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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: 15] [Impact Index Per Article: 2.1] [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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Witherspoon L, Liddy C, Afkham A, Keely E, Mahoney J. Improving access to urologists through an electronic consultation service. Can Urol Assoc J 2017; 11:270-274. [PMID: 28798830 DOI: 10.5489/cuaj.4314] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Access to specialist services is limited by wait times and geographic availability. Champlain Building Access to Specialist Advice (BASE) has been implemented in our service region to facilitate access to specialists by primary care providers (PCPs). Through a secure web-based system, PCPs are able to send eConsults instead of requesting a formal in-office consultation. METHODS Urology eConsults completed through the Champlain BASE service from March 2013 to January 2015 were analyzed. Each consult was characterized in regard to the type of question asked by the referring physician and the clinical content of the referral. Using the mandatory close-out surveys, we analyzed rates of referral avoidance, physician satisfaction, and overall impact on patient care. RESULTS Of 190 eConsultations, 70% were completed in less than 10 minutes. The most common clinical questions related to the interpretation of imaging reports (16%) and tests to choose for investigating a condition (15%). The most common diagnoses were hematuria (13%) and renal mass (8%). In 35% of cases, referral to a urologist had originally been contemplated and was avoided. In 8% of cases, a PCP did not believe a consultation was initially needed, but a referral was ultimately initiated after the eConsultation. CONCLUSIONS Our study shows that although certain clinical presentations still require a formal in-person urological consultation, eConsultations can potentially reduce unnecessary clinic visits while identifying patients who may benefit from early urological consultation. Through both these mechanisms, we may improve timely access to urologists.
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Affiliation(s)
| | - Clare Liddy
- Department of Family Medicine, University of Ottawa and C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute; Ottawa, ON, Canada
| | | | - Erin Keely
- Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute; Ottawa, ON, Canada
| | - John Mahoney
- Department of Urology, University of Ottawa; Ottawa, ON, Canada
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105
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Lowenstein M, Bamgbose O, Gleason N, Feldman MD. Psychiatric Consultation at Your Fingertips: Descriptive Analysis of Electronic Consultation From Primary Care to Psychiatry. J Med Internet Res 2017; 19:e279. [PMID: 28778852 PMCID: PMC5562932 DOI: 10.2196/jmir.7921] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 07/12/2017] [Accepted: 07/13/2017] [Indexed: 11/13/2022] Open
Abstract
Background Mental health problems are commonly encountered in primary care, with primary care providers (PCPs) experiencing challenges referring patients to specialty mental health care. Electronic consultation (eConsult) is one model that has been shown to improve timely access to subspecialty care in a number of medical subspecialties. eConsults generally involve a PCP-initiated referral for specialty consultation for a clinical question that is outside their expertise but may not require an in-person evaluation. Objective Our aim was to describe the implementation of eConsults for psychiatry in a large academic health system. Methods We performed a content analysis of the first 50 eConsults to psychiatry after program implementation. For each question and response, we coded consults as pertaining to diagnosis and/or management as well as categories of medication choice, drug side effects or interactions, and queries about referrals and navigating the health care system. We also performed a chart review to evaluate the timeliness of psychiatrist responses and PCP implementation of recommendations. Results Depression was the most common consult template selected by PCPs (20/50, 40%), followed by the generic template (12/50, 24%) and anxiety (8/50, 16%). Most questions (49/50, 98%) pertained primarily to management, particularly for medications. Psychiatrists commented on both diagnosis (28/50, 56%) and management (50/50, 100%), responded in an average of 1.4 days, and recommended in-person consultation for 26% (13/50) of patients. PCPs implemented psychiatrist recommendations 76% (38/50) of the time. Conclusions For the majority of patients, psychiatrists provided strategies for ongoing management in primary care without an in-person evaluation, and PCPs implemented most psychiatrist recommendations. eConsults show promise as one means of supporting PCPs to deliver mental health care to patients with common psychiatric disorders.
