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Growdon ME, Hunt LJ, Miller MJ, Halim M, Karliner LS, Gonzales R, Sudore RL, Steinman MA, Harrison KL. eConsultation for Deprescribing Among Older Adults: Clinician Perspectives on Implementation Barriers and Facilitators. J Gen Intern Med 2024:10.1007/s11606-024-08899-0. [PMID: 38941059 DOI: 10.1007/s11606-024-08899-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 06/12/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Electronic consultations (eConsults) enable asynchronous consultation between primary care providers (PCPs) and specialists. eConsults have been used successfully to manage a variety of conditions and have the potential to help PCPs manage polypharmacy and promote deprescribing. OBJECTIVE To elicit clinician perspectives on barriers/facilitators of using eConsults for deprescribing among older adults within a university health network. DESIGN Semi-structured interviews. PARTICIPANTS PCPs, geriatricians, and pharmacists. APPROACH We used the COM-B (Capability, Opportunity, Motivation, and Behavior) model to structure the interview guide and qualitative analysis methods to identify barriers/facilitators of (1) deprescribing and (2) use of eConsults for deprescribing. KEY RESULTS Of 28 participants, 19 were PCPs (13 physicians, 4 residents, 2 nurse practitioners), 7 were geriatricians, and 2 were pharmacists. Barriers and facilitators to deprescribing: PCPs considered deprescribing important but identified myriad barriers (e.g., time constraints, fragmented clinical care, lack of pharmacist integration, and patient/family resistance). Use of eConsults for deprescribing: Both PCPs and geriatricians highlighted the limits of contextual information available through electronic health record (vs. face-to-face) to render specific and actionable eConsults (e.g., knowledge of prior deprescribing attempts). Participants from all groups expressed interest in a targeted process whereby eConsults could be offered for select patients based on key factors (e.g., polypharmacy or certain comorbidities) and accepted or declined by PCPs, with pithy recommendations delivered in a timely manner relative to patient appointments. This was encapsulated by one PCP: "they need to be crisp and to the point to be helpful, with specific suggestions of something that could be discontinued or switched…not, 'hey, did you know your patient is on over 12 medicines?'". CONCLUSIONS Clinicians identified multifaceted factors influencing the utility of eConsults for deprescribing among older adults in primary care. Deprescribing eConsult interventions should be timely, actionable, and mindful of limitations of electronic chart review.
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Affiliation(s)
- Matthew E Growdon
- Division of Geriatrics, University of California, San Francisco, CA, USA.
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.
| | - Lauren J Hunt
- Department of Physiological Nursing, University of California, San Francisco, San Francisco, CA, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA, USA
| | - Matthew J Miller
- Department of Physical Therapy and Rehabilitation Science, University of California, San Francisco, CA, USA
| | - Madina Halim
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Leah S Karliner
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, CA, USA
| | - Ralph Gonzales
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, CA, USA
| | - Rebecca L Sudore
- Division of Geriatrics, University of California, San Francisco, CA, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Michael A Steinman
- Division of Geriatrics, University of California, San Francisco, CA, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Krista L Harrison
- Division of Geriatrics, University of California, San Francisco, CA, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA, USA
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Nabelsi V, Lévesque-Chouinard A. Successful Electronic Consultation Service Initiative in Quebec, Canada With Primary Care Physicians' and Specialists' Experiences on Acceptance and Use of Technological Innovation: Cross-Sectional Exploratory Study. JMIR Form Res 2024; 8:e52921. [PMID: 38814689 PMCID: PMC11176886 DOI: 10.2196/52921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 04/10/2024] [Accepted: 04/25/2024] [Indexed: 05/31/2024] Open
Abstract
BACKGROUND Electronic consultation (eConsult) is an eHealth service that allows primary care providers (PCPs) to electronically consult specialists regarding their patients' medical issues. Many studies have demonstrated that eConsult services improve timely access to specialist care; prevent unnecessary referrals; improve PCPs', specialists', and patients' satisfaction; and therefore have a large impact on costs. However, no studies have evaluated PCPs' and specialists' acceptance of eConsult services in Quebec, Canada, and worldwide. OBJECTIVE This exploratory study aims to identify factors affecting eConsult service acceptance by PCPs and specialists in urban and rural primary care clinics across 3 regions in the province of Quebec, Canada, by integrating the Unified Theory of Acceptance and Use of Technology and Task-Technology Fit (TTF) models and user satisfaction. This research was designed to broaden and assist in scaling up this effective eHealth service innovation across the province. METHODS A cross-sectional web-based survey was sent to all PCPs (n=263) and specialists (n=62) who used the eConsult Quebec Service between July 2017 and May 2021. We proposed a unified model integrating the Unified Theory of Acceptance and Use of Technology model and TTF model and user satisfaction by endorsing 11 hypotheses. The partial least squares was used to investigate factors influencing the acceptance of the eConsult Quebec Service. RESULTS Of the 325 end users, 136 (41.8%) users responded (PCPs: 101/263, 38.4%; specialists: 35/62, 57%). The results of the analysis with partial least squares method indicate that 9 of our 11 hypotheses are supported. The direct relationships uniting the various constructs of the model highlighted the importance of several key constructs and predominant correlations. The results suggest that satisfaction is the key driver behind the use of the eConsult Quebec Service. Performance expectancy (P<.001) and effort expectancy (P=.03) can have a positive impact on behavioral intention (BI), and BI (P<.001) can impact adoption. TTF has an influence on performance expectancy (P<.001), adoption (P=.02), and satisfaction (P<.001). However, the results show that there is no direct effect between social influence (P=.38) and BI or between facilitating conditions (P=.17) and adoption. CONCLUSIONS This study provides a better understanding of the factors influencing PCPs' and specialists' intention to adopt the eConsult Quebec Service. Furthermore, this study tests a research model and a technology that have never been explored in Quebec until now. On the basis of the results, the service is a good fit to meet the users' need to improve access to specialized medical advice. Therefore, the results of our study have made a valuable contribution to the implementation of the service by policy makers in order to maximize acceptance, use, adoption, and success across the province of Quebec. Moreover, after 4 successful years, the eConsult Quebec pilot project is now the Conseil Numérique digital consultation service.
