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Houchens N, Gupta A. Quality and safety in the literature: September 2020. BMJ Qual Saf 2020; 29:780-784. [DOI: 10.1136/bmjqs-2020-011887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 06/27/2020] [Indexed: 11/04/2022]
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Gonçalves-Bradley DC, J Maria AR, Ricci-Cabello I, Villanueva G, Fønhus MS, Glenton C, Lewin S, Henschke N, Buckley BS, Mehl GL, Tamrat T, Shepperd S. Mobile technologies to support healthcare provider to healthcare provider communication and management of care. Cochrane Database Syst Rev 2020; 8:CD012927. [PMID: 32813281 PMCID: PMC7437392 DOI: 10.1002/14651858.cd012927.pub2] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The widespread use of mobile technologies can potentially expand the use of telemedicine approaches to facilitate communication between healthcare providers, this might increase access to specialist advice and improve patient health outcomes. OBJECTIVES To assess the effects of mobile technologies versus usual care for supporting communication and consultations between healthcare providers on healthcare providers' performance, acceptability and satisfaction, healthcare use, patient health outcomes, acceptability and satisfaction, costs, and technical difficulties. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and three other databases from 1 January 2000 to 22 July 2019. We searched clinical trials registries, checked references of relevant systematic reviews and included studies, and contacted topic experts. SELECTION CRITERIA Randomised trials comparing mobile technologies to support healthcare provider to healthcare provider communication and consultations compared with usual care. DATA COLLECTION AND ANALYSIS We followed standard methodological procedures expected by Cochrane and EPOC. We used the GRADE approach to assess the certainty of the evidence. MAIN RESULTS We included 19 trials (5766 participants when reported), most were conducted in high-income countries. The most frequently used mobile technology was a mobile phone, often accompanied by training if it was used to transfer digital images. Trials recruited participants with different conditions, and interventions varied in delivery, components, and frequency of contact. We judged most trials to have high risk of performance bias, and approximately half had a high risk of detection, attrition, and reporting biases. Two studies reported data on technical problems, reporting few difficulties. Mobile technologies used by primary care providers to consult with hospital specialists We assessed the certainty of evidence for this group of trials as moderate to low. Mobile technologies: - probably make little or no difference to primary care providers following guidelines for people with chronic kidney disease (CKD; 1 trial, 47 general practices, 3004 participants); - probably reduce the time between presentation and management of individuals with skin conditions, people with symptoms requiring an ultrasound, or being referred for an appointment with a specialist after attending primary care (4 trials, 656 participants); - may reduce referrals and clinic visits among people with some skin conditions, and increase the likelihood of receiving retinopathy screening among people with diabetes, or an ultrasound in those referred with symptoms (9 trials, 4810 participants when reported); - probably make little or no difference to patient-reported quality of life and health-related quality of life (2 trials, 622 participants) or to clinician-assessed clinical recovery (2 trials, 769 participants) among individuals with skin conditions; - may make little or no difference to healthcare provider (2 trials, 378 participants) or participant acceptability and satisfaction (4 trials, 972 participants) when primary care providers consult with dermatologists; - may make little or no difference for total or expected costs per participant for adults with some skin conditions or CKD (6 trials, 5423 participants). Mobile technologies used by emergency physicians to consult with hospital specialists about people attending the emergency department We assessed the certainty of evidence for this group of trials as moderate. Mobile technologies: - probably slightly reduce the consultation time between emergency physicians and hospital specialists (median difference -12 minutes, 95% CI -19 to -7; 1 trial, 345 participants); - probably reduce participants' length of stay in the emergency department by a few minutes (median difference -30 minutes, 95% CI -37 to -25; 1 trial, 345 participants). We did not identify trials that reported on providers' adherence, participants' health status and well-being, healthcare provider and participant acceptability and satisfaction, or costs. Mobile technologies used by community health workers or home-care workers to consult with clinic staff We assessed the certainty of evidence for this group of trials as moderate to low. Mobile technologies: - probably make little or no difference in the number of outpatient clinic and community nurse consultations for participants with diabetes or older individuals treated with home enteral nutrition (2 trials, 370 participants) or hospitalisation of older individuals treated with home enteral nutrition (1 trial, 188 participants); - may lead to little or no difference in mortality among people living with HIV (RR 0.82, 95% CI 0.55 to 1.22) or diabetes (RR 0.94, 95% CI 0.28 to 3.12) (2 trials, 1152 participants); - may make little or no difference to participants' disease activity or health-related quality of life in participants with rheumatoid arthritis (1 trial, 85 participants); - probably make little or no difference for participant acceptability and satisfaction for participants with diabetes and participants with rheumatoid arthritis (2 trials, 178 participants). We did not identify any trials that reported on providers' adherence, time between presentation and management, healthcare provider acceptability and satisfaction, or costs. AUTHORS' CONCLUSIONS Our confidence in the effect estimates is limited. Interventions including a mobile technology component to support healthcare provider to healthcare provider communication and management of care may reduce the time between presentation and management of the health condition when primary care providers or emergency physicians use them to consult with specialists, and may increase the likelihood of receiving a clinical examination among participants with diabetes and those who required an ultrasound. They may decrease the number of people attending primary care who are referred to secondary or tertiary care in some conditions, such as some skin conditions and CKD. There was little evidence of effects on participants' health status and well-being, satisfaction, or costs.
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Affiliation(s)
| | - Ana Rita J Maria
- Nova Medical School, Faculdade de Ciências Médicas, Lisbon, Portugal
| | - Ignacio Ricci-Cabello
- Primary Care Research Unit, Instituto de Investigación Sanitaria Illes Balears, Palma de Mallorca, Spain
| | | | | | | | - Simon Lewin
- Norwegian Institute of Public Health, Oslo, Norway
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | | | - Brian S Buckley
- Department of Surgery, University of the Philippines, Manila, Philippines
| | - Garrett L Mehl
- Department of Sexual and Reproductive Health, World Health Organization, Geneva, Switzerland
| | - Tigest Tamrat
- Department of Sexual and Reproductive Health, World Health Organization, Geneva, Switzerland
| | - Sasha Shepperd
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Eze ND, Mateus C, Cravo Oliveira Hashiguchi T. Telemedicine in the OECD: An umbrella review of clinical and cost-effectiveness, patient experience and implementation. PLoS One 2020; 15:e0237585. [PMID: 32790752 PMCID: PMC7425977 DOI: 10.1371/journal.pone.0237585] [Citation(s) in RCA: 128] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 07/29/2020] [Indexed: 12/12/2022] Open
Abstract
Introduction Patients and policy makers alike have high expectations for the use of digital technologies as tools to improve health care service quality at a sustainable cost. Many countries within the Organisation for Economic Co-operation and Development (OECD) are investing in telemedicine initiatives, and a large and growing body of peer-reviewed studies on the topic has developed, as a consequence. Nonetheless, telemedicine is still not used at scale within the OECD. Seeking to provide a snapshot of the evidence on the use of telemedicine in the OECD, this umbrella review of systematic reviews summarizes findings on four areas of policy relevance: clinical and cost-effectiveness, patient experience, and implementation. Methods This review followed a prior written, unregistered protocol. Four databases (PubMed/Medline, CRD, and Cochrane Library) were searched for systematic reviews or meta-analyses published between January 2014 and February 2019. Based on the inclusion criteria, 98 systematic reviews were selected for analysis. Due to substantial heterogeneity, a meta-analysis was not conducted. The quality of included reviews was assessed using the AMSTAR 2 tool. Results Most reviews (n = 53) focused on effectiveness, followed by cost-effectiveness (n = 18), implementation (n = 17) and patient experience (n = 15). Eighty-three percent of clinical effectiveness reviews found telemedicine at least as effective as face-to-face care, and thirty-nine percent of cost-effectivenss reviews found telemedicine to be cost saving or cost-effective. Patients reported high acceptance of telemedicine and the most common barriers to implementation were usability and lack of reimbursement. However, the methodological quality of most reviews was low to critically low which limits generalizability and applicability of findings. Conclusion This umbrella review finds that telemedicine interventions can improve glycemic control in diabetic patients; reduce mortality and hospitalization due to chronic heart failure; help patients manage pain and increase their physical activity; improve mental health, diet quality and nutrition; and reduce exacerbations associated with respiratory diseases like asthma. In certain disease and specialty areas, telemedicine may be a less effective way to deliver care. While there is evidence that telemedicine can be cost-effective, generalizability is hindered by poor quality and reporting standards. This umbrella review also finds that patients report high levels of acceptance and satisfaction with telemedicine interventions, but that important barriers to wider use remain.
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Affiliation(s)
- Nkiruka D Eze
- Division of Health Research, Health Economics at Lancaster, Lancaster University, Lancaster, United Kingdom
| | - Céu Mateus
- Division of Health Research, Health Economics at Lancaster, Lancaster University, Lancaster, United Kingdom
| | - Tiago Cravo Oliveira Hashiguchi
- Health Division Organisation for Economic Co-operation and Development, Directorate for Employment, Labour and Social Affairs, Paris, France
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Sosnowski R, Kamecki H, Joniau S, Walz J, Dowling J, Behrendt M, Klaassen Z, Palou J, van Poppel H. Uro-oncology in the era of social distancing: the principles of patient-centered online consultations during the COVID-19 pandemic. Cent European J Urol 2020; 73:260-264. [PMID: 33133650 PMCID: PMC7587487 DOI: 10.5173/ceju.2020.0171] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 06/29/2020] [Accepted: 06/29/2020] [Indexed: 11/22/2022] Open
Abstract
Introduction The COVID-19 pandemic poses significant challenges to healthcare facilities and as per social distancing measures, many consultations are now being carried out via means of telemedicine. As some urologists may not be skilled with remote consultations, there is a need for recommendations on patient-centered online medical counseling. Material and methods We have identified eight areas of excellence and defined the principles based on our experience. Results A professional setting should be provided, in which the privacy of the patient can be ensured. Accompanying persons should be encouraged into the consultation. Proper introduction could serve not only to verify the personality of the patient, but also to provide them with a sense of confidentiality. The interview should be held in a way to overcome the limitations of non-physical encounters, and pande-mic-specific issues should be taken into consideration. When arranging plans, the physician should judge accordingly in regards to what type of management is inevitable or safe, as well as available at this point; strict follow-up should be arranged. As home isolation may lead to unfavorable changes in lifestyle, this issue should be addressed too. The patient should be guided on how to self-educate. Concluding the visit should be aimed at proper evaluation of the patient's comprehension of the consultation. Conclusions It is vital to pursue consistency in providing care to patients. While online counseling may seem challenging, if one adheres to the principles of patient-centered practice, telemedicine may become a valuable tool in maintaining the best-quality care amid the ongoing pandemic.
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Affiliation(s)
- Roman Sosnowski
- Department of Urooncology, Maria Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Hubert Kamecki
- Department of Urooncology, Maria Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Steven Joniau
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | - Jochen Walz
- Department of Urology, Institut Paoli-Calmettes Cancer Centre, Marseille, France
| | | | - Mark Behrendt
- Chairman EAU Patient Information, Groene Hart Ziekenhuis - Gouda Afd. Urologie, Gouda, The Netherlands
| | - Zachary Klaassen
- Department of Surgery, Division of Urology, Augusta University - Medical College of Georgia, Augusta, GA, USA
| | - Joan Palou
- Oncology Urology Unit, Department of Urology, Fundació Puigvert Universitat Autònoma de Barcelona, Barcelona, Spain
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Russell C, Sandu V, Moroz I, Tran C, Keely E, Liddy C. Key Components of Traditional Consultation Letters and Their Relevance to Electronic Consultation Replies: A Systematic Review. Telemed J E Health 2020; 26:689-699. [DOI: 10.1089/tmj.2019.0161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Affiliation(s)
- Christopher Russell
- Department of Family Medicine, McMaster University, Hamilton, Canada
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Victor Sandu
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Isabella Moroz
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Canada
| | | | - Erin Keely
- Department of Medicine, University of Ottawa, Ottawa, Canada
- Ontario eConsult Centre of Excellence, The Ottawa Hospital, Ottawa, Canada
| | - Clare Liddy
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Canada
- Ontario eConsult Centre of Excellence, The Ottawa Hospital, Ottawa, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Canada
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Hilty DM, Torous J, Parish MB, Chan SR, Xiong G, Scher L, Yellowlees PM. A Literature Review Comparing Clinicians' Approaches and Skills to In-Person, Synchronous, and Asynchronous Care: Moving Toward Competencies to Ensure Quality Care. Telemed J E Health 2020; 27:356-373. [PMID: 32412882 DOI: 10.1089/tmj.2020.0054] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Introduction: Research is increasing on asynchronous technologies used by specialist clinicians and primary care, including e-mail, text, e-consultation, and store-and-forward (asynchronous) options. Studies typically describe interventions and care outcomes rather than development of clinical skills for using technology. Methods: This article attempts to compare clinicians' approaches to, and skills for, asynchronous technologies versus in-person and synchronous (i.e., video) care. Literature from technology, health care, pedagogy, and business were searched from 2000 to 2019 for title words, including synchronous (e.g., video, telemental or behavioral health, telepsychiatry), asynchronous (e.g., app, e-consultation, e-mail, text, sensor in a wearable device), education, clinical, and consultation. Results: From a total of 4,812 potential references, two authors (D.M.H., J.T.) found 4,622 eligible for full text review and found 381 articles directly relevant to the concept areas in combination for full text review. However, exclusion criteria subtracted 305, leaving a total of 76 articles. While in-person and synchronous care are similar in many ways, the clinical approach to asynchronous care has many differences. As asynchronous technologies and models of care are feasible and effective, often for consultation, an outline of patient, primary care provider, and specialist clinician goals and skills are presented. Few studies specifically discuss skills or competencies for asynchronous care, but components from published clinical informatics, video, social media, and mobile health competencies were organized into Accreditation Council of Graduate Medical Education domains. Conclusions: Further implementation of science research is needed for asynchronous technology interventions, as well as clinician competencies using asynchronous technologies, to ensure optimal outcomes for patients in health care.