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Affiliation(s)
- Margaret Lowenstein
- University of Pennsylvania Perelman School of Medicine, National Clinician Scholars Program, Philadelphia, PA, United States
| | - Olusinmi Bamgbose
- Marin General Hospital, Department of Psychiatry, Greenbrae, CA, United States
| | - Nathaniel Gleason
- University of California, San Francisco, Division of General Internal Medicine, San Francisco, CA, United States
| | - Mitchell D Feldman
- University of California, San Francisco, Division of General Internal Medicine, San Francisco, CA, United States
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106
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Liddy C, Poulin PA, Hunter Z, Smyth C, Keely E. Patient perspectives on wait times and the impact on their life: A waiting room survey in a chronic pain clinic. Scand J Pain 2017; 17:53-57. [PMID: 28850374 DOI: 10.1016/j.sjpain.2017.07.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 06/14/2017] [Accepted: 07/07/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND AND AIMS Chronic pain is a debilitating condition that requires prompt access to care for effective treatment. Wait times for care often exceed benchmark recommendations, with potential consequences to patient health outcomes. The goal of this paper is to gain the perspectives of patients attending a chronic pain clinic regarding the acceptability of current wait times and the impact of their experiences of waiting for chronic pain care. METHODS The study took place in a chronic pain clinic at an academic-affiliated teaching hospital in Ottawa, Canada, which housed seven clinicians at the time of the study. New patients attending the chronic pain clinic between July 14, 2014 and August 5, 2015 were eligible to participate based on the availability of the research and clerical staff who administered the survey on a variety of days over the course of the study. Patients completed a self-administered 29-item survey. The survey took approximately five to ten minutes to complete. Questions pertained to patients' socioeconomic factors, chronicity and burden of pain symptoms, and satisfaction with current wait times. Actual wait times were self-reported. Survey results were entered into an Excel spreadsheet, exported to SPSS, and coded numerically to facilitate descriptive analyses using comparative graphs and tables. Open-text responses were reviewed by the authors. RESULTS Sixty-six patients completed the survey. While 83% of patients stated that their ideal wait time was less than three months, 32% reported receiving an appointment within this period, and 31% reported waiting a year or more. Only 37% of patients felt the wait time for their appointment was appropriate. During their wait, 41% of patients reported receiving written information about chronic pain and 47% were referred to a local chronic pain management group. 94% reported interference with social/recreational activities and normal activities of daily living, 31% had to miss work or school due to the frequency of ongoing symptoms, and 22% reported being unable to attend work or school altogether. Furthermore, 37% of patients reported visiting the emergency room within the previous year and 65% worried about having a serious undiagnosed disease. CONCLUSIONS Our study found that wait times for chronic pain care, even those triaged as urgent cases, far exceeded what patients considered ideal. Only a third of patients received care within three months of making their appointment, while nearly another third waited over a year. During the waiting period, nearly all patients experienced some impact on their day-to-day activities and work or school attendance, half were unemployed, and nearly a quarter reported a complete inability to attend work or school because of pain. IMPLICATIONS Wait times for chronic pain care exceed timelines deemed acceptable by patients, causing anxiety and reducing function. The patient perspective must be considered in initiatives attempting to improve access to care for this population with specific needs and goals. Innovative solutions, such as electronic consultation and shared care models, hold promise.
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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, Ontario, Canada.
