Ten steps to establishing an e-consultation service to improve access to specialist care

What are the cost savings associated with providing access to specialist care through the Champlain BASE eConsult service? A costing evaluation

OBJECTIVE

This study estimates the costs and potential savings associated with all eConsult cases completed between 1 April 2014 and 31 March 2015.

DESIGN

Costing evaluation from the societal perspective estimating the costs and potential savings associated with all eConsults completed during the study period.

SETTING

Champlain health region in Eastern Ontario, Canada.

POPULATION

Primary care providers and specialists registered to use the eConsult service.

MAIN OUTCOME MEASURES

Costs included (1) delivery costs; (2) specialist remuneration; (3) costs associated with traditional (face-to-face) referrals initiated as a result of eConsult. Potential savings included (1) costs of traditional referrals avoided; (2) indirect patient savings through avoided travel and lost wages/productivity. Net potential societal cost savings were estimated by subtracting total costs from total potential savings.

RESULTS

A total of 3487 eConsults were completed during the study period. In 40% of eConsults, a face-to-face specialist visit was originally contemplated but avoided as result of eConsult. In 3% of eConsults, a face-to-face specialist visit was not originally contemplated but was prompted as a result of the eConsult. From the societal perspective, total costs were estimated at $207 787 and total potential savings were $246 516. eConsult led to a net societal saving of $38 729 or $11 per eConsult.

CONCLUSIONS

Our findings demonstrate potential cost savings from the societal perspective, as patients avoided the travel costs and lost wages/productivity associated with face-to-face specialist visits. Greater savings are expected once we account for other costs such as avoided tests and visits and potential improved health outcomes associated with shorter wait times. Our findings are valuable for healthcare delivery decision-makers as they seek solutions to improve care in a patient-centred and efficient manner.

Electronic consultation systems: worldwide prevalence and their impact on patient care-a systematic review

BACKGROUND

Many health organizations are exploring the potential of electronic consultation (eConsult) services to address excessive wait times for specialist care.

OBJECTIVE

To understand the effectiveness, population impact and costs associated with implementation of eConsult services.

METHODS

We conducted a systematic review using a narrative synthesis approach. We searched Medline and Embase from inception to August 2014 (English/French). Included studies focused on communication between primary care providers and specialist physicians through an asynchronous, directed communication over a secure electronic medium. We assessed study quality with a modified version of the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies. We synthesized the results using the Triple Aim framework.

RESULTS

A total of 36 studies were included. Most were set in the USA and focused on single-specialty services (most commonly dermatology). Population health outcomes included patient populations, adoption/utilization and provider attitudes. Providers cited timely advice from specialists, good medical care, confirmation of diagnoses and educational benefits. No clinical outcomes were reported. Patient experience of care was generally positive, with quick specialist response times (4.6 hours to 3.9 days), avoided referrals (12-84%) and satisfaction ranging from 78% to 93%. System costs were reported in only seven studies using different outcome measures and settings, limiting comparability.

CONCLUSION

Though eConsult systems are highly acceptable for patients and providers and deliver improved access to specialist advice, gaps remain regarding eConsult's impact on population health and system costs. To achieve optimized health system performance, eConsult services must include specialty services as determined by community needs and further explore cost-effectiveness.

Ask the eConsultant: Improving access to haematology expertise using an asynchronous eConsult system

Introduction

The Champlain BASE (Building Access to Specialists through eConsultation) eConsultation service was designed to address the limited access to specialist care in Canada, which can lead to long waiting times and, subsequently, negative patient outcomes. Our primary objective was to perform an in-depth analysis of the use, content, and perceived value of haematology electronic consults (eConsults) submitted by primary care providers (PCPs) to the eConsult service.

Methods

We conducted a cross-sectional study using descriptive statistics to examine post-eConsult surveys for PCPs and other collected data including PCP designation, time for specialist to complete the eConsult, specialist response time, perceived value of the eConsult by the PCP, and the need for a face-to-face referral following the eConsult. A medically-trained author reviewed all haematology eConsults from April 2011 to January 2015, and categorized them by clinical topic and question type using validated taxonomies.