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Affiliation(s)
- Donald M Hilty
- Northern California Veterans Administration Health Care System, Mather, California, USA.,Department of Psychiatry & Behavioral Sciences, UC Davis, Sacramento, California, USA
| | - John Torous
- Division of Digital Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Michelle Burke Parish
- Department of Psychiatry & Behavioral Sciences, UC Davis, Sacramento, California, USA
| | - Steven R Chan
- Stanford University School of Medicine, Palo Alto, California, USA.,Veterans Affairs Palo Alto Health Care System, UC Davis School of Medicine, Sacramento, California, USA
| | - Glen Xiong
- Department of Psychiatry & Behavioral Sciences, UC Davis, Sacramento, California, USA.,Department of Internal Medicine, UC Davis School of Medicine, Sacramento, California, USA
| | - Lorin Scher
- Department of Psychiatry & Behavioral Sciences, UC Davis, Sacramento, California, USA
| | - Peter M Yellowlees
- Department of Psychiatry, UC Davis School of Medicine, Sacramento, California, USA
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Nickbakht M, Meyer C, Scarinci N, Beswick R. Exploring factors influencing the use of an eHealth intervention for families of children with hearing loss: An application of the COM-B model. Disabil Health J 2020; 13:100921. [PMID: 32335066 DOI: 10.1016/j.dhjo.2020.100921] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 01/26/2020] [Accepted: 04/04/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Prior to developing a successful eHealth intervention, it is important that we explore stakeholders' capacity to adapt to eHealth. OBJECTIVE To explore what factors influence the use eHealth services from the perspectives of families of children with hearing loss and professionals who support families as they transition into early intervention. METHODS A qualitative study incorporating semi-structured in-depth interviews was conducted with families (n = 17) and professionals (n = 11). Interview topic guides were developed based on the COM-B model of behaviour change to explore barriers and facilitators related to capability, opportunity, and motivation. RESULTS The COM-B model captured several factors that may influence the use eHealth interventions for families of children with hearing loss. The capability factors included computer literacy and familiarity with social media. The opportunity factors were access to online resources, reliable Internet, and affordable equipment. Professionals' and families' preferences and a culture of face-to-face services were also identified as barriers for using eHealth. The motivation factors included families' and professionals' confidence in using technology and beliefs that there were benefits (e.g., saving travel) associated with using eHealth services. In contrast, beliefs that eHealth may be difficult to set up and not able to replace in-person communication identified as barriers to families and professionals adopting eHealth interventions. CONCLUSION Findings of this study indicated that implementation of an eHealth intervention could be facilitated by addressing the barriers in stakeholders' capabilities, opportunities (e.g., equipment and social support), and motivation (e.g., negative beliefs about eHealth) before developing eHealth services.
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Affiliation(s)
- Mansoureh Nickbakht
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia.
| | - Carly Meyer
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia; The HEARing CRC, Melbourne, Australia
| | - Nerina Scarinci
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia; The HEARing CRC, Melbourne, Australia
| | - Rachael Beswick
- Children's Health Queensland Hospital and Health Service, Healthy Hearing, Brisbane, Australia
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Ackerman SL, Gleason N, Shipman SA. Comparing Patients' Experiences with Electronic and Traditional Consultation: Results from a Multisite Survey. J Gen Intern Med 2020; 35:1135-1142. [PMID: 32076987 PMCID: PMC7174441 DOI: 10.1007/s11606-020-05703-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 10/18/2019] [Accepted: 01/30/2020] [Indexed: 01/18/2023]
Abstract
BACKGROUND There have been no large-scale studies to date of patients' experiences with electronic consultation (eConsult) between primary and specialty care. OBJECTIVE Compare experiences with eConsult and referral for in-person specialist consultation. DESIGN Online survey 2-6 weeks following eConsult or referral at 9 US academic medical centers. PARTICIPANTS Adult patients with no more than one eConsult or referral order from a primary care provider (PCP) in the prior month. Over 9 months, 29,291 email invitations were sent (88% referral; 12% eConsult). MAIN MEASURES Trust in and satisfaction with PCP; consult type awareness; agreement with decision to seek specialist input; timeliness of care; mode of PCP-patient eConsult communication; satisfaction with specialist's recommendations; future preference for eConsult or referral. KEY RESULTS A 27.6% response rate yielded 8087 respondents (88.4% referral; 11.6% eConsult). Many did not know that their PCP had placed a referral (32.8% unaware) or eConsult (52.9%), and eConsult awareness was significantly higher among patients reporting better health (OR 1.62, 95% CI 1.18-2.23). Most (81.4% eConsult; 82.0% referral) were satisfied with the specialist's recommendations. Those who had a good primary care experience were more likely to be satisfied (eConsult: OR 10.63, 95% CI 2.95-38.32; referral: OR 2.87, 95% CI 1.86-4.44). For a similar problem in the future, 78% of eConsult and 32% percent of referral patients preferred eConsult. CONCLUSIONS This multisite study demonstrates that many patients find virtual consultation to be an acceptable strategy for the management of their medical condition and that trust and confidence in one's PCP are crucial ingredients for a satisfying eConsult experience. The lack of awareness of eConsult among many patients who were beneficiaries of the service warrants an increased effort to include patients in eConsult decision-making and communication. Further research is needed to assess eConsult acceptability and satisfaction in more diverse patient populations.
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Affiliation(s)
- Sara L Ackerman
- Department of Social and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, USA.
| | - Nathaniel Gleason
- Division of General Internal Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Scott A Shipman
- Association of American Medical Colleges, Washington, DC, USA
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Anderson D, Porto A, Koppel J, Macri G, Wright M. Impact of Endocrinology eConsults on Access to Endocrinology Care for Medicaid Patients. Telemed J E Health 2020; 26:1383-1390. [PMID: 32023182 DOI: 10.1089/tmj.2019.0238] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Access to endocrinologists is a particular challenge for medically underserved populations. Introduction: Electronic consultations (eConsults) are a promising tool to help address this problem. Materials and Methods: This retrospective cohort study compared two groups: (1) Medicaid patients referred to an endocrinologist 1 year before the implementation of eConsults and (2) those referred in the 1 year after implementation. Data included patient demographics, dates of referral requests, appointment dates, eConsult response dates and times, diagnosis codes, and consultants' recommendations. Provider perspectives of eConsults were determined by using a survey. Results: Before eConsult implementation, only 138 out of 365 (37.8%) of referrals to endocrinology were completed. Postimplementation, 281 out of 469 (59.9%) of referrals were completed either by a confirmed face-to-face visit with an endocrinologist or by an eConsult, of whom 194 (41.4%) did not require a face-to-face visit. Thyroid conditions were the most common reason for a consult, accounting for roughly 40% of all consults. Overall, 32 out of 36 (89%) primary care providers (PCPs) indicated that they were satisfied with eConsults and 19 out of 36 (53%) felt that the process did not create additional work or burden for them. Discussion: These findings demonstrate that eConsult use can help address poor access to specialty care for Medicaid-insured patients. eConsults were able to significantly decrease the need for face-to-face visits and enabled PCPs to address specialty-related issues in primary care. Conclusions: Widespread adoption of eConsults could be a potential solution for major challenges that our health care system faces today.
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Affiliation(s)
| | | | - Jonathan Koppel
- Frank H. Netter MD School of Medicine, Quinnipiac University, North Haven, Connecticut, USA
| | | | - Megan Wright
- Weitzman Institute, Middletown, Connecticut, USA
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Ackerman SL, Dowdell K, Clebak KT, Quinn M, Shipman SA. Patients Assess an eConsult Model's Acceptability at 5 US Academic Medical Centers. Ann Fam Med 2020; 18:35-41. [PMID: 31937531 PMCID: PMC7227466 DOI: 10.1370/afm.2487] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 06/29/2019] [Accepted: 07/19/2019] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Electronic consultation (eConsult), involving asynchronous primary care clinician-to-specialist consultation, is being adopted at a growing number of health systems. Most evaluations of eConsult programs have assessed clinical and financial impacts and clinician acceptability. Less attention has been focused on patients' opinions. We set out to understand patient perspectives and preferences for hypothetical eConsult use at 5 US academic medical centers in the process of adopting an eConsult model. METHODS We invited adult primary care patients to participate in focus groups. Participants were introduced to the eConsult model, considered its potential benefits and drawbacks, judged the acceptability of a hypothetical copay, and expressed their preferences for future involvement in eConsult decision making and communication. Thematic analysis was used for data interpretation. RESULTS One focus group was conducted at each of the 5 sites with a total of 52 participants. Focus groups responded positively to the idea of eConsult, with quicker access to specialty care and convenience identified as key benefits. Approval was particularly high among those with a trusted primary care clinician. Preference for involvement in eConsult decision making and communication varied and enthusiasm about eConsult waned when a hypothetical copay was introduced. Concerns included potential misuse of eConsult and exclusion of the patient's illness narrative in the eConsult exchange. CONCLUSIONS Primary care patients expressed strong support for eConsult, particularly when used by a trusted primary care clinician, in addition to voicing several concerns. Patient involvement in eConsult outreach and education efforts could help to enhance the model's effectiveness and acceptability.
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Affiliation(s)
- Sara L Ackerman
- Department of Social and Behavioral Sciences, University of California San Francisco, San Francisco, California
| | - Kim Dowdell
- Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Karl T Clebak
- Department of Family and Community Medicine, Penn State College of Medicine, Hershey, Pennsylvania
| | - Meagban Quinn
- American Association of Medical Colleges, Washington, DC
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Ramelson H, Nederlof A, Karmiy S, Neri P, Kiernan D, Krishnamurthy R, Allen A, Bates DW. Closing the loop with an enhanced referral management system. J Am Med Inform Assoc 2019; 25:715-721. [PMID: 29471355 DOI: 10.1093/jamia/ocy004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 01/07/2018] [Indexed: 12/17/2022] Open
Abstract
Objective To evaluate the impact of a referral manager tool on primary care practices. Materials and Methods We evaluated a referral manager module in a locally developed electronic health record (EHR) that was enhanced to improve the referral management process in primary care practices. Baseline (n = 61) and follow-up (n = 35) provider and staff surveys focused on the ease of performing various steps in the referral process, confidence in completing those steps, and user satisfaction. Additional metrics were calculated that focused on completed specialist visits, acknowledged notes, and patient communication. Results Of 1341 referrals that were initiated during the course of the study, 76.8% were completed. All the steps of the referral process were easier to accomplish following implementation of the enhanced referral manager module in the EHR. Specifically, tracking the status of an in-network referral became much easier (+1.43 [3.91-2.48] on a 5-point scale, P < .0001). Although we found improvement in the ease of performing out-of-network referrals, there was a greater impact on in-network referrals. Discussion Implementation of an electronic tool developed using user-centered design principles along with adequate staff to monitor and intervene when necessary made it easier for primary care practices to track referrals and to identify if a breakdown in the process occurred. This is especially important for high-priority referrals. Out-of-network referrals continue to present challenges, which may eventually be helped by improving interoperability among EHRs and scheduling systems. Conclusion An enhanced referral manager system can improve referral workflows, leading to enhanced efficiency and patient safety and reduced malpractice risk.
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Affiliation(s)
- Harley Ramelson
- Information Systems, Partners HealthCare, Somerville, MA, USA.,Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Amanda Nederlof
- Information Systems, Partners HealthCare, Somerville, MA, USA
| | - Sam Karmiy
- Information Systems, Partners HealthCare, Somerville, MA, USA
| | - Pamela Neri
- Information Systems, Partners HealthCare, Somerville, MA, USA
| | - David Kiernan
- Information Systems, Partners HealthCare, Somerville, MA, USA
| | | | | | - David W Bates
- Information Systems, Partners HealthCare, Somerville, MA, USA.,Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA.,Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA
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What is curbside consultation for the nurse practitioner? J Am Assoc Nurse Pract 2019; 33:29-37. [PMID: 31738271 DOI: 10.1097/jxx.0000000000000322] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 08/09/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Curbside or informal consultations between clinicians regarding patient care occur frequently in clinical practice. Evaluation of curbside consultation (CC) among nurse practitioners (NPs) is limited. PURPOSE To develop an understanding of NP perceptions of the CC process. METHODOLOGICAL ORIENTATION A qualitative descriptive design was used to assess the context of CCs among NPs. Inductive content analysis was conducted, and Atlas.ti was used to organize the data. SAMPLE Purposive sampling was used to recruit 20 NPs within primary care and specialty settings. CONCLUSIONS Themes describing CC included the description of the CC process, advantages and disadvantages, documentation, legal liability, unspoken rules, and patient-centered engagement. There was a lack of consensus on the boundaries of the CC definition including difficulty in distinguishing a CC from a formal consultation. Generally, the NP acknowledges limitations and views the CC favorably as a helpful tool for receiving practical feedback and expanding learning, collegiality, and collaboration. IMPLICATIONS FOR PRACTICE Findings provide insight regarding the common practice of CC in management of patients at the point of care, what it means to the NP, and a description of the breadth of the CC use. Given its potentially substantial impact on patient care, further assessment of the context of CC among NPs is obligatory.
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Gilani S, Bommakanti K, Friedman L. Electronic Consults in Otolaryngology: A Pilot Study to Evaluate the Use, Content, and Outcomes in an Academic Health System. Ann Otol Rhinol Laryngol 2019; 129:170-174. [PMID: 31625409 DOI: 10.1177/0003489419882726] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To categorize the primary reasons for electronic consults (eConsults) to otolaryngology from primary care physicians (PCPs). To determine how many patients avoided subsequent in-person otolaryngology office visits. METHODS This is a retrospective analysis of a pilot study that took place between 2016 and 2017 regarding eConsults to adult otolaryngology placed by primary care physicians at the University of California, San Diego (UCSD) Medical Center. The complaints were categorized as related to the following: ear, nose, throat or neck. Initial recommendations were classified as (1) providing education only (no intervention), (2) suggesting medical therapy provided by the PCP, or (3) suggesting surgical intervention. Univariate statistics and multinomial logistic regression were used to analyze the association of problem type with the need for follow-up in the otolaryngology offices. The data was analyzed for differences in patient age and gender. RESULTS The study population included 64 patients (average age 54.6 years, 60.9% male). Within this group, 41% of consults were for ear complaints, 15% for nose complaints, 28% had throat-related complaints, and 16% had neck-related complaints. In-person follow-up was not required for 82.8% of the consults. Overall, 76.9% of ear, 100% of nose, 88.9% of throat, and 70.0% of neck complaints did not require in-person visits. CONCLUSIONS eConsults to otolaryngology were primarily for ear concerns. Of the eConsults, 82.4% did not require in-person follow-up. We therefore conclude that the use of eConsults prevented substantial office visits that would not otherwise be necessary. Efforts should be made to promote the widespread use of eConsults, which may to the more efficient use of resources.
