters. If only a small fraction of eligible cases go through the e-consult system, the population-level effect will be hard to detect.
This is a classic lesson in healthcare innovation: a good tool is not the same as a transformative system change.
A Patient Story: When an E-Consult Helps, Even Without Avoiding Referral
Consider a fictional patient, Sarah, a 52-year-old elementary school teacher in Michigan. She visits her family physician because of months of numbness in her right hand and occasional weakness. Her doctor suspects carpal tunnel syndrome but worries about cervical radiculopathy or another neurologic problem.
In the past, Sarah might have waited several weeks for a neurology appointment. Instead, her physician sends an e-consult with exam findings and a few focused questions. The neurologist replies within two days: order a wrist splint trial, check thyroid function and B12, and refer for in-person evaluation if weakness progresses or if symptoms fail to improve.
Was a referral avoided? Maybe. But even if Sarah later needs specialty care, the e-consult still added value. It accelerated decision-making, improved the workup, and may have made any eventual referral more appropriate.
This is the key point: the benefit of e-consults is not always captured by counting fewer hospital visits.
What Earlier Research Has Suggested
The broader literature on e-consults has generally been encouraging, though not uniformly definitive. Studies from the United States, Canada, and Europe have reported faster access to specialist advice, high clinician satisfaction, and in some settings, reduced need for face-to-face visits.
For example, e-consult programs in integrated health systems and academic centers have shown that a meaningful share of specialist questions can be answered without an in-person consultation. Some studies have also suggested shorter wait times for patients who truly do need specialist appointments, because low-complexity questions can be resolved electronically.
However, the evidence base is mixed when it comes to harder outcomes such as downstream utilization, cost savings, and long-term clinical outcomes. Much depends on specialty, workflow, reimbursement, digital infrastructure, and whether clinicians receive training on when to use the service.
That is why the new Dutch study is valuable. It adds a more rigorous, long-term, real-world perspective and reminds us that implementation science matters just as much as the technology itself.
Where E-Consults Probably Work Best
Not every specialty question is equally suited to asynchronous digital advice. E-consults appear most useful when the specialist can make recommendations from a clear clinical question plus available data, such as labs, images, medication lists, and a focused history.
Common examples include medication adjustments, abnormal lab interpretation, mild dermatologic rashes with photos, endocrine questions, hematology workups, and decisions about whether referral is necessary.
By contrast, e-consults may be less effective when diagnosis hinges on a hands-on physical examination, a procedure, or nuanced bedside assessment. Neurology, surgery, and certain musculoskeletal problems can fall into this category, which may help explain why some specialties in the Dutch study did not show reduced referrals.
Here is a simple way to think about it:
| Clinical scenario | E-consult likely useful? | Why |
|---|---|---|
| Borderline abnormal thyroid tests | Often yes | Specialist can advise on interpretation and next steps from labs and history |
| New changing skin lesion with good photos | Often yes | Images may support triage or initial management |
| Progressive focal neurologic deficit | Usually limited | Patient may need urgent examination and testing |
| Pre-operative surgical question | Variable | Useful for triage, but many patients still need in-person assessment |
| Chronic kidney disease medication advice | Often yes | Recommendations can be based on labs, blood pressure, and medication review |
Common Misconceptions About Digital Specialist Advice
One misconception is that e-consults are just a cheaper substitute for specialist care. In reality, they are best viewed as a communication tool, not a blanket replacement.
A second misconception is that fewer referrals automatically mean better care. That is not always true. The real goal is better-targeted referrals: avoiding unnecessary visits while ensuring that patients who need specialty care get it promptly.
A third misconception is that digital efficiency always lowers workload. Sometimes e-consults shift work rather than eliminate it. Primary care clinicians may spend time gathering information, and specialists need protected time to respond thoughtfully.
A fourth misconception is that patient benefit is only measured by referral counts. Patients may value quicker answers, less travel, reduced time away from work, and more coordinated care even when a referral still happens later.
What Good E-Consult Programs Need
If health systems want e-consults to succeed, the lesson from this study is not to abandon them. It is to implement them more strategically.
First, the clinical question must be well defined. A vague message such as “Please advise” is less useful than a focused question about diagnosis, medication safety, or whether referral is indicated.