Results

Haematology accounted for 436 out of 5601 (7.8%) total eConsults, making it the third most popular service utilized. In 66% of haematology eConsults, a face-to-face consultation was not needed. Anaemia, neutropenia, and hyperferritinemia were the most common clinical queries. Most eConsult question types concerned the management of haematological disorders or the interpretation of laboratory tests. Most eConsults were answered within three days, using less than 15 minutes of the specialists’ time. PCPs highly valued the service.

Discussion

This initiative increases access to haematology care and has the potential to reduce the long waiting times for non-urgent traditional consultation, along with the benefit of cost savings to the healthcare system.

Electronic Consultations to Improve the Primary Care-Specialty Care Interface for Cardiology in the Medically Underserved: A Cluster-Randomized Controlled Trial

PURPOSE

Communication between specialists and primary care clinicians is suboptimal, and access to referrals is often limited, which can lead to lower quality, inefficiency, and errors. An electronic consultation (e-consultation) is an asynchronous, non-face-to-face consultation between a primary care clinician and a specialist using a secure electronic communication platform. The purpose of this study was to conduct a randomized controlled trial of e-consultations to test its efficacy and effectiveness in reducing wait times and improving access to specialty care.

METHODS

Primary care clinicians were randomized into a control (9 traditional) or an intervention (17 e-consultation) arm for referrals to cardiologists. Primary care clinicians were recruited from 12 practice sites in a community health center in Connecticut with mainly medically underserved patients. Two end points were analyzed with a Cox proportional hazards model where the hazard of either a visit or an e-consultation was linked to study arm, sex, race, and age.

RESULTS

Thirty-six primary care clinicians participated in the study, referring 590 patients. In total, 69% of e-consultations were resolved without a visit to a cardiologist. After adjusting for covariates, median days to a review for an electronic consultation vs a visit for control patients were 5 and 24, respectively. A review of 6-month follow-up data found fewer cardiac-related emergency department visits for the intervention group.

CONCLUSION

E-consultation referrals improved access to and timeliness of care for an underserved population, reduced overall specialty utilization, and streamlined specialty referrals without any increase in adverse cardiovascular outcomes. e-consultations are a potential solution for improving access to specialty care.

Facilitators and barriers to implementing electronic referral and/or consultation systems: a qualitative study of 16 health organizations

Background

Access to specialty care remains a challenge for primary care providers and patients. Implementation of electronic referral and/or consultation (eCR) systems provides an opportunity for innovations in the delivery of specialty care. We conducted key informant interviews to identify drivers, facilitators, barriers and evaluation metrics of diverse eCR systems to inform widespread implementation of this model of specialty care delivery.

Methods

Interviews were conducted with leaders of 16 diverse health care delivery organizations between January 2013 and April 2014. A limited snowball sampling approach was used for recruitment. Content analysis was used to examine key informant interview transcripts.

Results

Electronic referral systems, which provide referral management and triage by specialists, were developed to enhance tracking and operational efficiency. Electronic consultation systems, which encourage bi-directional communication between primary care and specialist providers facilitating longitudinal virtual co-management, were developed to improve access to specialty expertise. Integrated eCR systems leverage both functionalities to enhance the delivery of coordinated, specialty care at the population level. Elements of successful eCR system implementation included executive and clinician leadership, established funding models for specialist clinician reimbursement, and a commitment to optimizing clinician workflows.

Conclusions

eCR systems have great potential to streamline access to and enhance the coordination of specialty care delivery. While different eCR models help solve different organizational challenges, all require institutional investments for successful implementation, such as funding for program management, leadership and clinician incentives.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-1233-1) contains supplementary material, which is available to authorized users.

Impact of Question Content on e-Consultation Outcomes

BACKGROUND

By facilitating direct communication of primary care providers (PCPs) with specialists for advice, electronic consult (e-consult) services can reduce the need for patients to wait for and travel to face-to-face consultations with specialists. An association between avoiding face-to-face referrals using an e-consult service and specific content within each e-consult has not been rigorously explored.