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Affiliation(s)
- Sapideh Gilani
- Department of Surgery, Division of Head and Neck Surgery, University of California San Diego, San Diego, CA, USA
| | - Krishna Bommakanti
- University of California San Diego School of Medicine, La Jolla, CA, USA
| | - Lawrence Friedman
- Department of Internal Medicine, University of California San Diego, San Diego, CA, USA
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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. [PMID: 31637228 PMCID: PMC6787760 DOI: 10.3389/fpubh.2019.00279] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 09/16/2019] [Indexed: 11/13/2022] Open
Abstract
Background: Patients with complex circumstances pertaining to geography, socioeconomic status, or functional health often face inequities in accessing care. Electronic consultation (eConsult) is a secure online application that allows primary care providers (PCPs) and specialists to communicate regarding a patient's care. eConsult has demonstrated an ability to improve access to specialist care, and may be of particular use in cases of inequitable access. Methods: We examined how eConsult is used to improve equity of access for patients in complex circumstances by conducting a multiple case study of eConsults from seven patient groups: addiction, frail elderly, homeless, long-term care, rural, special needs, and transgender. Cases from these groups were selected from all eConsult cases completed between January 1 and December 31, 2017 using a data collection strategy tailored to each group. An access framework by Levesque et al. was applied to the data to examine five dimensions of access, arranged in chronological order, that reflect the process of a patient seeking care: approachability, acceptability; availability, affordability, and appropriateness. Two reviewers analyzed the cases using an iterative approach, regularly presenting findings to the research team for discussion and interpretation. Results: Eight hundred and twenty-five cases emerged across the seven target groups. The selected cases highlighted a number of key factors, including the value of the patient-PCP relationship, the importance of considering patient perspectives when providing care, and efforts to accommodate patients facing particular challenges to accessing care. Examples emerged among all five dimensions of the Levesque et al. access framework, with the final dimension, appropriateness, emerging across all cases. Conclusions: By leveraging the eConsult platform, PCPs can help improve equitable access to specialist care. More research is needed to understand why patients with complex circumstances face a longer wait time compared to the general population, and the impact that eConsults can have in improving health outcomes and wait times for this population.
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Affiliation(s)
- Clare Liddy
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada.,Ontario eConsult Centre of Excellence, The Ottawa Hospital, Ottawa, ON, Canada
| | - Justin Joschko
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada
| | - Sheena Guglani
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada
| | - Amir Afkham
- The Champlain Local Health Integration Network, Ottawa, ON, Canada
| | - Erin Keely
- Ontario eConsult Centre of Excellence, The Ottawa Hospital, Ottawa, ON, Canada.,Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Division of Endocrinology/Metabolism, The Ottawa Hospital, Ottawa, ON, Canada
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Osman MA, Schick-Makaroff K, Thompson S, Bialy L, Featherstone R, Kurzawa J, Zaidi D, Okpechi I, Habib S, Shojai S, Jindal K, Braam B, Keely E, Liddy C, Manns B, Tonelli M, Hemmelgarn B, Klarenbach S, Bello AK. Barriers and facilitators for implementation of electronic consultations (eConsult) to enhance access to specialist care: a scoping review. BMJ Glob Health 2019; 4:e001629. [PMID: 31565409 PMCID: PMC6747903 DOI: 10.1136/bmjgh-2019-001629] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 08/04/2019] [Accepted: 08/10/2019] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION Electronic consultation (eConsult)-provider-to-provider electronic asynchronous exchanges of patient health information at a distance-is emerging as a potential tool to improve the interface between primary care providers and specialists. Despite growing evidence that eConsult has clinical benefits, it is not widely adopted. We investigated factors influencing the adoption and implementation of eConsult services. METHODS We applied established methods to guide the review, and the recently published Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews to report our findings. We searched five electronic databases and the grey literature for relevant studies. Two reviewers independently screened titles and full texts to identify studies that reported barriers to and/or facilitators of eConsult (asynchronous (store-and-forward) use of telemedicine to exchange patient health information between two providers (primary and secondary) at a distance using secure infrastructure). We extracted data on study characteristics and key barriers and facilitators were analysed thematically and classified using the Quadruple Aim framework taxonomy. No date or language restrictions were applied. RESULTS Among the 2579 publications retrieved, 130 studies met eligibility for the review. We identified and summarised key barriers to and facilitators of eConsult adoption and implementation across four domains: provider, patient, healthcare system and cost. Key barriers were increased workload for providers, privacy concerns and insufficient reimbursement for providers. Main facilitators were remote residence location, timely responses from specialists, utilisation of referral coordinators, addressing medicolegal concerns and incentives for providers to use eConsult. CONCLUSION There are multiple barriers to and facilitators of eConsult adoption across the domains of Quadruple Aim framework. Our findings will inform the development of practice tools to support the wider adoption and scalability of eConsult implementation.
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Affiliation(s)
- Mohamed A Osman
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Stephanie Thompson
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Liza Bialy
- Alberta Research Centre for Health Evidence, University of Alberta, Edmonton, Alberta, Canada
- Alberta SPOR SUPPORT Unit, Knowledge Translation platform, Edmonton, Alberta, Canada
| | - Robin Featherstone
- Alberta Research Centre for Health Evidence, University of Alberta, Edmonton, Alberta, Canada
- Alberta SPOR SUPPORT Unit, Knowledge Translation platform, Edmonton, Alberta, Canada
| | - Julia Kurzawa
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Deenaz Zaidi
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Ikechi Okpechi
- Division of Nephrology and Hypertension, University of Cape Town, Cape Town, South Africa
| | - Syed Habib
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Soroush Shojai
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Kailash Jindal
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Branko Braam
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Erin Keely
- Departments of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Division of Endocrinology/Metabolism, The Ottawa Hospital, Ottawa, Ontario, Canada
- Ottawa Research Institute, Ottawa, Ontario, Canada
| | - Clare Liddy
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
- CT Lamont Primary Healthcare Research Centre, Bruyere Research Institute, Ottawa, Ontario, Canada
| | - Braden Manns
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Marcello Tonelli
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Brenda Hemmelgarn
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Scott Klarenbach
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Aminu K Bello
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Bhavsar I, Wang J, Burke SM, Dowdell K, Hays RA, Intagliata NM. Electronic Consultations to Hepatologists Reduce Wait Time for Visits, Improve Communication, and Result in Cost Savings. Hepatol Commun 2019; 3:1177-1182. [PMID: 31497739 PMCID: PMC6719752 DOI: 10.1002/hep4.1402] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 06/24/2019] [Indexed: 01/19/2023] Open
Affiliation(s)
| | - Jennifer Wang
- University of Virginia Health System Charlottesville VA
| | - Sean M Burke
- University of Virginia Health System Charlottesville VA
| | | | - R Ann Hays
- University of Virginia Health System Charlottesville VA
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Liddy C, de Man G, Moroz I, Afkham A, Mercer J, Keely E. Effective Integration of an eConsult Service into an Existing Referral Workflow Within a Primary Care Clinic. Telemed J E Health 2019; 26:659-664. [PMID: 31414979 DOI: 10.1089/tmj.2019.0014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background: When implementing e-health solutions, effective integration into a clinic's existing processes is essential to facilitate adoption and sustained usage. Introduction: This article examines the effectiveness of adoption/utilization of an electronic consultation (eConsult) service by primary care providers (PCPs) using a "delegate model," through which referral clerks manage requests on behalf of PCPs, thereby reducing PCPs' administrative burden. Materials and Methods: We conducted a retrospective cross-sectional study of all eConsults submitted between May 1, 2013, and December 31, 2017, by the Bruyère Academic Family Health Team (FHT), after the clinic implemented the service using a delegate model. We assessed system utilization, including monthly volume of submitted eConsults, requested specialties, and impact on PCP referral behavior based on the mandatory closeout surveys. We also conducted a subanalysis to compare the volumes of eConsults per provider between the FHT and all other providers. Results: The Bruyère Academic FHT submitted 3,233 eConsult cases. Volume increased 3.5 fold, from 285 in the first year to 1,016 in the last year. Active Bruyère Academic FHT providers (those who submitted ≥3 cases in 6 months) submitted a median of 25 eConsults (interquartile range [IQR]: 14.75-35.25) versus 14 (IQR 8-24) for all other active users. In 36% of cases, a referral was originally contemplated but avoided based on specialist advice. In 5% of cases, the referral was not originally contemplated but deemed appropriate by the PCP based on specialist advice. Discussion: Our findings show high levels of eConsult use in the clinic utilizing a delegate model, which persisted throughout the study period and was reported to significantly reduce the backlog of traditional referrals at the clinic. Conclusions: The integration of eConsult capability into existing clinic operations was successful in that it allowed the PCPs to request eConsult using a familiar process, avoiding the challenges associated with adopting a new and unfamiliar technology.
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Affiliation(s)
- Clare Liddy
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, Canada
| | - Gwen de Man
- Faculty of Medical Sciences, Radboud University, Nijmegen, Netherlands
| | - Isabella Moroz
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Amir Afkham
- Champlain Local Health Integration Network, Ottawa, Canada
| | - Jay Mercer
- Bruyère Academic Family Health Team, Bruyère Continuing Care, Ottawa, Canada
| | - Erin Keely
- Department of Medicine, University of Ottawa, Ottawa, Canada.,Division of Endocrinology/Metabolism, The Ottawa Hospital, Ottawa, Canada
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Radcliffe K, Lyson HC, Barr-Walker J, Sarkar U. Collective intelligence in medical decision-making: a systematic scoping review. BMC Med Inform Decis Mak 2019; 19:158. [PMID: 31399099 PMCID: PMC6688241 DOI: 10.1186/s12911-019-0882-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 07/29/2019] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Collective intelligence, facilitated by information technology or manual techniques, refers to the collective insight of groups working on a task and has the potential to generate more accurate information or decisions than individuals can make alone. This concept is gaining traction in healthcare and has potential in enhancing diagnostic accuracy. We aim to characterize the current state of research with respect to collective intelligence in medical decision-making and describe a framework for diverse studies in this topic. METHODS For this systematic scoping review, we conducted a systematic search for published literature using PubMed, Embase, Web of Science, and CINAHL on August 8, 2017. We included studies that combined the insights of two or more medical experts to make decisions related to patient care. Studies that examined medical decisions such as diagnosis, treatment, and management in the context of an actual or theoretical patient case were included. We include studies of complex medical decision-making rather than identification of a visual finding, as in radiology or pathology. We differentiate between medical decisions, in which synthesis of multiple types of information is required over time, and studies of radiological scans or pathological specimens, in which objective identification of a visual finding is performed. Two reviewers performed article screening, data extraction, and final inclusion for analysis. RESULTS Of 3303 original articles, 15 were included. Each study examined the medical decisions of two or more individuals; however, studies were heterogeneous in their methods and outcomes. We present a framework to characterize these diverse studies, and future investigations, based on how they operationalize collective intelligence for medical decision-making: 1) how the initial decision task was completed (group vs. individual), 2) how opinions were synthesized (information technology vs. manual vs. in-person), and 3) the availability of collective intelligence to participants. DISCUSSION Collective intelligence in medical decision-making is gaining popularity to advance medical decision-making and holds promise to improve patient outcomes. However, heterogeneous methods and outcomes make it difficult to assess the utility of collective intelligence approaches across settings and studies. A better understanding of collective intelligence and its applications to medicine may improve medical decision-making.
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Affiliation(s)
- Kate Radcliffe
- Center for Vulnerable Populations, University of California, San Francisco, USA
| | - Helena C Lyson
- Center for Vulnerable Populations, University of California, San Francisco, USA
| | - Jill Barr-Walker
- Zuckerberg San Francisco General Hospital Library, University of California, San Francisco, San Francisco, CA, USA
| | - Urmimala Sarkar
- Center for Vulnerable Populations, University of California, San Francisco, USA.
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Deeds SA, Dowdell KJ, Chew LD, Ackerman SL. Implementing an Opt-in eConsult Program at Seven Academic Medical Centers: a Qualitative Analysis of Primary Care Provider Experiences. J Gen Intern Med 2019; 34:1427-1433. [PMID: 31197734 PMCID: PMC6667576 DOI: 10.1007/s11606-019-05067-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 01/31/2019] [Accepted: 04/11/2019] [Indexed: 01/20/2023]
Abstract
BACKGROUND Electronic consultation (eConsult), which involves primary care provider (PCP)-to-specialist asynchronous consultation, is increasingly used in health care systems to streamline care and to improve patient access. The Association of American Medical Colleges (AAMC) formed a collaborative to support the implementation of an electronic medical record (EMR)-based, opt-in eConsult program across multiple academic medical centers (AMCs). In this model, PCPs can elect to send either an eConsult or a traditional referral. OBJECTIVE We sought to understand the PCP experience with eConsult to identify facilitators of and barriers to the successful adoption of the model. DESIGN AND PARTICIPANTS We conducted 35 semi-structured interviews and 6 focus groups with a range of primary care providers at 7 AMCs participating in the AAMC collaborative. APPROACH Interviews were recorded and transcribed or detailed field notes were taken. We used the constant comparative method to identify recurring themes within and across sites, and resolve interpretive discrepancies. KEY RESULTS We identified three major themes related to the eConsult program: (1) eConsult increases the comprehensiveness of primary care and fills PCPs' knowledge gaps through case-based learning. (2) Factors that influence PCPs to order an eConsult rather than a traditional referral include patient preference, case complexity, and need for expert guidance. (3) Implementation challenges included increasing PCPs' awareness of the program, addressing PCPs' concerns about increased workload, recruiting engaged specialist consultants, and ensuring high quality eConsult responses. Implementation success relied on PCP ownership of the consultation process, mitigating unintended consequences, ongoing education about the program, and mechanisms for providing feedback to clinicians. CONCLUSIONS Our findings demonstrate that an opt-in eConsult program at AMCs has the potential to increase PCP knowledge and enhance the comprehensiveness of primary care. For these benefits to be realized, program implementation requires sustained efforts to overcome barriers to use and establish norms guiding eConsult communication.