| | - Patricia A Poulin
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; The Ottawa Hospital, Department of Psychology, Ottawa, Ontario, Canada
| | - Zoë Hunter
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Catherine Smyth
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital Research Institute, 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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107
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Kwok J, Olayiwola JN, Knox M, Murphy EJ, Tuot DS. Electronic consultation system demonstrates educational benefit for primary care providers. J Telemed Telecare 2017; 24:465-472. [PMID: 28614974 DOI: 10.1177/1357633x17711822] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Electronic consultation systems allow primary care providers to receive timely speciality expertise via iterative electronic communication. The use of such systems is expanding across the USA with well-documented high levels of user satisfaction. We characterise the educational impact for primary care providers of a long-standing integrated electronic consultation and referral system. Methods Primary care providers' perceptions of the educational value inherent to electronic consultation system communication and the impact on their ability to manage common speciality clinical conditions and questions were examined by electronic survey using five-point Likert scales. Differences in primary care providers' perceptions were examined overall and by primary care providers' speciality, provider type and years of experience. Results Among 221 primary care provider participants (35% response rate), 83.9% agreed or strongly agreed that the integrated electronic consultation and referral system provided educational value. There were no significant differences in educational value reported by provider type (attending physician, mid-level provider, or trainee physician), primary care providers' speciality, or years of experience. Perceived benefit of the electronic consultation and referral system in clinical management appeared stronger for laboratory-based conditions (i.e. subclinical hypothyroidism) than more diffuse conditions (i.e. abdominal pain). Nurse practitioners/physician assistants and trainee physicians were more likely to report improved abilities to manage specific clinical conditions when using the electronic consultation and/or referral system than were attending physicians, as were primary care providers with ≤10 years experience, versus those with >20 years of experience. Conclusions Primary care providers report overwhelmingly positive perceptions of the educational value of an integrated electronic consultation and referral system. Nurse practitioners, physician assistants, trainee physicians and less-experienced primary care providers report the greatest clinical educational benefit, particularly for conditions involving lab-based diagnosis and management.
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Affiliation(s)
- Jonas Kwok
- 1 School of Medicine, State University of New York Downstate, USA
| | - J Nwando Olayiwola
- 2 Department of Family Medicine, University of California, USA.,3 Center for Excellence in Primary care, University of California, USA
| | - Margae Knox
- 2 Department of Family Medicine, University of California, USA.,3 Center for Excellence in Primary care, University of California, USA
| | | | - Delphine S Tuot
- 4 Department of Medicine, University of California, USA.,5 Center for Innovation in Access and Quality, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, USA
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108
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Easley J, Miedema B, O'Brien MA, Carroll J, Manca D, Webster F, Grunfeld E. The role of family physicians in cancer care: perspectives of primary and specialty care providers. ACTA ACUST UNITED AC 2017; 24:75-80. [PMID: 28490920 DOI: 10.3747/co.24.3447] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Currently, the specific role of family physicians (fps) in the care of people with cancer is not well defined. Our goal was to explore physician perspectives and contextual factors related to the coordination of cancer care and the role of fps. METHODS Using a constructivist grounded theory approach, we conducted telephone interviews with 58 primary and cancer specialist health care providers from across Canada. RESULTS The participants-21 fps, 15 surgeons, 12 medical oncologists, 6 radiation oncologists, and 4 general practitioners in oncology-were asked to describe both the role that fps currently play and the role that, in their opinion, fps should play in the future care of cancer patients across the cancer continuum. Participants identified 3 key roles: coordinating cancer care, managing comorbidities, and providing psychosocial care to patients and their families. However, fps and specialists discussed many challenges that prevent fps from fully performing those roles: ■ The fps described communication problems resulting from not being kept "in the loop" because they weren't copied on patient reports and also the lack of clearly defined roles for all the various health care providers involved in providing care to cancer patients.■ The specialists expressed concerns about a lack of patient access to fp care, leaving specialists to fill the care gaps. The fps and specialists both recommended additional training and education for fps in survivorship care, cancer screening, genetic testing, and new cancer treatments. CONCLUSIONS Better communication, more collaboration, and further education are needed to enhance the role of fps in the care of cancer patients.