MATERIALS AND METHODS

Cases submitted to the Champlain Building Access to Specialists through eConsultation service between April 2011 to May 2013 were evaluated. Factors analyzed include question type (e.g., diagnosis or management), formulation (if interventions or outcomes were specified), and the addressed specialty. An avoided referral was present if the PCP indicated so in a mandatory close-out survey. A discrepancy was present if the PCP made a referral when the specialist did not indicate one was necessary, or if the PCP did not request a referral despite the specialist recommending one.

RESULTS

There were 426 (40%) avoided referrals among 1,055 cases analyzed. Questions associated with the highest avoided referral rates included ones pertaining to diagnosis (44%), nonspecific requests for direction (44%), questions without specified interventions or outcomes (47%), and dermatology cases (49.5%). Specialists agreed on the need for a referral in 82% of cases, with most discrepancies due to the PCP making a referral without the specialist recommending one.

CONCLUSIONS

Referral outcomes are associated with the type of question being asked, the formulation of each question, and the specialty being addressed. Discrepancies among PCPs and specialists regarding which patients require face-to-face referrals may help identify knowledge gaps and guide professional development.

E-referral Solutions: Successful Experiences, Key Features and Challenges- a Systematic Review

BACKGROUND

around the world health systems constantly face increasing pressures which arise from many factors, such as an ageing population, patients and providers demands for equipment's and services. In order to respond these challenges and reduction of health system's transactional costs, referral solutions are considered as a key factor. This study was carried out to identify referral solutions that have had successes.

METHODS

relevant studies identified using keywords of referrals, consultation, referral system, referral model, referral project, electronic referral, electronic booking, health system, healthcare, health service and medical care. These searches were conducted using PubMed, ProQuest, Google Scholar, Scopus, Emerald, Web of Knowledge, Springer, Science direct, Mosby's index, SID, Medlib and Iran Doc data bases. 4306 initial articles were obtained and refined step by step. Finally, 27 articles met the inclusion criteria.

RESULTS

we identified seventeen e-referral systems developed in UK, Norway, Finland, Netherlands, Denmark, Scotland, New Zealand, Canada, Australia, and U.S. Implemented solutions had variant degrees of successes such as improved access to specialist care, reduced wait times, timeliness and quality of referral communication, accurate health information transfer and integration of health centers and services.

CONCLUSION

each one of referral solutions has both positive and changeable aspects that should be addressed according to sociotechnical conditions. These solutions are mainly formed in a small and localized manner.

Optimizing Telehealth Strategies for Subspecialty Care: Recommendations from Rural Pediatricians

BACKGROUND

Telehealth offers strategies to improve access to subspecialty care for children in rural communities. Rural pediatrician experiences and preferences regarding the use of these telehealth strategies for children's subspecialty care needs are not known. We elicited rural pediatrician experiences and preferences regarding different pediatric subspecialty telehealth strategies.

MATERIALS AND METHODS

Seventeen semistructured telephone interviews were conducted with rural pediatricians from 17 states within the United States. Interviewees were recruited by e-mails to a pediatric rural health listserv and to rural pediatricians identified through snowball sampling. Themes were identified through thematic analysis of interview transcripts. Institutional Review Board approval was obtained.

RESULTS

Rural pediatricians identified several telehealth strategies to improve access to subspecialty care, including physician access hotlines, remote electronic medical record access, electronic messaging systems, live video telemedicine, and telehealth triage systems. Rural pediatricians provided recommendations for optimizing the utility of each of these strategies based on their experiences with different systems. Rural pediatricians preferred specific telehealth strategies for specific clinical contexts, resulting in a proposed framework describing the complementary role of different telehealth strategies for pediatric subspecialty care. Finally, rural pediatricians identified additional benefits associated with the use of telehealth strategies and described a desire for telehealth systems that enhanced (rather than replaced) personal relationships between rural pediatricians and subspecialists.

CONCLUSIONS

Rural pediatricians described complementary roles for different subspecialty care telehealth strategies. Additionally, rural pediatricians provided recommendations for optimizing individual telehealth strategies. Input from rural pediatricians will be crucial for optimizing specific telehealth strategies and designing effective telehealth systems.