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Affiliation(s)
- Stefanie A Deeds
- Department of Medicine, Veterans Affairs Puget Sound Healthcare System, Division of General Internal Medicine , University of Washington School of Medicine, Seattle, WA, USA.
| | - Kimberly J Dowdell
- Department of Medicine, Division of General, Geriatric, Palliative & Hospital Medicine, University of Virginia, Charlottesville, VA, USA
| | - Lisa D Chew
- Department of Medicine, Harborview Medical Center, Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA, 98195, USA
| | - Sara L Ackerman
- Department of Social & Behavioral Sciences, School of Nursing, University of California, San Francisco, San Francisco, CA, USA
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Wang C, Liddy C, Afkham A, Islam S, Shehata F, Posner G, Keely E. Pathology perspective on gynaecologic malignancy screening questions in electronic consultation. J Telemed Telecare 2019; 27:123-130. [PMID: 31364473 DOI: 10.1177/1357633x19864825] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The electronic consultation service, eConsult, is an asynchronous web-based platform for provider-to-provider consultation with specialists. This study described the utilization of eConsult by primary care providers to obtain specialist opinion in gynaecologic malignancy screening, with a specific focus on pathology-related inquiries. METHODS This is a cross-sectional retrospective review of eConsults submitted to obstetrics/gynaecology between September 2011 and December 2016. All questions pertaining to gynaecologic cancer screening and their pathologies were included. Each question was classified based on a pre-determined taxonomy. The mandatory primary care providers' exit surveys were analysed to determine eConsult's influence on patient care, primary care providers' referral patterns, primary care providers' satisfaction and educational value. RESULTS In total, 1,357 electronic consultations were submitted to the obstetrics and gynaecology service during the study period, of which 329 met inclusion criteria. Indications for a screening test based on patient risk factors made up 36% of consults pertaining to gynaecologic malignancy screening and 17% were inquiries about test intervals based on previous results. Primary care providers pointed out gaps in current screening guidelines. In total, 38% of primary care providers reported the eConsult service helped avoid a specialist referral, whereas 47% of primary care providers received new or additional courses of action. Pathology report interpretation accounted for 5% of eConsults and 6% of primary care providers wished for clarification of incidental pathology findings. CONCLUSION This study uncovered areas of uncertainty among primary care providers regarding gynaecologic cancer screening and gaps in current clinical guidelines. Furthermore, the role of pathology consultants in an eConsult platform is explored and may be extrapolated into practice.
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Affiliation(s)
- Carol Wang
- Department of Medicine, University of Ottawa, Canada
| | - Clare Liddy
- C.T. Lamont Primary Health Care Research Centre, Department of Family Medicine, University of Ottawa, Canada.,Bruyère Research Institute, Canada.,Ontario eConsult Centre of Excellence, The Ottawa Hospital, Canada
| | - Amir Afkham
- Champlain Local Health Integration Network, Canada
| | - Shahidul Islam
- Department of Pathology and Laboratory Medicine, University of Ottawa, Canada
| | - Fady Shehata
- Department of Obstetrics and Gynecology, University of Ottawa, Canada
| | - Glen Posner
- Department of Obstetrics and Gynecology, University of Ottawa, Canada
| | - Erin Keely
- Department of Medicine, University of Ottawa, Canada.,Ontario eConsult Centre of Excellence, The Ottawa Hospital, Canada.,Division of Endocrinology/Metabolism, The Ottawa Hospital, Canada
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Richter JM, Ha JB, Marx M, Campbell EJ, Pandolfi MC. A Digital Preprocedure Instruction Program for Outpatient Colonoscopy. Telemed J E Health 2019; 26:468-476. [PMID: 31298628 DOI: 10.1089/tmj.2019.0050] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Introduction: Many patients struggle with colonoscopy preparation, which is complex and can be an uncomfortable as well as a time-consuming process. The confusion and anxiety from the preprocedure process may lead patients to delay their colonoscopy or skip it altogether. Digital health technology that focuses on patient engagement can play an important role in promoting colorectal cancer screening. Methods: A digital preprocedure instruction program was implemented for outpatient colonoscopy by sending critical reminders and instructions to patients through a series of short message service messages and/or emails. Eligible patients included English speakers on GoLYTELY®/NuLYTELY® or MiraLAX® preparation regimens with a valid cellphone or email address in the electronic health record. We examined the impact of digital instructions on bowel preparation quality, no-show and same-day cancellations over a 3-month period between an intervention group of 756 patients and a control group of 2,103 patients. Patients who enrolled in the digital instructions also received a patient satisfaction survey. Results: Our controlled study demonstrated the effectiveness of digital instructions to reduce no-show and same-day cancellation rates for outpatient colonoscopy from 10.40% to 6.08% (p < 0.001). Bowel preparation quality was not significantly different between the two groups (p = 0.23). However, 90% of patients who enrolled in the program rated their satisfaction with the digital reminders very highly. Discussion: A digital preprocedure instruction program can have a positive impact on operational efficiency, quality of care, and patient satisfaction. This study shows how digital health tools can effectively engage patients scheduled for a colonoscopy, increase appointment adherence, and, therefore, lead to better cancer screening.
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Affiliation(s)
- James M Richter
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Jasmine B Ha
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
| | - Madeline Marx
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
| | - Emily J Campbell
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
| | - Michael C Pandolfi
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
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Lee L, Hillier LM, Locklin J, Lumley-Leger K, Molnar F. Specialist and family physician collaboration: Insights from primary care-based memory clinics. HEALTH & SOCIAL CARE IN THE COMMUNITY 2019; 27:e522-e533. [PMID: 30977237 DOI: 10.1111/hsc.12751] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Revised: 03/13/2019] [Accepted: 03/15/2019] [Indexed: 06/09/2023]
Abstract
Given limited available geriatric specialists and complexity of dementia care, there is a need for greater collaboration between primary care and specialists to better meet the needs of persons with dementia. Meaningful family physician-specialist collaboration has the potential to improve health outcomes, timely access to care and more appropriate healthcare resource utilisation. Primary Care Collaborative Memory Clinics (PCCMCs), which include specialist support, provide a significant opportunity for studying the family physician-specialist interface. This study aimed to explore the nature of collaborative relationships between memory clinic family physicians and specialists caring for persons with memory concerns in PCCMCs across Ontario, Canada. Family physicians (N = 71) attending an education session and specialists (N = 21) completed a survey in the fall of 2017 that measured frequency and amount of collaboration, perceptions of their relationship and identified factors that enable and challenge collaboration. Descriptive statistics were generated for quantitative data and themes for responses to open-ended questions were explored using descriptive qualitative content analysis. Specialists and memory clinic family physicians valued their collaboration particularly as related to capacity building for dementia care and desired more time devoted to collaboration. Identified enablers and barriers to collaboration have implications for further integration of specialist support to potentially support improved patient care and further build capacity in primary care to manage dementia care. Opportunities exist for expanding and more intentionally supporting how family physicians and specialists interact with the creation of more formalised processes to support optimal collaboration, including a clear delineation of roles, responsibilities and expectations, more formally planned and structured relationship building and monitoring, identifying and addressing unique barriers to collaboration and use of a variety of methods of communication. Study findings have implications for how specialists and family physicians communicate and collaborate in other programmes for complex chronic conditions.
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Affiliation(s)
- Linda Lee
- Centre for Family Medicine Family Health Team, Kitchener, Ontario, Canada
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Loretta M Hillier
- Geriatric Education and Research in Aging Sciences (GERAS) Centre, Hamilton, Ontario, Canada
| | - Jason Locklin
- Centre for Family Medicine Family Health Team, Kitchener, Ontario, Canada
| | | | - Frank Molnar
- Regional Geriatric Program of Eastern Ontario, Ottawa, Ontario, Canada
- Division of Geriatrics, University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital, Ottawa, Ontario, Canada
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Liddy C, Moroz I, Keely E, Taljaard M, Deri Armstrong C, Afkham A, Kendall CE. Understanding the impact of a multispecialty electronic consultation service on family physician referral rates to specialists: a randomized controlled trial using health administrative data. Trials 2019; 20:348. [PMID: 31182123 PMCID: PMC6558850 DOI: 10.1186/s13063-019-3393-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 05/04/2019] [Indexed: 12/03/2022] Open
Abstract
Background Electronic consultation (eConsult) services are secure online applications facilitating provider-to-provider communication. They have been found to improve access to specialist care. However, little is known about eConsult’s impact on family physicians’ referral rates to specialty care. The objective of this study was to assess the impact of a multispecialty eConsult service on referral rates from primary care. Methods In this parallel-arm, randomized controlled trial, we recruited primary care providers across Ontario not previously enrolled with eConsult. We randomly assigned participants to intervention and control arms. Participants in the intervention arm received access to eConsult for a period of 1 year while those in the control arm received no access to eConsult. The main outcome was specialist referral rate, expressed as the total number of referrals to (1) specialties available through eConsult, and (2) all medical specialties, per 100 patients seen. Multivariable negative binomial regression analysis was used to evaluate the effect of the intervention before and after adjusting for provider characteristics, using health administrative data. Results One hundred and thirteen participants were randomized (56 to control and 57 to intervention). For the primary outcome (referrals to eConsult specialties), the results show a statistically significant reduction in the number of referrals in both arms (control-arm Rate Ratio (RR), 0.85, 95% CI 0.79 to 0.91; intervention-arm RR, 0.80, 95% CI 0.74 to 0.85; unadjusted and adjusted RR values almost identical), as compared to the baseline data collected during the 12-month period before randomization, with a non-statistically significant 6% greater reduction in referrals in the intervention arm, compared to the control arm (unadjusted RR 0.94, 95% CI 0.85 to 1.03; adjusted RR 0.93, 95% CI 0.85 to 1.03). Conclusions Our randomized controlled trial of a multispecialty eConsult service demonstrated inconclusive results in terms of the impact of eConsult on physician referral rates. Findings are discussed in light of important limitations associated with conducting randomized controlled trials (RCTs) of complex interventions in the primary care context with intent to inform the design and analysis of future trials. Trial registration Clinicaltrials.gov, ID: NCT02053467. Registered prospectively on 3 February 2014.
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Affiliation(s)
- Clare Liddy
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, 43 Bruyère St. Annex E, Room 106, Ottawa, ON, K1N 5C8, Canada. .,Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada.
| | - Isabella Moroz
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, 43 Bruyère St. Annex E, Room 106, Ottawa, ON, K1N 5C8, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Erin Keely
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Division of Endocrinology/Metabolism, The Ottawa Hospital, Ottawa, ON, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Amir Afkham
- Champlain Local Health Integration Network, Ottawa, ON, Canada
| | - Claire E Kendall
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, 43 Bruyère St. Annex E, Room 106, Ottawa, ON, K1N 5C8, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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74
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van der Velden T, Schalk BWM, Harmsen M, Adriaansens G, Schermer TR, Ten Dam MA. Implementation of web-based hospital specialist consultations to improve quality and expediency of general practitioners' care: a feasibility study. BMC FAMILY PRACTICE 2019; 20:73. [PMID: 31142267 PMCID: PMC6540440 DOI: 10.1186/s12875-019-0960-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 05/03/2019] [Indexed: 11/21/2022]
Abstract
Background Rising healthcare costs due to unnecessary referrals to secondary healthcare services underscore the need for optimizing current referral procedures. This study investigates whether the use of web-based consultation (WBC) in general practice is a feasible alternative to decrease referrals. Methods Patients with lumbosacral radicular syndrome, knee complaints, or thyroid dysfunction, who visited the general practitioner (GP) between May 2015 and December 2016 were included for a WBC. We determined whether the GP would refer a patient to an outpatient clinic in the absence of a WBC and then compared this decision with the referral advice from a specialist. We further assessed the user-friendliness of the WBC service based on average recorded user time and feedback from the GPs. Results Seventy eligible WBCs submitted by GPs were analyzed. Our data showed a 46% absolute reduction in in-persons referrals in our study population. These findings confirmed the feasibility of using WBC. The median time spent to submit a WBC was five and 10 min for GPs and specialists respectively. On average, the WBC service saved €286 per WBC. The results of a questionnaire showed that GPs found WBC to be a user-friendly option which could help reduce the number of in-person referrals. Conclusion We demonstrated that WBC is not only feasible but has the potential to reduce nearly half of all in-person referrals to outpatient clinics. WBC decreased healthcare expenses and proved to be a user-friendly and safe alternative to the standard referral process. WBC may potentially have a profound impact on healthcare expenditure if applied in a wider medical setting. For follow-up research, we recommend including a control group for comparative analyses. Electronic supplementary material The online version of this article (10.1186/s12875-019-0960-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Thomas van der Velden
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Bianca W M Schalk
- Department of Primary and Community Care, Radboud University Medical Center, Radboudumc Transmural Knowledge and Innovation Center, postal route 117, PO Box 9101, 6500, HB, Nijmegen, the Netherlands.
| | - Mirjam Harmsen
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Tjard R Schermer
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Marc A Ten Dam
- Department of Internal Medicine, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
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75
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Azogil-López LM, Pérez-Lázaro JJ, Medrano-Sánchez EM, Gómez-Salgado J, Coronado-Vázquez V. DETELPROG Study. Effectiveness of a New Model of Scheduled Telephone Referral from Primary Care to Internal Medicine. A Randomised Controlled Study. J Clin Med 2019; 8:jcm8050688. [PMID: 31100835 PMCID: PMC6572186 DOI: 10.3390/jcm8050688] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 05/09/2019] [Accepted: 05/13/2019] [Indexed: 12/16/2022] Open
Abstract
In Spain, the average waiting time for a specialist consultation is 58 days. A determinant factor that contributes to this situation is the poor communication between primary care and specialised care, which is mainly due to the waiting days for a consultation, number of avoided/avoidable face-to-face referrals, and waiting days for the resolution of the process. DETELPROG is a referral system in which the family physician requests a scheduled outpatient internal medicine consultation, integrated into the usual consultations agenda of both physicians, the family, and the outpatient clinic physician, in order to have a telephone consultation. A randomized controlled clinical trial has been carried out to assess the effectiveness of DELTELPROG. In a sample of 255 patients, the experimental group was referred via a scheduled telephone call, and those in the control group, by face-to-face hospital consultation area. The results showed statistically significant differences between both groups of 27 days (95% confidence interval (CI): 20–33) regarding specialised consultation, 47 days (95% CI: 17–74) as for the resolution of the process, and 91.7% for avoided face-to-face consultations. The DETELPROG resulted as a low coverage system (53%), which makes it a complementary referral model. It is necessary to make an in-depth analysis of the causes that have led to this technologically low coverage.
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Affiliation(s)
| | - Juan José Pérez-Lázaro
- Andalusian School of Public Health, Department of Preventive Medicine and Public Health, University of Granada, 18080 Granada, Spain.
| | | | - Juan Gómez-Salgado
- Department of Sociology, Social Work and Public Health, University of Huelva, 21007 Huelva, Spain.
- Safety and Health Posgrade Program, Universidad Espíritu Santo, Guayaquil 091650, Ecuador.
| | - Valle Coronado-Vázquez
- General Directorate of Health Assistance-Aragonese Health Service, 50071 Zaragoza, Spain.