Second, clinicians need easy workflows inside the electronic record. If sending an e-consult takes too many clicks, adoption will stay low.
Third, specialists need time and reimbursement. Unpaid digital labor is not sustainable.
Fourth, programs should target high-yield use cases. Rather than opening every specialty equally, systems may get better results by focusing on areas where asynchronous advice is known to work well.
Fifth, quality metrics should go beyond referral volume. Better measures might include time to specialist input, avoided duplicate testing, patient travel burden, clinician satisfaction, and whether referred patients arrive with a better workup already completed.
What Patients Should Know
Patients increasingly encounter digital tools in healthcare, but many are unsure what an e-consult means for them.
If your doctor says they will “curbside” or electronically consult a specialist, it usually means the specialist is reviewing your case information without seeing you directly. That can be helpful, but it is not appropriate for every condition.
Patients can ask a few practical questions:
Will the specialist review my chart only, or do they need photos, labs, or imaging?
Will I still need an appointment later?
How quickly should I expect an answer?
What symptoms should prompt urgent in-person care instead of waiting?
These questions help set expectations and reduce confusion.
The Bigger Policy Picture
Healthcare systems worldwide are trying to solve the same equation: too many patients, not enough time, and limited specialist capacity. E-consults are attractive because they promise to extend specialist expertise without building new clinics.
But the Dutch data suggest a crucial policy lesson: digital access alone may not substantially bend referral trends unless usage reaches meaningful scale and is paired with thoughtful clinical targeting.
For policymakers, that means success should not be judged solely on whether referral rates fall. An e-consult platform may still be worthwhile if it improves appropriateness, shortens wait times, or reduces inequities for patients in rural or underserved areas.
For clinicians, the message is similarly balanced. E-consults are not magic, but they can be valuable when matched to the right patient, the right question, and the right specialty.
Expert Takeaway
The most important insight from the new study is that healthcare innovation often produces smaller, more context-dependent effects than early enthusiasm predicts. That is not a disappointment; it is how mature evidence works.
In medicine, tools rarely solve problems by themselves. Outcomes depend on workflow, incentives, patient mix, clinician behavior, and local practice culture. E-consults are likely no exception.
The future probably lies not in asking, “Do e-consults reduce referrals?” but in asking better questions: Which specialties benefit most? Which patients are appropriate? What quality measures matter most? And how can digital consultation improve care without simply adding another layer of administrative work?
Bottom Line
The promise of e-consults remains real, but the latest evidence suggests their impact is more selective than sweeping. The new Netherlands study found little overall reduction in hospital referrals after implementation of a multi-specialty e-consult service, though the picture varied by specialty.
That does not mean e-consults are ineffective. It means their greatest value may be in improving triage, speeding expert advice, and refining referrals rather than eliminating them outright.
For patients, that can still mean faster answers and more coordinated care. For health systems, it means the next phase of digital medicine should focus less on hype and more on precision: using e-consults where they truly fit, measuring the outcomes that matter, and designing systems around real clinical practice rather than technological optimism.
References
1. Peeters KMM, Muris DMJ, Gidding LG, Hek K, Krekels M, Cals JWL. Effect of a Multi-specialty E-consultation Service on Hospital Referrals: An Interrupted Time-Series Study in the Netherlands. Journal of General Internal Medicine. 2026 May 19. PMID: 42154383.
2. Vimalananda VG, Gupte G, Seraj SM, et al. Electronic consultations (e-consults) to improve access to specialty care: A systematic review and narrative synthesis. Journal of Telemedicine and Telecare. 2015;21(6):323-330.
3. 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. Telemedicine and e-Health. 2019;25(3):184-198.
4. Keely E, Liddy C, Afkham A. Utilization, benefits, and impact of an e-consultation service across diverse specialties and primary care providers. Telemedicine and e-Health. 2013;19(10):733-738.
5. Gleason N, Prasad PA, Ackerman S, et al. Adoption and impact of an eConsult system in an academic health system. Journal of General Internal Medicine. 2017;32(9):1036-1043.
6. Centers for Medicare & Medicaid Services. Medicare Telemedicine Health Care Provider Fact Sheet. Baltimore, MD: CMS; updated periodically.
7. World Health Organization. Global strategy on digital health 2020-2025. Geneva: World Health Organization; 2021.
