Family nurse practitioners (FNPs) are filling the provider gaps in primary care. Nurse practitioners provide high-quality care, and in today's fast-paced care environment, their time is limited (Conelius et al., 2019). Although many patients require referrals to various specialty providers, there is often great demand, and appointments for specialty providers are not readily available (Osman et al., 2019).
Electronic consultation (e-consult) has become a time-saving approach to improve access to specialists from primary care providers. It can improve communication between and among providers and decrease the duplication of tests and delayed diagnoses while also lessening patient anxiety (Vimalananda et al., 2020). E-consults are "an asynchronous consultative communication between providers occurring with a shared electronic health record (EHR) or a shared web-based platform" (Dicerbo et al., 2015). These types of consults provide structure and reimbursement for consultants, often eliminating quick "curbside consults" by providers.
Research has shown that e-consult is a cost-effective and convenient way to care for patients while improving access and coordinating interprofessional specialty care and primary care (Venkatesh et al., 2020). Although e-consults are being implemented in large health care systems, electronic health records are not universal throughout these systems, and there are therefore no established e-consult templates. Providers are likely the developers of templates that work in their individual practices. It has been noted that FNPs are either not aware of this type of service or do not believe e-consults would be beneficial for their practices (Chernitzer & Gustin, 2020), likely because of a lack of training.
Training in the use of e-consults as students would help nurse practitioners become comfortable incorporating them in their practices for managing patients. Learning through the use of checklists has been shown to improve metacognitive behavior and foster the independence that is needed for internalizing complex tasks (Dudden-Rowlands, 2007). Given the ever-changing health care environment and the increased implementation of telehealth, using checklists and writing e-consults are valuable skills for FNP students to learn and practice. This article details the development of an e-consult checklist for graduate FNP students and describes a teaching format that provides students the tools to implement a comprehensive e-consult checklist.
DEVELOPMENT PROCESS
The e-consult checklist was developed initially following a review of the literature using seven databases: PubMed, CINAHL, ERIC (EBSCO), PsycARTICLE, and Cochrane Database of Systematic Reviews. Search terms included e-consult, checklist development, teaching e-consultation, and electronic consultation. Only articles from the last 10 years were included in the search. Four articles were found that aided in the development of the e-consult checklist for FNP students. Specific components highlighted in the articles included the reason for the consultation and a comprehensive history of present illnesses (Tran et al., 2020; Tuot et al., 2012; Wrenn et al., 2017). Physical exam, impression, and diagnostics were also identified (Keely et al., 2017; Tran et al., 2020). Three of the four studies identified the importance of present management and rationales (Keely et al., 2017; Tran et al., 2020; Tuot et al., 2012).
The initial version of our e-consult checklist was developed based on these studies. It consisted of eight components for a total of 15 points. The components were patient name; gender and age (2 points); chief complaint and specific reason for consult (5 points); history of present illness, including PQRST, that is, precipitating factors, quality of pain, region of radiation of pain, subjective description of pain, temporal nature of pain (5 points); significant physical exam findings (1 point); impression (1 point); diagnostics (2 points); and present management with rational (2 points).
To teach e-consult writing, students participated in two "on-call" scenarios in each of their clinical courses (pediatrics, women's health, and adult primary care). For each scenario, the students were required to join an on-call platform and sign up for a designated 15-minute time slot. During that time, students, working alone, received a chief complaint and had to determine a management plan for the patient, which included e-consulting a specialist. Once students identified that the case scenario would benefit from a consult, they had to write up an e-consult and send it via email to the specialist.
There was a debriefing after each session using the PEARLS method of debriefing (Eppich & Cheng, 2015). This method, used throughout the school's entire simulation program, was selected as the scenario related to students' decision-making. Students also received direct feedback from specialists regarding their e-consults using the e-consult checklist. They were given feedback regarding how they met checklist requirements and areas needing improvement. The specialist also provided feedback to nursing faculty about whether to add, modify, or delete checklist items. Specialists were recruited from the preceptor list for students and were available for all three courses.
CHECKLIST COMMENTS AND REVISION
Based on the specialist feedback, the checklist was expanded from its original version (8 parts, 15 points) to a 20-point checklist (12 parts). The 12 items are gender and age (2 points); chief complaint and specific reason for consult (5 points); history of present illness, including PQRST (5 points); significant medical history (1 point); significant surgical history (1 point); current medications (1 point); allergies (1 point); significant physical exam findings (1 point); impression (1 point); and diagnostics and rationale (3 points).
DISCUSSION/FUTURE RESEARCH
Use of e-consultation in the primary care setting has multiple benefits. Benefits for providers include helping to build effective communication skills and improving patient care; e-consults provide guidance for care and have been found to save time, reducing the need for a specialty care visit (Wrenn et al., 2017). Moreover, primary care providers (physicians, nurse practitioners, and physician assistants) find an educational value in the specialist response, which can expand their ability to manage patients (Keely et al., 2017; Kwok et al., 2018). Patients find e-consults to be convenient and time-saving, providing access to specialists in cases where access is geographically and otherwise difficult (Osman et al., 2019).
Educating FNPs on the use of e-consults will advance their future practice (Chernitzer & Gustin, 2020). FNPs need to be introduced to this concept early during their training and have it incorporated into their curricula. Knowing when to use and how to properly write an e-consult is a skill that should be developed in various health care settings. Future research will include having graduate FNP students use the checklist with various patient populations in simulated environments.
Although the essential elements of the e-consult were identified through a review of literature and specialist feedback, there remains the need for student feedback. Student feedback on facilitators and/or barriers to using the checklist will be best identified in a simulated environment. FNP students care for patients of all ages in various setting, from hospitals to clinic settings. Therefore, this checklist should be trialed with various patient populations and settings.
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