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76
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Keely E, Afkham A, Liddy C. Insights into Specialists' Participation and Self-Reported Billing Times in a Multispecialty eConsult Service: Correlating Response Length with Outcomes and Satisfaction. Telemed J E Health 2019; 26:419-425. [PMID: 31059380 DOI: 10.1089/tmj.2019.0032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Electronic consultation (eConsult) services have been shown to reduce the need for face-to-face consultations. The largest expense is remunerating the specialist. Introduction: The Champlain BASE™ eConsult service remunerates specialists based on their self-reported billing time. It is important for funders of eConsult systems to understand and plan for specialist remuneration. This study examined specialists' time commitments pertaining to eConsult, identified factors that affect their self-reported billing time, and determined if self-reported billing time is associated with changes in primary care provider (PCP) behavior. Methods: A cross-sectional study of eConsults was completed between January 1 and December 31, 2017. Data were collected automatically by the service and through mandatory closeout surveys. Logistic regressions identified associations between specialists' self-reported billing time and volume of cases completed, PCP characteristics, specialty group, impact on PCP behaviors, and PCP satisfaction. Results: A total of 11,985 cases met inclusion criteria. Self-reported billing time was <5 min in 18.3% of cases, 5-10 min in 35.6%, 10-15 min in 27.3%, 15-20 min in 11.3%, and >20 min in 7.5%. Self-reported billing time demonstrated significant variation between specialty groups. Cases with higher self-reported billing time were more likely to lead to new/additional course of action for PCPs (p ≤ 0.0001), resulted in fewer referrals (p ≤ 0.0001), and received higher rankings for helpfulness and educational value (p ≤ 0.0001). Discussion: A thorough understanding of when and how specialists respond to eConsult cases is critical to ensuring the service's long-term sustainability. Examining these factors and their impact on PCP behaviors helps us to better understand the service's overall value and serve to inform the structure of its remuneration process. Conclusions: Specialists' self-reported billing time varies by specialty group and is associated with changes in PCP behavior and satisfaction. Further research is needed to identify what factors influence self-reported billing time and how eConsult can be best incorporated into clinicians' workflows.
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Affiliation(s)
- Erin Keely
- Department of Medicine, University of Ottawa, Ottawa, Canada.,Division of Endocrinology/Metabolism, The Ottawa Hospital, Ottawa, Canada
| | - Amir Afkham
- Enabling Technologies, Champlain Local Health Integration Network, Ottawa, Canada
| | - Clare Liddy
- Department of Family Medicine, C.T. Lamont Primary Health Care Research Centre, University of Ottawa, Ottawa, Canada.,Bruyère Research Institute, Ottawa, Canada
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de Man G, Moroz I, Mercer J, Keely E, Liddy C. Primary Care Clinician Adherence to Specialist Advice in Electronic Consultation. Ann Fam Med 2019; 17:150-157. [PMID: 30858258 PMCID: PMC6411398 DOI: 10.1370/afm.2355] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 12/14/2018] [Accepted: 12/31/2018] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Electronic consultation (eConsult) services can improve access to specialist advice. Little is known, however, about whether and how often primary care clinicians adhere to the advice they receive. We evaluated how primary care clinicians use recommendations conveyed by specialists via the Champlain BASE (Building Access to Specialists through eConsultation) eConsult service and how eConsult affects clinical management of patients in primary care. METHODS This is a descriptive analysis based on a retrospective chart audit of 291 eConsults done between January 20, 2017 and August 31, 2017 at the Bruyère Family Health Team, located in Ottawa, Canada. Patients' charts were reviewed until 6 months after specialist response for the following main outcomes: implementation of specialist advice by primary care clinicians, communication of the results to the patients, method, and time frame of communication. RESULTS Primary care clinicians adhered to specialist advice in 82% of cases. Adherence ranged from 62% to 93% across recommendation categories. Questions asked by primary care clinicians related to diagnosis (63%), management (27%), drug treatment (10%), and procedures (1%). Recommendations of the eConsult were communicated to patients in 79% of cases, most often by face-to-face visit (38%), telephone call (32%), or use of the patient portal (9%). Communication occurred in a median of 5 days. CONCLUSIONS We found little evidence of barriers to implementing specialist advice with use of eConsult, which suggests recommendations given through service were actionable. With a high primary care clinician adherence to specialist recommendations and primary care clinician-to-patient communication, we conclude that eConsult delivers good-quality care and improves patient management.
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Affiliation(s)
- Gwen de Man
- CT Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Radboud University, Nijmegen, The Netherlands
| | - Isabella Moroz
- CT Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Jay Mercer
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Bruyère Academic Family Health Team, Bruyère Continuing Care, Ottawa, Ontario, Canada
| | - Erin Keely
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Division of Endocrinology/Metabolism, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Clare Liddy
- CT Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada .,Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
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78
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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; 25:184-198. [DOI: 10.1089/tmj.2018.0005] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Affiliation(s)
- Clare Liddy
- C.T. Lamont Primary Health Care Research Center, Bruyère Research Institute, Ottawa, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Canada
| | - Isabella Moroz
- C.T. Lamont Primary Health Care Research Center, Bruyère Research Institute, Ottawa, Canada
| | - Ariana Mihan
- C.T. Lamont Primary Health Care Research Center, Bruyère Research Institute, Ottawa, Canada
| | - Nikhat Nawar
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Erin Keely
- Department of Medicine, University of Ottawa, Ottawa, Canada
- Division of Endocrinology/Metabolism, The Ottawa Hospital, Ottawa, Canada
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Bachelet VC, Goyenechea M, Carrasco VA. Policy strategies to reduce waiting times for elective surgery: A scoping review and evidence synthesis. Int J Health Plann Manage 2019; 34:e995-e1015. [PMID: 30793372 DOI: 10.1002/hpm.2751] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 01/14/2019] [Accepted: 01/15/2019] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES The purpose of this evidence-based review is to identify and describe the interventions that have been implemented to reduce waiting times for major elective surgery. METHODS Scoping review and presentation of the results according to the SUPPORT tools. We searched MEDLINE/PubMed, Embase, Cochrane Library, SciELO, DARE-HTA, and Google Scholar. The inclusion criteria for research design were comprehensive. RESULTS We identified 5200 records. After eliminating duplicates and screening by title and abstract, 171 records remained for full-text assessment, of which 12 were ultimately included for this review because they reported specific interventions and 96 records were included for further reference. The included studies show significant variability regarding elective procedures, population, and type of provider, as well as in the characteristics of the interventions and the settings. All the studies had methodological limitations. We graded the certainty of the evidence as very low. CONCLUSIONS According to the evidence found for this review, interventions most likely should be multidimensional, with prioritization strategies on the waiting lists to incorporate equity criteria, together with quality management improvements of the surgical pathways and the use of operating rooms, as well as improvements in the planning of the surgical schedule.
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Affiliation(s)
- Vivienne C Bachelet
- Escuela de Medicina, Facultad de Ciencias Médicas, Universidad de Santiago de Chile, Santiago, Chile.,Medwave Estudios Limitada, Santiago, Chile
| | | | - Víctor A Carrasco
- Escuela de Medicina, Facultad de Ciencias Médicas, Universidad de Santiago de Chile, Santiago, Chile.,Medwave Estudios Limitada, Santiago, Chile
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80
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A pilot eConsultation service in Eastern Ontario: bridging clinical genetics and primary care. Eur J Hum Genet 2019; 27:1026-1032. [PMID: 30778171 DOI: 10.1038/s41431-019-0342-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 12/04/2018] [Accepted: 01/05/2019] [Indexed: 12/15/2022] Open
Abstract
With the rising demand for clinical genetics services, it is a challenge for clinical geneticists to meet the needs of patients and referring primary care providers in a timely way, using current models of genetics health care delivery. One method of providing primary care providers with greater access to clinical genetics expertise is through an electronic consultation (eConsult) service. We describe here a pilot project of a clinical genetics eConsult service that our genetics centre in Eastern Ontario, Canada provided, using the Champlain Building Access to Specialists through eConsultation (BASE)TM web-based application. We analyzed 111 genetics eConsults submitted by primary care providers to a single clinical geneticist over a 28-month time period. More than half (54%) of the eConsult questions were regarding (1) hereditary cancer and (2) genetic syndromes, with the remainder encompassing a wide variety of clinical genetics topics. We avoided a referral to the Genetics clinic for an in-person appointment for 30% of the eConsult cases, based on a contemplated referral rate to Genetics clinic of 72% prior to eConsult and a planned referral rate to Genetics clinic of 42% following all eConsults. Primary care providers rated the eConsult service of high value to themselves and also to their patients. This pilot service supports the potential of an eConsultation service to create a stronger and more dynamic link between clinical genetics and primary care providers, which may lead to better patient care.
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81
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Tran C, Archibald D, Humphrey-Murto S, Liddy C, Keely E. What makes a high-quality electronic consultation (eConsult)? A nominal group study. J Telemed Telecare 2019; 26:239-247. [PMID: 30717627 DOI: 10.1177/1357633x18822885] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Poor communication between health professionals can compromise patient safety, yet specialists rarely receive feedback on their written communication. Although worldwide implementation of electronic consultation (eConsult) services is rising rapidly, little is known about the features of effective communication when specialists provide online advice to primary care providers (PCP). To inform efforts to ensure and maintain high-quality communication via eConsult, we aim to identify features of high-quality eConsult advice to incorporate into an assessment tool that can provide specialists with feedback on their correspondence. METHODS Initial items for the tool were generated by PCPs and specialists using the nominal group technique (NGT). Invited PCPs were above-median eConsult users between July 2016 and June 2017. Specialists were purposively recruited to represent the range of available specialties. Participants individually wrote down items they felt should be included in the tool. A moderator with consensus group expertise then led a round-robin discussion for each item. Items were ranked anonymously and included if highly-ranked by over 70% of participants. RESULTS Eight PCPs (six family physicians, two nurse practitioners) and three specialists (dermatology, hematology, pediatric orthopedics) produced 49 items that were refined to 14 after group discussion and two rounds of ranking. Highly-ranked items encompassed specific, up-to-date, patient-individualized, and practical advice that the PCP could implement. DISCUSSION Features of high-quality eConsult correspondence derived from consensus methods highlight similarities and differences between face-to-face consultation letters and eConsult. Our findings could be used to inform feedback and education for eConsult specialists on their advice to PCPs.
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Affiliation(s)
| | | | | | - Clare Liddy
- Department of Family Medicine, University of Ottawa, Canada.,C.T. Lamont Primary Healthcare Research Centre, Bruyère Research Institute, Canada
| | - Erin Keely
- Department of Medicine, University of Ottawa, Canada
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82
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Blosnich JR, Rodriguez KL, Hruska KL, Kavalieratos D, Gordon AJ, Matza A, Mejia SM, Shipherd JC, Kauth MR. Utilization of the Veterans Affairs' Transgender E-consultation Program by Health Care Providers: Mixed-Methods Study. JMIR Med Inform 2019; 7:e11695. [PMID: 31344672 PMCID: PMC6682290 DOI: 10.2196/11695] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 10/02/2018] [Accepted: 10/09/2018] [Indexed: 11/16/2022] Open
Abstract
Background In 2015, the Department of Veterans Affairs (VA) nationally implemented a transgender e-consultation (e-consult) program with expert clinical guidance for providers. Objective This mixed-methods project aimed to describe providers’ program experiences, reasons for nonuse of the program, and ways to improve the program use. Methods From January to May 2017, 15 urban and rural VA providers who submitted at least one e-consult in the last year participated in semistructured interviews about their program experiences, which were analyzed using content analysis. From November to December 2017, 53 providers who encountered transgender patients but did not utilize the program participated in a brief online survey on the reasons for nonuse of the program and the facilitators encouraging use. Results Qualitative analysis showed that providers learned of the program through email; colleagues; the electronic health record (EHR) system; and participation in the VA Lesbian, Gay, Bisexual, and Transgender committees or educational trainings. Providers used the program to establish care plans, hormone therapy recommendations, sexual and reproductive health education, surgical treatment education, patient-provider communication guidance, and second opinions. The facilitators of program use included understandable recommendations, ease of use through the EHR system, and status as the only transgender resource for rural providers. Barriers to use included time constraints, communication-related problems with the e-consult, impractical recommendations for underresourced sites, and misunderstanding of the e-consult purpose. Suggestions for improvement included addition of concise or sectioned responses, expansion of program awareness among providers or patients, designation of a follow-up contact person, and increase in provider education about transgender veterans and related care. Quantitative analysis showed that the common reasons for nonuse of the program were no knowledge of the program (54%), no need of the program (32%), and receipt of help from a colleague outside of e-consult (24%). Common suggestions to improve the program use in quantitative analyses included provision of more information about where to find e-consult in the chart, guidance on talking with patients about the program, and e-mail announcements to improve provider awareness of the program. Post hoc exploratory analyses showed no differences between urban and rural providers. Conclusions The VA transgender e-consult program is useful for providers, but there are several barriers to implementing recommendations, some of which are especially challenging for rural providers. Addressing the identified barriers and enhancing the facilitators may improve program use and quality care for transgender veterans.