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Affiliation(s)
- J Easley
- Dalhousie University, Family Medicine Teaching Unit, Fredericton, NB
| | - B Miedema
- Dalhousie University, Family Medicine Teaching Unit, Fredericton, NB
| | - M A O'Brien
- University of Toronto, Department of Family and Community Medicine, and
| | - J Carroll
- University of Toronto, Department of Family and Community Medicine, and.,Sinai Health System, Toronto, ON
| | - D Manca
- University of Alberta, Department of Family Medicine, Edmonton, AB
| | - F Webster
- University of Toronto, Department of Family and Community Medicine, and
| | - E Grunfeld
- University of Toronto, Department of Family and Community Medicine, and
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Strymish J, Gupte G, Afable MK, Gupta K, Kim EJ, Vimalananda V, Simon SR, Orlander JD. Electronic Consultations (E-consults): Advancing Infectious Disease Care in a Large Veterans Affairs Healthcare System. Clin Infect Dis 2017; 64:1123-1125. [PMID: 28158475 DOI: 10.1093/cid/cix058] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 01/24/2017] [Indexed: 12/12/2022] Open
Abstract
The impact of e-consults on total consultative services was evaluated. After implementing infectious diseases e-consults within an electronically integrated healthcare system, consultation volume increased. As compared with face-to-face consultations, e-consults were more often related to antimicrobial guidance and were requested by off-site providers. E-consults increased the breadth and volume of total consults.
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Affiliation(s)
- Judith Strymish
- Department of Medicine, Division of Infectious Diseases, Boston University School of Medicine, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Gouri Gupte
- Department of Health Law, Policy and Management, Boston University School of Public Health, Massachusetts, USA
| | - Melissa K Afable
- Department of Health Law, Policy and Management, Boston University School of Public Health, Massachusetts, USA
| | - Kalpana Gupta
- Department of Medicine, Division of Infectious Diseases, Boston University School of Medicine, Boston, MA, USA.,Evans Department of Medicine, Boston University School of Medicine, MA, USA
| | - Eun Ji Kim
- Evans Department of Medicine, Boston University School of Medicine, MA, USA.,Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial Veterans Affairs Medical Center, Bedford, USA
| | - Varsha Vimalananda
- Evans Department of Medicine, Boston University School of Medicine, MA, USA.,Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial Veterans Affairs Medical Center, Bedford, USA
| | - Steven R Simon
- Department of Medicine, Division of Infectious Diseases, Boston University School of Medicine, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jay D Orlander
- Department of Medicine, Division of Infectious Diseases, Boston University School of Medicine, Boston, MA, USA.,Evans Department of Medicine, Boston University School of Medicine, MA, USA
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110
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Murthy R, Rose G, Liddy C, Afkham A, Keely E. eConsultations to Infectious Disease Specialists: Questions Asked and Impact on Primary Care Providers' Behavior. Open Forum Infect Dis 2017; 4:ofx030. [PMID: 28470015 PMCID: PMC5407213 DOI: 10.1093/ofid/ofx030] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 02/07/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Since 2010, the Champlain BASE (Building Access to Specialist Advice through eConsultation) has allowed primary care providers (PCPs) to submit clinical questions to specialists through a secure web service. The study objectives are to describe questions asked to Infectious Diseases specialists through eConsultation and assess impact on physician behaviors. METHODS eConsults completed through the Champlain BASE service from April 15, 2013 to January 29, 2015 were characterized by the type of question asked and infectious disease content. Usage data and PCP responses to a closeout survey were analyzed to determine eConsult response time, change in referral plans, and change in planned course of action. RESULTS Of the 224 infectious diseases eConsults, the most common question types were as follows: interpretation of a clinical test 18.0% (41), general management 16.5 % (37), and indications/goals of treating a particular condition 16.5% (37). The most frequently consulted infectious diseases were as follows: tuberculosis 14.3% (32), Lyme disease 14.3% (32), and parasitology 12.9% (29). Within 24 hours, 63% of cases responded to the questions, and 82% of cases took under 15 minutes to complete. In 32% of cases, a face-to-face referral was originally planned by the PCP but was no longer needed. In 8% of cases, the PCP referred the patient despite originally not planning to make a referral. In 55% of cases, the PCP either received new information or changed their course of action. CONCLUSIONS An eConsult service provides PCPs with timely access to infectious disease specialists' advice that often results in a change in plans for a face-to-face referral.