Transaction cost analysis of in-clinic versus telehealth consultations for chronic pain: preliminary evidence for rapid and affordable access to interdisciplinary collaborative consultation

OBJECTIVES

With ever increasing mandates to reduce costs and increase the quality of pain management, health care institutions are faced with the challenge of adopting innovative technologies and shifting workflows to provide value-based care. Transaction cost economic analysis can provide comparative evaluation of the consequences of these changes in the delivery of care. The aim of this study was to establish proof-of-concept using transaction cost analysis to examine chronic pain management in-clinic and through telehealth.

METHODS

Participating health care providers were asked to identify and describe two comparable completed transactions for patients with chronic pain: one consultation between patient and specialist in-clinic and the other a telehealth presentation of a patient's case by the primary care provider to a team of pain medicine specialists. Each provider completed two on-site interviews. Focus was on the time, value of time, and labor costs per transaction. Number of steps, time, and costs for providers and patients were identified.

RESULTS

Forty-six discrete steps were taken for the in-clinic transaction, and 27 steps were taken for the telehealth transaction. Although similar in costs per patient ($332.89 in-clinic vs. $376.48 telehealth), the costs accrued over 153 business days in-clinic and 4 business days for telehealth. Time elapsed between referral and completion of initial consultation was 72 days in-clinic, 4 days for telehealth.

CONCLUSIONS

U.S. health care is moving toward the use of more technologies and practices, and the information provided by transaction cost analyses of care delivery for pain management will be important to determine actual cost savings and benefits.

A division of medical communications in an academic medical center's department of medicine

Excellent physician communication skills (physician-to-patient and patient-to-physician) have been found to have a positive impact on patient satisfaction and may positively affect patient health behaviors and health outcomes. Such skills are also essential for accurate, succinct, and clear peer-to-peer (physician-to-physician), physician-to-lay-public, and physician-to-media communications. These skills are not innate, however; they must be learned and practiced repeatedly. The Division of Medical Communications (DMC) was created within the Department of Medicine at Brigham and Women's Hospital as an intellectual home for physicians who desire to learn and teach the wide variety of skills needed for effective communication.In this Perspective, the authors provide an overview of the key types of medical communications and share the DMC model as an innovative approach to providing expert guidance to physicians and physicians-in-training as they develop, practice, and refine their communication skills. Current DMC projects and programs include a Volunteer Patient Teaching Corps, which provides feedback to medical students, residents, and faculty on communication skills; a controlled trial of a modified team-based learning method for attending rounds; expert coaching in preparation for presentations of all types (e.g., grand rounds; oral presentations or poster presentations on basic science, clinical, or medical education research); sessions on speaking to the media and running a meeting well; and courses on writing for publication. Objective assessment of the impact of each of these interventions is planned.

Impact of Diabetes E-Consults on Outpatient Clinic Workflow

BACKGROUND

An e-consult is an electronic communication system between clinicians, usually a primary care physician (PCP) and a medical or surgical specialist, regarding general or patient-specific, low complexity questions that would not need an in-person consultation. The objectives of this study were to understand and quantify the impact of the e-consult initiative on outpatient clinic workflow and outcomes.

METHODS

We collected data from 5 different Veterans Affairs (VA) outpatient clinics and interviewed several physicians and staff members. We then developed a simulation model for a primary care team at an outpatient clinic. A detailed experimental study was conducted to determine the effects of factors, such as e-consult demand, view-alert notification arrivals, walk-in patient arrivals, and PCP unavailability, on e-consult cycle time.

RESULTS

Statistical tests indicated that 4 factors related to outpatient clinic workflow were significant, and levels within each of the 4 significant factors resulted in statistically different e-consult cycle times. The arrival rate of electronic notifications, along with patient walk-ins, had a considerable effect on cycle time. Splitting the workload of an unavailable PCP among the other PCPs, instead of the current practice of allocating it to a single PCP, increases the system's ability to handle a much larger e-consult demand.

CONCLUSIONS

The full potential of e-consults can only be realized if the workflow at the outpatient clinics is designed or modified to support this initiative. This study furthers our understanding of how e-consult systems can be analyzed and alternative workflows tested using statistical and simulation modeling to improve care delivery and outcomes.