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Affiliation(s)
- John R Blosnich
- Center for Health Equity Research and Promotion, Department of Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, United States.,Division of General Internal Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Keri L Rodriguez
- Center for Health Equity Research and Promotion, Department of Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, United States.,Division of General Internal Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Kristina L Hruska
- Center for Health Equity Research and Promotion, Department of Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, United States
| | - Dio Kavalieratos
- Center for Health Equity Research and Promotion, Department of Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, United States.,Division of General Internal Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Adam J Gordon
- Informatics, Decision-Enhancement, and Analytic Sciences Center, Department of Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, United States.,Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, UT, United States
| | - Alexis Matza
- Lesbian, Gay, Bisexual, and Transgender Health Program, Office of Patient Care Services, Veterans Health Administration, Washington, DC, United States
| | - Susan M Mejia
- Lesbian, Gay, Bisexual, and Transgender Health Program, Office of Patient Care Services, Veterans Health Administration, Washington, DC, United States.,South Central Mental Illness Research, Education and Clinical Center, Michael E DeBakey Veterans Affairs Medical Center, Houston, TX, United States
| | - Jillian C Shipherd
- Lesbian, Gay, Bisexual, and Transgender Health Program, Office of Patient Care Services, Veterans Health Administration, Washington, DC, United States.,National Center for Posttraumatic Stress Disorder, Department of Veterans Affairs Boston Healthcare System, Boston, MA, United States.,Boston University School of Medicine, Boston, MA, United States
| | - Michael R Kauth
- Lesbian, Gay, Bisexual, and Transgender Health Program, Office of Patient Care Services, Veterans Health Administration, Washington, DC, United States.,South Central Mental Illness Research, Education and Clinical Center, Michael E DeBakey Veterans Affairs Medical Center, Houston, TX, United States.,Department of Psychiatry, Baylor College of Medicine, Houston, TX, United States
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83
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McQuillen DP, Schmitt SK. Declare the Past, Diagnose the Present, Foretell the Future: Electronic Consultations in Infectious Disease Practice. Clin Infect Dis 2018; 64:1126-1128. [PMID: 28158405 DOI: 10.1093/cid/cix062] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 01/20/2017] [Indexed: 11/14/2022] Open
Affiliation(s)
- Daniel P McQuillen
- Center for Infectious Diseases and Prevention, Lahey Hospital & Medical Center, Tufts University School of Medicine, Burlington, Massachusetts, USA
| | - Steven K Schmitt
- Department of Infectious Diseases, Medicine Institute, Cleveland Clinic, Ohio, USA
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Joschko J, Keely E, Grant R, Moroz I, Graveline M, Drimer N, Liddy C. Electronic Consultation Services Worldwide: Environmental Scan. J Med Internet Res 2018; 20:e11112. [PMID: 30578187 PMCID: PMC6320413 DOI: 10.2196/11112] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 07/18/2018] [Accepted: 07/18/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Excessive wait times for specialist care pose a serious concern for many patients, leading to duplication of tests, patient anxiety, and poorer health outcomes. In response to this issue, many health care systems have begun implementing technological innovations designed to improve the referral-consultation process. Among these services is electronic consultation (eConsult), which connects primary care providers and specialists through a secure platform to facilitate discussion of patients' care. OBJECTIVE This study aims to examine different eConsult services available worldwide and compare the strategies, barriers, and successes of their implementation in different health care contexts. METHODS We conducted an environmental scan comprising 3 stages as follows: literature review; gray literature search; and targeted, semistructured key informant interviews. We searched MEDLINE and EMBASE (literature review) and Google (gray literature search). Upon completing the search, we generated a list of potential interview candidates from among the stakeholders identified. Potential participants included researchers, physicians, and decision makers. The maximum variation sampling was used to ensure sufficient breadth of participant experience. In addition, we conducted semistructured interviews by telephone using an interview guide based on the RE-AIM framework. Analyses of transcripts were conducted using a thematic synthesis approach. RESULTS A total of 53 services emerged from the published and gray literature. Respondents from 10 services participated in telephonic interviews. The following 4 major themes emerged from the analysis: service structure; benefits of eConsult; implementation challenges; and implementation enablers. CONCLUSIONS eConsult services have emerged in a variety of countries and health system contexts worldwide. Despite differences in structure, platform, and delivery of their services, respondents described similar barriers and enablers to the implementation and growth and reported improved access and high levels of satisfaction.
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Affiliation(s)
- Justin Joschko
- CT Lamont Primary Health Care Research Centre, Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Erin Keely
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Division of Endocrinology/Metabolism, The Ottawa Hospital, Ottawa, ON, Canada
| | - Rachel Grant
- Faculty of Education, University of Ottawa, Ottawa, ON, Canada
| | - Isabella Moroz
- CT Lamont Primary Health Care Research Centre, Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | - Neil Drimer
- Canadian Foundation for Healthcare Improvement, Ottawa, ON, Canada
| | - Clare Liddy
- CT Lamont Primary Health Care Research Centre, Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada
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85
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Liddy C, Moroz I, Keely E, Taljaard M, Mark Fraser A, Deri Armstrong C, Afkham A, Kendall C. The use of electronic consultations is associated with lower specialist referral rates: a cross-sectional study using population-based health administrative data. Fam Pract 2018; 35:698-705. [PMID: 29635449 DOI: 10.1093/fampra/cmy020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The referral-consultation process can be difficult to navigate. Electronic consultations (eConsults) can help streamline referrals by facilitating inter-provider communication. OBJECTIVE We evaluated the potential effect of eConsult on specialist referral rates in Ontario among family physicians providing comprehensive care. METHODS We conducted a retrospective 1:3 matched cohort study examining total referrals and referrals to all available medical specialties from primary care providers between 1 April 2014 and 31 March 2015. We used multivariable random effects Poisson regression analysis to compare referral rates between eConsult and non-eConsult users while adjusting for relevant patient and provider characteristics. Referral rates were expressed per physician, per 100 patients and per 100 patient encounters. RESULTS There were 113197 referrals across all medical specialties made by 119 eConsult physicians and 352 matched controls. Referral rates per physician were significantly lower in the eConsult group for all specialty groupings [unadjusted rate ratio (RR) = 0.87, 95% confidence interval (CI) = 0.80-0.95; adjusted RR = 0.92, 95% CI = 0.85-1.00]. Referral rates per patient were lower among eConsult physicians (unadjusted RR = 0.91, 95% CI = 0.84-0.98) but this difference was not statistically significant after adjustment (adjusted RR = 0.96, 95% CI = 0.90-1.02). No statistically significant difference was observed when referrals were expressed per 100 patient encounters. CONCLUSION This is the first Canadian study to examine the potential effect of eConsult on overall referrals at a population level. Our findings demonstrate that using eConsult service is associated with fewer referrals from primary to specialist care, with considerable potential for cost savings to our single-payer system.
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Affiliation(s)
- Clare Liddy
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, Canada
| | - Isabella Moroz
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Erin Keely
- Department of Medicine, University of Ottawa, Ottawa, Canada.,Division of Endocrinology/Metabolism, The Ottawa Hospital, Ottawa, Canada
| | - Monica Taljaard
- Ottawa Hospital Research Institute, Ottawa, Canada.,School of Epidemiology, Public Health, and Preventive Medicine, University of Ottawa, Ottawa, Canada
| | - Amy Mark Fraser
- Ottawa Hospital Research Institute, Ottawa, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Canada
| | | | - Amir Afkham
- Enabling Technologies, Champlain Local Health Integration Network, Ottawa, Canada
| | - Claire Kendall
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, Canada
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86
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Tuot DS, Liddy C, Vimalananda VG, Pecina J, Murphy EJ, Keely E, Simon SR, North F, Orlander JD, Chen AH. Evaluating diverse electronic consultation programs with a common framework. BMC Health Serv Res 2018; 18:814. [PMID: 30355346 PMCID: PMC6201558 DOI: 10.1186/s12913-018-3626-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 10/15/2018] [Indexed: 11/17/2022] Open
Abstract
Background Electronic consultation is an emerging mode of specialty care delivery that allows primary care providers and their patients to obtain specialist expertise without an in-person visit. While studies of individual programs have demonstrated benefits related to timely access to specialty care, electronic consultation programs have not achieved widespread use in the United States. The lack of common evaluation metrics across health systems and concerns related to the generalizability of existing evaluation efforts may be hampering further growth. We sought to identify gaps in knowledge related to the implementation of electronic consultation programs and develop a set of shared evaluation measures to promote further diffusion. Methods Using a case study approach, we apply the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) and the Quadruple Aim frameworks of evaluation to examine electronic consultation implementation across diverse delivery systems. Data are from 4 early adopter healthcare delivery systems (San Francisco Health Network, Mayo Clinic, Veterans Administration, Champlain Local Health Integration Network) that represent varied organizational structures, care for different patient populations, and have well-established multi-specialty electronic consultation programs. Data sources include published and unpublished quantitative data from each electronic consultation database and qualitative data from systems’ end-users. Results Organizational drivers of electronic consultation implementation were similar across the systems (challenges with timely and/or efficient access to specialty care), though unique system-level facilitators and barriers influenced reach, adoption and design. Effectiveness of implementation was consistent, with improved patient access to timely, perceived high-quality specialty expertise with few negative consequences, garnering high satisfaction among end-users. Data about patient-specific clinical outcomes are lacking, as are policies that provide guidance on the legal implications of electronic consultation and ideal remuneration strategies. Conclusion A core set of effectiveness and implementation metrics rooted in the Quadruple Aim may promote data-driven improvements and further diffusion of successful electronic consultation programs. Electronic supplementary material The online version of this article (10.1186/s12913-018-3626-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Delphine S Tuot
- Center for Innovation in Access and Quality at Priscilla Chan and Mark Zuckerberg San Francisco General Hospital and Trauma Center, University of California San Francisco, San Francisco, CA, 94110, USA. .,Deparment of Medicine, University of California, San Francisco, San Francisco, CA, USA.
| | - Clare Liddy
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Varsha G Vimalananda
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Medical Center, Bedford, MA, USA.,Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Jennifer Pecina
- Department of Family Medicine, Mayo Clinic, Rochester, MN, USA
| | - Elizabeth J Murphy
- Center for Innovation in Access and Quality at Priscilla Chan and Mark Zuckerberg San Francisco General Hospital and Trauma Center, University of California San Francisco, San Francisco, CA, 94110, USA.,Deparment of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Erin Keely
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,The Ottawa Hospital, Ottawa, ON, Canada
| | - Steven R Simon
- Harvard Medical School, Boston, USA.,VA Boston Healthcare System, Boston, USA
| | - Frederick North
- Department of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jay D Orlander
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA.,VA Boston Healthcare System, Boston, USA
| | - Alice Hm Chen
- Center for Innovation in Access and Quality at Priscilla Chan and Mark Zuckerberg San Francisco General Hospital and Trauma Center, University of California San Francisco, San Francisco, CA, 94110, USA.,Deparment of Medicine, University of California, San Francisco, San Francisco, CA, USA
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87
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Osman MA, Schick-Makaroff K, Thompson S, Featherstone R, Bialy L, Kurzawa J, Okpechi IG, Habib S, Shojai S, Jindal K, Klarenbach S, Bello AK. Barriers and facilitators for implementation of electronic consultations (eConsult) to enhance specialist access to care: a scoping review protocol. BMJ Open 2018; 8:e022733. [PMID: 30269069 PMCID: PMC6169744 DOI: 10.1136/bmjopen-2018-022733] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
INTRODUCTION Electronic consultations (eConsult), asynchronous exchanges of patient health information at a distance, are increasingly used as an option to facilitate patient care and collaboration between primary care providers and specialists. Although eConsult has demonstrated success in increasing efficiency in the referral process and enhancing access to care, little is known about the factors influencing its wider adoption and implementation by end users. In this paper, we describe a protocol to conduct a scoping review of the literature on the barriers and facilitators to a wider adoption and implementation of eConsult service. METHODS AND ANALYSIS This scoping review will be based on the framework pioneered by Arksey and O'Malley and later developed by Levac et al. We will use the guidance for scoping reviews developed by the Joanna Briggs Institute to report our findings. In addition to several electronic databases (Medline, Embase, Cochrane Library, CINAHL, EBSCOhost and PsycINFO) studies will be identified by including relevant grey literature. Two reviewers will independently screen titles and full texts for inclusion. Studies reporting on barriers and/or facilitators in settings similar to eConsult will be included. Data on study characteristics and key barriers and facilitators will be extracted. Data will be analysed thematically and classified using the Quadruple Aim framework. ETHICS AND DISSEMINATION Approval by research ethics board is not required since the review will only include published and publicly accessible data. Review findings will be used to inform future studies and the development of practice tools to support the wider adoption and success of eConsult implementation. We plan to publish our findings in a peer-reviewed journal and develop a useful and accessible summary of the results.
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Affiliation(s)
- Mohamed A Osman
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Stephanie Thompson
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Robin Featherstone
- Alberta SPOR SUPPORT Unit KT Platform, Edmonton, Alberta, Canada
- Alberta Research Centre for Health Evidence, University of Alberta, Edmonton, Alberta, Canada
| | - Liza Bialy
- Alberta SPOR SUPPORT Unit KT Platform, Edmonton, Alberta, Canada
- Alberta Research Centre for Health Evidence, University of Alberta, Edmonton, Alberta, Canada
| | - Julia Kurzawa
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Ikechi G Okpechi
- Division of Nephrology and Hypertension, University of Cape Town, Cape Town, South Africa
| | - Syed Habib
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Soroush Shojai
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Kailash Jindal
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Scott Klarenbach
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Aminu K Bello
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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88
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Olayiwola JN, Knox M, Dubé K, Lu EC, Woldeyesus T, James IE, Willard‐Grace R, Tuot D. Understanding the Potential for Patient Engagement in Electronic Consultation and Referral Systems: Lessons From One Safety Net System. Health Serv Res 2018; 53:2483-2502. [PMID: 28940495 PMCID: PMC6051985 DOI: 10.1111/1475-6773.12776] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE To understand patient, primary care clinician (PCC), and subspecialist perspectives on potential, unexplored roles for patients in electronic consultation and referral (eCR) systems. DATA SOURCES Primary focus group and survey data collected April-November 2015. Zuckerberg San Francisco General Hospital (ZSFG) is part of an integrated public health delivery system. Its mature eCR system was first implemented in 2005. STUDY DESIGN This mixed-methods study synthesizes patient, subspecialist, and PCC perspectives through two patient focus groups in English, Spanish, and Cantonese (n = 6); subspecialist focus groups (n = 2); and an electronic survey of all PCCs (n = 222/634, 35 percent response). DATA COLLECTION/EXTRACTION METHODS Focus groups were audio-recorded and transcribed. Two researchers coded the transcripts to identify recurrent themes. Survey data were analyzed using summary and bivariate statistics. PRINCIPAL FINDINGS Patients expressed minimal desire to directly engage in eCR, instead of emphasizing their PCC's role in advocating, informing, and finding health solutions. Subspecialists requested more consistent communication to patients about the electronic consultation process. Most PCCs (52 percent) supported patient engagement in the eCR process, particularly patient ability to track consult status and securely message with subspecialists. CONCLUSIONS Results suggest a continuum of opportunities for patients and their caregivers to engage in eCR systems.