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Affiliation(s)
| | | | - Clare Liddy
- Bruyere Research Institute, Department of Family Medicine, University of Ottawa, Canada; and
| | - Amir Afkham
- BEng, Champlain Local Health Integration Network, Ottawa, Canada
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111
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Price EL, Sewell JL, Chen AH, Sarkar U. Minding the Gaps: Assessing Communication Outcomes of Electronic Preconsultation Exchange. Jt Comm J Qual Patient Saf 2017; 42:341-54. [PMID: 27456415 DOI: 10.1016/s1553-7250(16)42048-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Effective communication between referring and specialty providers is key to optimizing patient safety. Communication was assessed in an electronic referral system by review of referrals to a public urban health care system's gastroenterology clinic that were not scheduled for appointments. METHODS All electronic referrals to a publicly funded, urban health care system's adult gastroenterology clinic from November 1, 2009, to November 30, 2010, were reviewed that did not result in scheduling of appointments. An assessment was made of whether in-person visits were unnecessary by preconsultation exchange or whether the referrals remained unscheduled for other reasons. For the latter group, reasons why the referrals remained unscheduled were examined, and medical records were reviewed for actual patient harm when sufficient information was present in the chart or for potential harm when no further information about the referral complaint was available. RESULTS Eighty-six (32%) of 266 not-scheduled referrals were resolved via preconsultation exchange. For another 96 (36%), patients were not ultimately considered to require appointments or were scheduled via other routes. Nine patients received unplanned care while awaiting scheduling decisions, 5 of whom had harm that was related to referral complaints, although scheduling of appointments may not have avoided this harm. Of 75 patients for whom further information was not available about the referral complaints, most were not seen back in primary care, and 55 (73%) had potential for major harm. CONCLUSION Few adverse outcomes in electronic referrals not scheduled for in-person gastroenterology visits were found, and none were clearly due to communication lapses in the referral process. Contributors to the potential for harm in referrals that were unintentionally left unscheduled included discontinuity of care and lack of patient or provider follow-up.
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112
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Keely EJ, Archibald D, Tuot DS, Lochnan H, Liddy C. Unique Educational Opportunities for PCPs and Specialists Arising From Electronic Consultation Services. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2017; 92:45-51. [PMID: 28030423 DOI: 10.1097/acm.0000000000001472] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Health care reform should be driven by the goals of better patient experience, improved population health, lower per capita costs, and improved provider satisfaction. Electronic consultation (eConsult) services have been adopted by several jurisdictions in the United States, Canada, and Europe to improve access to specialists by primary care providers (PCPs) and are being heralded as a key component for delivery of coordinated care. The primary intent of an eConsult service is to provide PCPs with efficient, timely, direct access to specialist expertise to help guide the management of their patients, reduce the need for unnecessary face-to-face specialty consultations, and improve the quality of the initial face-to-face consultation when needed, through the preconsultative communication.In addition to improving access to care, eConsult services have been praised by PCPs and specialists for their educational value, in particular their ability to enrich practice-based learning. Less recognized, but equally important from the educational perspective, include the abilities of eConsult programs to promote reflection by PCPs and specialists, improve collegiality and professionalism between primary and specialist care, inform continuing professional development activities and maintenance of certification, and enhance training programs' teaching of effective communication and care coordination.As eConsult services become increasingly available, the medical community must leverage the educational opportunities inherent in eConsult programs to further improve the delivery of coordinated specialty care. The educational role of eConsults should be considered as a priority outcome in their evaluation and must be highlighted and optimized in next iterations of eConsult systems design.