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Affiliation(s)
- Jacqueline Nwando Olayiwola
- Center for Excellence in Primary CareDepartment of Family & Community MedicineUniversity of CaliforniaSan FranciscoCA94110
| | - Margae Knox
- Center for Excellence in Primary CareDepartment of Family & Community MedicineUniversity of CaliforniaSan FranciscoCA94110
| | - Kate Dubé
- University of California, BerkeleyBerkeleyCA
| | - Emily Chen‐Yuan Lu
- Department of Family & Community MedicineUniversity of California, San FranciscoSan FranciscoCA
| | - Tem Woldeyesus
- Department of Family & Community MedicineUniversity of California, San FranciscoSan FranciscoCA
| | - Iguehi E. James
- Division of EndocrinologyZuckerberg San Francisco General HospitalCenter for Innovation in Access and QualityUniversity of California, San FranciscoSan FranciscoCA
| | - Rachel Willard‐Grace
- Center for Excellence in Primary CareDepartment of Family & Community MedicineUniversity of CaliforniaSan FranciscoCA94110
| | - Delphine Tuot
- Division of NephrologyeReferral at Zuckerberg San Francisco General Hospital (ZSFG)Center for Innovation in Access and Quality at ZSFGUCSF Center for Vulnerable Populations at ZSFGUniversity of California, San FranciscoSan FranciscoCA
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89
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Shaw S, Wherton J, Vijayaraghavan S, Morris J, Bhattacharya S, Hanson P, Campbell-Richards D, Ramoutar S, Collard A, Hodkinson I, Greenhalgh T. Advantages and limitations of virtual online consultations in a NHS acute trust: the VOCAL mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2018. [DOI: 10.3310/hsdr06210] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BackgroundThere is much enthusiasm from clinicians, industry and the government to utilise digital technologies and introduce alternatives to face-to-face consultations.Objective(s)To define good practice and inform digital technology implementation in relation to remote consultations via Skype™ (Microsoft Corporation, Redmond, WA, USA) and similar technologies.DesignMultilevel mixed-methods study of remote video consultations (micro level) embedded in an organisational case study (meso level), taking account of the national context and wider influences (macro level).SettingThree contrasting clinical settings (Diabetes, Antenatal Diabetes and Cancer Surgery) in a NHS acute trust.Data collection and analysisMacro level – interviews with 12 national-level stakeholders combined with document analysis. Meso level – longitudinal organisational ethnography comprising over 300 hours of observations, 24 staff interviews and analysis of 16 documents. Micro level – 30 video-recorded remote consultations; 17 matched audio-recorded face-to-face consultations. Interview and ethnographic data were analysed thematically and theorised using strong structuration theory. Consultations were transcribed verbatim and analysed using the Roter interaction analysis system (RIAS), producing descriptive statistics on different kinds of talk and interaction.ResultsPolicy-makers viewed remote video consultations as a way of delivering health care efficiently in the context of rising rates of chronic illness and growing demand for services. However, the reality of establishing such services in a busy and financially stretched NHS acute trust proved to be far more complex and expensive than anticipated. Embedding new models of care took much time and many resources, and required multiple workarounds. Considerable ongoing effort was needed to adapt and align structures, processes and people within clinics and across the organisation. For practical and safety reasons, virtual consultations were not appropriate for every patient or every consultation. By the end of this study, between 2% and 20% of all consultations were being undertaken remotely in participating clinics. Technical challenges in setting up such consultations were typically minor, but potentially prohibitive. When clinical, technical and practical preconditions were met, virtual consultations appeared to be safe and were popular with both patients and staff. Compared with face-to-face consultations, virtual consultations were very slightly shorter, patients did slightly more talking and both parties sometimes needed to make explicit things that typically remained implicit in a traditional encounter. Virtual consultations appeared to work better when the clinician and the patient knew and trusted each other. Some clinicians used Skype adaptively to support ad hoc clinician-initiated and spontaneous patient-initiated encounters. Other clinicians chose not to use the new service model at all.ConclusionsVirtual consultations appear to be safe, effective and convenient for patients who are preselected by their clinicians as ‘suitable’, but such patients represent a small fraction of clinic workloads. There are complex challenges to embedding virtual consultation services within routine practice in the NHS. Roll-out (across the organisation) and scale-up (to other organisations) are likely to require considerable support.LimitationsThe focus on a single NHS organisation raises questions about the transferability of findings, especially quantitative data on likely uptake rates.Future researchFurther studies on the micro-analysis of virtual consultations and on the spread and scale-up of virtual consulting services are planned.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Sara Shaw
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Joseph Wherton
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | | | | | | | | | | | | | | | - Trisha Greenhalgh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Lee MS, Ray KN, Mehrotra A, Giboney P, Yee HF, Barnett ML. Primary Care Practitioners' Perceptions of Electronic Consult Systems: A Qualitative Analysis. JAMA Intern Med 2018; 178:782-789. [PMID: 29801079 PMCID: PMC6145753 DOI: 10.1001/jamainternmed.2018.0738] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Safety-net health systems across the country are implementing electronic consult (eConsult) systems in which primary care practitioners (PCPs) submit all requests for specialty assistance electronically to be reviewed and discussed with specialists. Evidence suggests that eConsult systems can make significant improvements in specialty access, but the outcomes of these systems for frontline PCPs is poorly understood. OBJECTIVE To understand PCP perceptions of the results of eConsult initiation on PCP workflow, specialist access, and patient care. DESIGN, SETTING, AND PARTICIPANTS Qualitative interviews were conducted from December 1, 2016, to April 15, 2017, with 40 safety-net PCPs in Los Angeles County who use the Los Angeles County Department of Health Services (DHS) eConsult system. Interviewees were recruited to include diversity in PCP type, practice setting, and employer (DHS employed vs DHS affiliated). Participants were interviewed about their perceptions of clinical workflow, access to specialists, relationships with specialists, and referral decision making. MAIN OUTCOMES AND MEASURES Perceptions of the results of eConsult, including positive and negative themes and remaining perceived gaps in specialty care. RESULTS Of the 40 participants, 27 (68%) were women; 24 (60%) PCPs performed 5 or more eConsults per week. Primary care practitioners' perceptions of eConsult clustered around 4 main themes: access and timeliness of specialty care, shift of work to PCPs, relationships with specialists, and eConsult interface issues. Many PCPs praised the improved timeliness of specialist input with eConsult, as well as the added clinical and educational value of dialogue with specialists, particularly compared with the limitations of the prior referral process. However, PCPs also consistently perceived that eConsult shifted some of the work of specialty care to them. Many PCPs believed that this extra burden was worth the effort given the benefits of eConsult, such as improved timeliness of care and ability to manage specialty conditions. In contrast, others were frustrated by the increased administrative burden, broadened clinical responsibility, and restructuring of specialty care delivery. CONCLUSIONS AND RELEVANCE While associated with improved specialty care access, eConsult systems simultaneously created new challenges for PCPs, such as an increased burden of work in providing specialty care. Primary care practitioners varied in their enthusiasm for these workflow changes with diverging perceptions of the same processes. Our findings provide insights on challenges future primary care transformation efforts may face.
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Affiliation(s)
- Michelle S Lee
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Kristin N Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Paul Giboney
- Los Angeles County Department of Health Services, Los Angeles, California
| | - Hal F Yee
- Los Angeles County Department of Health Services, Los Angeles, California
| | - Michael L Barnett
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
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91
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Keely E, Canning S, Saloojee N, Afkham A, Liddy C. Improving Access to Gastroenterologist Using eConsultation: A Way to Potentially Shorten Wait Times. J Can Assoc Gastroenterol 2018; 1:124-128. [PMID: 31294353 PMCID: PMC6507275 DOI: 10.1093/jcag/gwy017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background Wait times for gastroenterologists in Canada continue to exceed recommended targets. Electronic consultation (eConsult) may reduce the need for face-to-face gastroenterologist visits. Objective The goal of this study was to identify the cases submitted to gastroenterologists though the Champlain BASE™ (Building Access to Specialists through eConsultation) eConsult service and explore their impact on primary care physicians' (PCPs) courses of action. Methods Gastroenterology cases submitted between June 2013 and January 2015 were categorized using a modification of the International Classification for Primary Care (ICPC-2) taxonomy. Question type (e.g., diagnosis or management) was classified using a validated taxonomy. Results Of the 121 gastroenterology consults reviewed, 33% were related to hepatology, 23% to GI symptoms, and 13% to specific luminal diseases. Among hepatology eConsults (n=40), 47% pertained to abnormal liver function testing. Overall, 51% of eConsults were related to diagnosis, 30% to management, 9% to drug treatments and 7% to procedures. PCPs received a reply within a median of 2.9 days. Only 25% of cases resulted in a face-to-face referral. Conclusions The eConsult service provided timely, highly regarded advice from gastroenterologists directly to PCPs and often eliminated the need for a face-to-face consultation. An evaluation of the most commonly-posed questions could inform future continuing medical education activities for PCPs.
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Affiliation(s)
- Erin Keely
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa Ontario, Canada
| | - Stephanie Canning
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Nav Saloojee
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Amir Afkham
- The Champlain Local Health Integration Network, Ottawa, Ontario, Canada
| | - Clare Liddy
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada.,Department of Family Medicine University of Ottawa, Ottawa, Ontario, Canada
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Archibald D, Stratton J, Liddy C, Grant RE, Green D, Keely EJ. Evaluation of an electronic consultation service in psychiatry for primary care providers. BMC Psychiatry 2018; 18:119. [PMID: 29720133 PMCID: PMC5932827 DOI: 10.1186/s12888-018-1701-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 04/23/2018] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND This study explores the effectiveness of an electronic consultation (eConsult) service between primary care providers and psychiatry, and the types and content of the clinical questions that were asked. METHODS This is a retrospective eConsult review study. All eConsults directed to Psychiatry from July 2011 to January 2015 by Primary care providers were reviewed. Response time and the amount of time reported by the specialist to answer each eConsult was analyzed. Each eConsult was also categorized by clinical topic and question type in predetermined categories. Mandatory post-eConsult surveys for primary care providers were analyzed to determine the number of traditional consults avoided and to gain insight into the perceived value of eConsults. RESULTS Of the 5597 eConsults, 169 psychiatry eConsults were completed during the study period. The average response time for a specialist to a primary care provider was 2.3 days. Eighty-seven percent of clinical responses were completed by the psychiatrist in less than 15 min. The primary care providers most commonly asked clinical questions were about depressive and anxiety disorders. 88.7% of PCPs rated the eConsult service a 5 (excellent value) or 4. CONCLUSIONS This study indicates that an eConsult psychiatry service has tremendous potential to improve access to psychiatric advice and expand the capacity to treat mental illness in primary care. Future research may include follow-up with PCPs regarding the implementation of specialist advice.
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Affiliation(s)
- Douglas Archibald
- Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada. .,Bruyère Research Institute, 85 Primrose Avenue, Ottawa, ON, K1R 6M1, Canada.
| | - Julia Stratton
- 0000 0001 2182 2255grid.28046.38Department of Psychiatry, University of Ottawa, Ottawa, ON Canada
| | - Clare Liddy
- 0000 0001 2182 2255grid.28046.38Department of Family Medicine, University of Ottawa, Ottawa, ON Canada ,0000 0000 9064 3333grid.418792.1Bruyère Research Institute, 85 Primrose Avenue, Ottawa, ON K1R 6M1 Canada
| | - Rachel E. Grant
- 0000 0001 2182 2255grid.28046.38Faculty of Education, University of Ottawa, Ottawa, ON Canada
| | - Douglas Green
- 0000 0001 2182 2255grid.28046.38Department of Psychiatry, University of Ottawa, Ottawa, ON Canada
| | - Erin J. Keely
- 0000 0001 2182 2255grid.28046.38Department of Medicine, University of Ottawa, Ottawa, ON Canada ,0000 0000 9606 5108grid.412687.eOttawa Hospital Research Institute, Ottawa, ON Canada
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93
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Barnett ML, Yee HF, Mehrotra A, Giboney P. Los Angeles Safety-Net Program eConsult System Was Rapidly Adopted And Decreased Wait Times To See Specialists. Health Aff (Millwood) 2018; 36:492-499. [PMID: 28264951 DOI: 10.1377/hlthaff.2016.1283] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Lack of timely access to specialty care is a significant problem among disadvantaged populations, such as those served by the Los Angeles County Department of Health Services. In 2012 the department implemented an electronic system for the provision of specialty care called the eConsult system, in which all requests from primary care providers for specialty assistance were reviewed by specialists. In many cases, the specialist can address the primary care provider's question via an electronic dialogue, thereby eliminating the need for the patient to see a specialist in person. We observed rapid growth in the use of eConsult: By 2015 the system was in use by over 3,000 primary care providers, and 12,082 consultations were taking place per month, compared to 86 in the third quarter of 2012. The median time to an electronic response from a specialist was one day, and 25 percent of eConsults were resolved without a specialist visit. Three to four years after implementation, the median time to a specialist appointment decreased significantly, while the volume of visits remained stable. eConsult systems are a promising and sustainable intervention that could improve access to specialist care for underserved patients.
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Affiliation(s)
- Michael L Barnett
- Michael L. Barnett is an assistant professor of health policy and management at the Harvard T. H. Chan School of Public Health and an instructor in the Division of General Medicine and Primary Care at Brigham and Women's Hospital, both in Boston, Massachusetts
| | - Hal F Yee
- Hal F. Yee Jr. is chief medical officer at the Los Angeles County Department of Health Services, in Los Angeles, California
| | - Ateev Mehrotra
- Ateev Mehrotra is an associate professor of health care policy at Harvard Medical School, in Boston
| | - Paul Giboney
- Paul Giboney is director of specialty care at the Los Angeles County Department of Health Services
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Abstract
PURPOSE Excessive wait times for specialist appointments pose a serious barrier to patient care. To improve access to specialist care and reduce wait times, we launched the Champlain BASE (Building Access to Specialists through eConsultation) eConsult service in April 2011. The objective of this study is to report on the impact of our multiple specialty eConsult service during the first 5 years of use after implementation, with a focus on growth and sustainability. METHODS We conducted a cross-sectional study of all eConsult cases submitted between April 1, 2011 and April 30, 2016, and measured impact with system utilization data and mandatory close-out surveys completed at the end of each eConsult. Impact indicators included time interval to obtain specialist advice, effect of specialist advice on the primary care clinician's course of action, and rate of avoidance of face-to-face visits. RESULTS A total of 14,105 eConsult cases were directed to 56 different medical specialty groups, completed with a median response time of 21 hours, and 65% of all eConsults were resolved without a specialist visit. We observed rapid growth in the use of eConsult during the study period: 5 years after implementation the system was in use by 1,020 primary care clinicians, with more than 700 consultations taking place per month. CONCLUSIONS This study presents the first in-depth look at the growth and sustainability of the multispecialty eConsult service. The results show the positive impact of an eConsult service and can inform other regions interested in implementing similar systems.
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Affiliation(s)
- Clare Liddy
- CT Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada .,Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Isabella Moroz
- CT Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Amir Afkham
- The Champlain Local Health Integration Network, Ottawa, Ontario, Canada
| | - Erin Keely
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Division of Endocrinology/Metabolism, The Ottawa Hospital, Ottawa, Ontario, Canada
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Keely E, Li J, Magner P, Afkham A, Liddy C. Nephrology eConsults for Primary Care Providers: Original Investigation. Can J Kidney Health Dis 2018; 5:2054358117753619. [PMID: 29399366 PMCID: PMC5788130 DOI: 10.1177/2054358117753619] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 10/09/2017] [Indexed: 11/25/2022] Open
Abstract
Background: The Champlain BASE™ (Building Access to Specialists through eConsultation) eConsult service allows primary care providers (PCPs) to submit patient-specific clinical questions to specialists via a secure web service. Objective: Our objective was to describe the types of nephrology questions asked through an eConsult service based in eastern Ontario and assess the service’s impact on the need for face-to-face consultations. Design: Cross-sectional study using descriptive statistics was conducted using nephrology cases submitted between May 2011 and January 2015. Specialist response times and referral avoidance were collected. Validated taxonomies were used to categorize cases based on question type and content. Setting: Patient cases were collected from PCPs in Ottawa, Ontario, and its surrounding communities and submitted to nephrologists at the Ottawa Hospital. Patients: During the study period, 155 eConsults were submitted to nephrology. Measurement: Utilization and survey data were collected for all eConsults. Questions were categorized by subject matter and question type. Results: A traditional consult visit was avoided in 45% of cases based on the specialist’s advice; 21% cases required referral. Thirty-two percent of eConsults took specialists less than 10 minutes to complete, 55% took 10 to 15 minutes, 11% took 15 to 20 minutes, and only 2% took more than 20 minutes. Twenty-five percent of cases were related to proteinuria, 18% to chronic kidney disease (CKD), 17% to imaging, and 12% to drug use in CKD. Common question types included general management (37%), interpretation of laboratory test (17%), interpretation of an image report (13%), and need for nephrology referral (11%). Limitations: Some consults contained multiple categories and question types. Our analyses required a single classification, which may underestimate the number of questions in each category. Our study had a small sample size using cases completed in a single health jurisdiction, limiting generalizability. Conclusions: The Champlain BASE™ eConsult service provided guidance to PCPs and reduced the number of face-to-face nephrology consultations.
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Affiliation(s)
- Erin Keely
- Department of Medicine, University of Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ontario, Canada
| | - Jennifer Li
- Faculty of Medicine, University of Ottawa, Ontario, Canada
| | - Peter Magner
- Department of Medicine, University of Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ontario, Canada
| | - Amir Afkham
- Champlain Local Health Integration Network, Ottawa, Ontario, Canada
| | - Clare Liddy
- Department of Family Medicine, University of Ottawa, Ontario, Canada.,Bruyere Research Institute, University of Ottawa, Ontario, Canada
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Joschko J, Liddy C, Moroz I, Reiche M, Crowe L, Afkham A, Keely E. Just a click away: exploring patients' perspectives on receiving care through the Champlain BASETM eConsult service. Fam Pract 2018; 35:93-98. [PMID: 28968806 DOI: 10.1093/fampra/cmx073] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Excessive wait times for specialist care can have a substantial negative impact on health outcomes. The Champlain BASETM (Building Access to Specialists through eConsultation) eConsult service based in Ottawa, Canada has demonstrated the ability to improve patients' access to specialist care. OBJECTIVE We interviewed patients who were treated using eConsult in order to explore their attitudes towards the service and their experiences of receiving care via the service. METHODS We conducted a thematic analysis of patient interviews using a constant comparative approach. Patients whose primary care providers used the eConsult service in their care were contacted by telephone between June 2015 and January 2016 and completed 15-min semi-structured interviews. RESULTS Of 43 contacted participants, 30 completed interviews (70%). Over half of all respondents (n = 16) reported receiving a follow-up call or appointment within 1 week, and 26 stated that eConsult was useful in their case. Participants unanimously agreed that eConsult was an acceptable way to access specialist care, and 29 stated that they would ask their primary care provider to use eConsult on their behalf in the future. Three themes emerged from the thematic analysis of patient comments: access, acceptability of eConsult and strengthened role of the primary care provider. CONCLUSIONS Patients expressed acceptance for eConsult as a model for improving access to specialist care, had largely positive experiences with it as a model of care delivery, and supported its use in their future care.
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Affiliation(s)
- Justin Joschko
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada
| | - Clare Liddy
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Isabella Moroz
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada
| | - Marnie Reiche
- Winchester District Memorial Hospital, Ottawa, ON, Canada
| | - Lois Crowe
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada
| | - Amir Afkham
- Winchester District Memorial Hospital, Ottawa, ON, Canada.,The Champlain Local Health Integration Network, Ottawa, ON, Canada
| | - Erin Keely
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Division of Endocrinology/Metabolism, The Ottawa Hospital, Ottawa, ON, Canada
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Archibald D, Liddy C, Lochnan HA, Hendry PJ, Keely EJ. Using Clinical Questions Asked by Primary Care Providers Through eConsults to Inform Continuing Professional Development. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2018; 38:41-48. [PMID: 29351133 DOI: 10.1097/ceh.0000000000000187] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
INTRODUCTION Continuing professional development (CPD) offerings should address the educational needs of health care providers. Innovative programs, such as electronic consultations (eConsults), provide unique educational opportunities for practice-based needs assessment. The purpose of this study is to assess whether CPD offerings match the needs of physicians by coding and comparing session content to clinical questions asked through eConsults. METHODS This study analyzes questions asked by primary care providers between July 2011 and January 2015 using a service that allows specialists to provide consultation over a secure web-based server. The content of these questions was compared with the CPD courses offered in the area in which these primary care providers are practicing over a similar period (2012-2014). The clinical questions were categorized by the content area. The percentage of questions asked about each content area was calculated for each of the 12 specialties consulted. CPD course offerings were categorized using the same list of content areas. Percentage of minutes dedicated to each content area was calculated for each specialty. The percentage of questions asked and the percentage of CPD course minutes for each content area were compared. RESULTS There were numerous congruencies and discrepancies between the proportion of questions asked about a given content area and the CPD minutes dedicated to it. DISCUSSION Traditional needs assessment may underestimate the need to address topics that are frequently the subject of eConsults. Planners should recognize eConsult questions as a valuable source of practice-associated challenges that can identify professional development needs of physicians.
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Affiliation(s)
- Douglas Archibald
- Dr. Archibald: Assistant Professor, CT Lamont Primary Health Care Research Centre, Department of Family Medicine, University of Ottawa; Bruyère Research Institute, Ottawa, Ontario, Canada. Dr. Liddy: Associate Professor, CT Lamont Primary Health Care Research Centre, Department of Family Medicine, University of Ottawa; Bruyère Research Institute, Ottawa, Ontario, Canada. Dr. Lochnan: Associate Professor, Department of Medicine, University of Ottawa; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada. Dr. Hendry: Professor, Department of Surgery, University of Ottawa; University of Ottawa Heart Institute, Ottawa, Ontario, Canada. Dr. Keely: Professor, Department of Medicine, University of Ottawa; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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98
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The use of eConsults to improve access to specialty care in thrombosis medicine. Thromb Res 2017; 160:105-108. [PMID: 29145030 DOI: 10.1016/j.thromres.2017.11.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 10/25/2017] [Accepted: 11/06/2017] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Electronic consultations (eConsults) are asynchronous, consultative electronic-based communications that are aimed to improve efficient and timely access to specialist advice. Our study aim was to evaluate the use and impact of the Canadian Champlain BASE™ (Building Access to Specialists through eConsultation) eConsult service in the specialty of thrombosis medicine. METHODS We conducted a cross-sectional study that included descriptive statistics of provider and patient demographic information and consultative-specific data. The impact of eConsults on primary care provider (PCP) referral patterns and satisfaction was assessed using a mandatory close-out survey upon completion of each eConsult. RESULTS There were 162 thrombosis eConsult cases completed between June 2012 and March 2016. The most common referral topics were for thrombophilia testing, management of superficial vein thrombosis, and the choice and duration of anticoagulation for venous thromboembolism. By completing an eConsult, PCPs reported 47.5% of face-to-face consultations were avoided, and 4.3% prompted a thrombosis referral that was not originally contemplated. Primary care providers' responses to a thrombosis eConsult service were overwhelmingly positive, which included appreciation for timely access for patients, expert guidance and providing additional educational opportunities. CONCLUSION An eConsult service in thrombosis medicine improved timely access to specialist advice and potentially reduces the number of face-to-face consultations needed. Further research is needed to understand how a thrombosis eConsult service affects thrombosis clinic performance data and patient outcomes.
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Parikh PJ, Mowrey C, Gallimore J, Harrell S, Burke B. Evaluating e-consultation implementations based on use and time-line across various specialties. Int J Med Inform 2017; 108:42-48. [PMID: 29132630 DOI: 10.1016/j.ijmedinf.2017.09.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Revised: 09/05/2017] [Accepted: 09/14/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Electronic Consultation (e-consults) can provide improved access, enhance patient and provider satisfaction, and reduce beneficiary travel expenses. We explored how e-consults were implemented across three specialty areas, diabetes (Diab), gastroenterology (GI), and neurosurgery (Neuro), at two Veterans Affairs hospitals in terms of strategies for use and time-lines. METHODS We conducted observations and electronically shadowed patient e-consultations submitted to a specialty care service by primary care provider(s) at the two sites during a thirteen-month period. We divided the e-consult process in each specialty into three broad milestones; Request (from primary to specialty), Response (from specialty back to primary), and Follow up (from primary to patient), and recorded the flow and time in each category. An overall hierarchy of e-consults was developed to illustrate the many ways an e-consult was used. The Kolmogorov-Smirnov test was used to compare the distribution of time across specialties. RESULTS A total of 394 consults submitted between April 14, 2012 and May 2, 2013 were reviewed (Diab=152, GI=169, Neuro=73). Of the 152 diabetes specialty clinic e-consults, 35% required some sort of direct contact with the patient by the specialty clinic before a recommendation was provided. Overall, 58% of the e-consults were completed within 20days, while 68% were completed within 30days. The Response times between Diab and GI were significantly different (median=0 vs. 3days; p<0.0001) and so were Follow up times (median=0 vs. 4days; p<0.0001). All three stages were statistically different between Diab and Neuro; however, there was not enough evidence to suggest any differences between GI and Neuro. CONCLUSIONS The use of an e-consult is likely to vary based on the specialty, but the often significant variations in time may continue to hinder prompt access to care. E-consult design, implementation, documentation, training, self-learning, and monitoring should be tailored to get the most benefit out of this system.
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Affiliation(s)
- Pratik J Parikh
- Dept of Biomedical, Industrial and Human Factors Engineering, Wright State University, Dayton, OH, United States; Dept of Surgery, Wright State University, Dayton, OH, United States.
| | - Corinne Mowrey
- Dept of Biomedical, Industrial and Human Factors Engineering, Wright State University, Dayton, OH, United States.
| | - Jennie Gallimore
- Dept of Biomedical, Industrial and Human Factors Engineering, Wright State University, Dayton, OH, United States; Dept of Surgery, Wright State University, Dayton, OH, United States.
| | - Stephen Harrell
- Dept of Biomedical, Industrial and Human Factors Engineering, Wright State University, Dayton, OH, United States.
| | - Brian Burke
- Dayton Veterans Affairs Medical Center, Dayton, OH, United States; Dept of Internal Medicine, Wright State University, Dayton, OH, United States.
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Liddy C, Arbab-Tafti S, Moroz I, Keely E. Primary care physician referral patterns in Ontario, Canada: a descriptive analysis of self-reported referral data. BMC FAMILY PRACTICE 2017; 18:81. [PMID: 28830380 PMCID: PMC5567435 DOI: 10.1186/s12875-017-0654-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 08/09/2017] [Indexed: 01/16/2023]
Abstract
Background In many countries, the referral-consultation process faces a number of challenges from inefficiencies and rising demand, resulting in excessive wait times for many specialties. We collected referral data from a sample of family doctors across the province of Ontario, Canada as part of a larger program of research. The purpose of this study is to describe referral patterns from primary care to specialist and allied health services from the primary care perspective. Methods We conducted a prospective study of patient referral data submitted by primary care providers (PCP) from 20 clinics across Ontario between June 2014 and January 2016. Monthly referral volumes expressed as a total number of referrals to all medical and allied health professionals per month. For each referral, we also collected data on the specialty type, reason for referral, and whether the referral was for a procedure. Results PCPs submitted a median of 26 referrals per month (interquartile range 11.5 to 31.8). Of 9509 referrals eligible for analysis, 97.8% were directed to medical professionals and 2.2% to allied health professionals. 55% of medical referrals were directed to non-surgical specialties and 44.8% to surgical specialties. Medical referrals were for procedures in 30.8% of cases and non-procedural in 40.9%. Gastroenterology received the largest share (11.2%) of medical referrals, of which 62.3% were for colonoscopies. Psychology received the largest share (28.3%) of referrals to allied health professionals. Conclusion We described patterns of patient referral from primary care to specialist and allied health services for 30 PCPs in 20 clinics across Ontario. Gastroenterology received the largest share of referrals, nearly two-thirds of which were for colonoscopies. Future studies should explore the use of virtual care to help manage non-procedural referrals and examine the impact that procedural referrals have on wait times for gastroenterology. Electronic supplementary material The online version of this article (doi:10.1186/s12875-017-0654-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Clare Liddy
- C.T. Lamont Primary Healthcare Research Centre, Bruyère Research Institute, 43 Bruyere St, Annex E, Room 106, Ottawa, ON, K1N 5C8, Canada. .,Department of Family Medicine, University of Ottawa, 75 Laurier Ave E, Ottawa, ON, Canada.
| | - Sadaf Arbab-Tafti
- Faculty of Medicine, University of Ottawa, 75 Laurier Ave E, Ottawa, ON, Canada
| | - Isabella Moroz
- C.T. Lamont Primary Healthcare Research Centre, Bruyère Research Institute, 43 Bruyere St, Annex E, Room 106, Ottawa, ON, K1N 5C8, Canada
| | - Erin Keely
- Department of Medicine, University of Ottawa, 75 Laurier Ave E, Ottawa, ON, Canada.,Division of Endocrinology/Metabolism, The Ottawa Hospital, 1967 Riverside Drive, Ottawa, ON, Canada
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