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Affiliation(s)
- Erin J Keely
- E.J. Keely is full professor, Department of Medicine, Faculty of Medicine, University of Ottawa, and chief, Division of Endocrinology and Metabolism, Ottawa Hospital, Ottawa, Ontario, Canada, and specialist lead, Champlain BASE eConsult Service.D. Archibald is assistant professor, Department of Family Medicine, Faculty of Medicine, University of Ottawa, and education researcher, C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada.D.S. Tuot is assistant professor, Department of Medicine, University of California, San Francisco; Division of Nephrology, San Francisco General Hospital; and director, San Francisco General Hospital eReferral program and University of California, San Francisco, Center for Innovation in Access and Quality, San Francisco, California.H. Lochnan is associate professor, Department of Medicine, and assistant dean, Continuing Professional Development and Education Programming, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.C. Liddy is associate professor, Department of Family Medicine, Faculty of Medicine, University of Ottawa, clinician investigator, C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada, and primary care lead, Champlain BASE eConsult Service
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Tuot DS, Boulware LE. Telehealth Applications to Enhance CKD Knowledge and Awareness Among Patients and Providers. Adv Chronic Kidney Dis 2017; 24:39-45. [PMID: 28224941 PMCID: PMC5324778 DOI: 10.1053/j.ackd.2016.11.017] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 11/21/2016] [Accepted: 11/22/2016] [Indexed: 12/31/2022]
Abstract
CKD affects 13% of the US adult population, causes excess mortality, and is associated with significant sociodemographic disparities. Optimal CKD management slows progression of disease and reduces cardiovascular-related outcomes. Resources for patients and primary care providers, major stakeholders in preventive CKD care, are critically needed to enhance understanding of the disease and to optimize CKD health, particularly because of the asymptomatic nature of kidney disease. Telehealth is defined as the use of electronic communication and telecommunications technology to support long-distance clinical health care, patient and professional health-related education, and public health and health administration. It provides new opportunities to enhance awareness and understanding among these important stakeholders. This review will examine the role of telehealth within existing educational theories, identify telehealth applications that can enhance CKD knowledge and behavior change among patients and primary care providers, and examine the advantages and disadvantages of telehealth vs usual modalities for education.
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Affiliation(s)
- Delphine S Tuot
- Division of Nephrology, Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, CA; Center for Innovation in Access and Quality, University of California, San Francisco, San Francisco, CA; and Division of General Internal Medicine, Duke University School of Medicine, Durham, NC.
| | - L Ebony Boulware
- Division of Nephrology, Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, CA; Center for Innovation in Access and Quality, University of California, San Francisco, San Francisco, CA; and Division of General Internal Medicine, Duke University School of Medicine, Durham, NC
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114
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Liddy C, Drosinis P, Deri Armstrong C, McKellips F, Afkham A, Keely E. What are the cost savings associated with providing access to specialist care through the Champlain BASE eConsult service? A costing evaluation. BMJ Open 2016; 6:e010920. [PMID: 27338880 PMCID: PMC4932271 DOI: 10.1136/bmjopen-2015-010920] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE This study estimates the costs and potential savings associated with all eConsult cases completed between 1 April 2014 and 31 March 2015. DESIGN Costing evaluation from the societal perspective estimating the costs and potential savings associated with all eConsults completed during the study period. SETTING Champlain health region in Eastern Ontario, Canada. POPULATION Primary care providers and specialists registered to use the eConsult service. MAIN OUTCOME MEASURES Costs included (1) delivery costs; (2) specialist remuneration; (3) costs associated with traditional (face-to-face) referrals initiated as a result of eConsult. Potential savings included (1) costs of traditional referrals avoided; (2) indirect patient savings through avoided travel and lost wages/productivity. Net potential societal cost savings were estimated by subtracting total costs from total potential savings. RESULTS A total of 3487 eConsults were completed during the study period. In 40% of eConsults, a face-to-face specialist visit was originally contemplated but avoided as result of eConsult. In 3% of eConsults, a face-to-face specialist visit was not originally contemplated but was prompted as a result of the eConsult. From the societal perspective, total costs were estimated at $207 787 and total potential savings were $246 516. eConsult led to a net societal saving of $38 729 or $11 per eConsult. CONCLUSIONS Our findings demonstrate potential cost savings from the societal perspective, as patients avoided the travel costs and lost wages/productivity associated with face-to-face specialist visits. Greater savings are expected once we account for other costs such as avoided tests and visits and potential improved health outcomes associated with shorter wait times. Our findings are valuable for healthcare delivery decision-makers as they seek solutions to improve care in a patient-centred and efficient manner.
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Affiliation(s)
- Clare Liddy
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Paul Drosinis
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada
| | | | - Fanny McKellips
- C.T. 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
- Division of Endocrinology and Metabolism, The Ottawa Hospital—Riverside Campus, Ottawa, Ontario, Canada
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