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Affiliation(s)
- Véronique Nabelsi
- Department of Administrative Sciences, Université du Québec en Outaouais, Gatineau, QC, Canada
| | - Annabelle Lévesque-Chouinard
- GMF-U de la Haute-Ville du Centre intégré universitaire de santé et des services sociaux de la Capitale-Nationale, Sainte-Foy, QC, Canada
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Marco-Ibáñez A, Aguilar-Palacio I, Aibar C. Does virtual consultation between primary and specialised care improve healthcare quality? A scoping review of healthcare quality domains assessment. BMJ Open Qual 2023; 12:e002388. [PMID: 37832971 PMCID: PMC10582872 DOI: 10.1136/bmjoq-2023-002388] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 09/25/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Virtual consultation has been proposed as a promising tool to improve the coordination and quality of healthcare between primary and specialised care. However, despite its potential facilitators, the evidence on the usefulness of virtual consultation for improving healthcare quality domains is fragmented and unclear. This scoping review aims to assess the impact of virtual consultation on different healthcare quality domains. MATERIAL AND METHODS We conducted a scoping review with a rigorous search strategy on PubMed, EMBASE and Cochrane Library databases. The inclusion criteria were original articles, reviews, meta-analyses or letters to the editor, published between 1 January 2017 and 24 June 2022, and available in English, Spanish or French. For each of the articles selected, we identified the addressed healthcare quality domains, their facilitators and barriers, areas of improvement and data gaps. We have adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Review reporting standards. RESULTS 1284 manuscripts were retrieved. Finally, 235 papers were included in this review, most of which were original, descriptive studies. The most evaluated quality domain was effectiveness (223 articles). Safety and patient-centred care were the least evaluated. Simultaneous assessment of more than one domain was observed in 117 papers, being effectiveness and timeliness the most frequent combination. Our analysis revealed that virtual consultation is in development and underused. This tool has the potential to improve access to specialised care and enhance coordination between professionals. CONCLUSIONS Virtual consultation has the potential to provide effective, efficient, equitable and timely attention. However, its contribution to safety and patient-centered care needs further evaluation. Our review emphasises the need for more rigorous research and standardised quality assessment criteria to obtain robust evidence on the usefulness of virtual consultation for improving healthcare quality domains.
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Affiliation(s)
- Almudena Marco-Ibáñez
- Primary Health Physician, Aragon Health Service, Zaragoza, Spain
- Health Services Research Group (GRISSA), Aragon Health Research Institute, Zaragoza, Spain
| | - Isabel Aguilar-Palacio
- Health Services Research Group (GRISSA), Aragon Health Research Institute, Zaragoza, Spain
- Preventive Medicine and Public Health, University of Zaragoza, Zaragoza, Spain
| | - Carlos Aibar
- Health Services Research Group (GRISSA), Aragon Health Research Institute, Zaragoza, Spain
- Preventive Medicine and Public Health, Hospital Clinico Universitario Lozano Blesa, Zaragoza, Spain
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Grant R, McMurtry A, Archibald D. Mapping Health Professions Education: Using Complexity Science to Make Sense of Learning Through Electronic Consultations. MEDICAL SCIENCE EDUCATOR 2023; 33:233-242. [PMID: 37008438 PMCID: PMC10060472 DOI: 10.1007/s40670-023-01730-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/09/2023] [Indexed: 06/19/2023]
Abstract
Phenomena studied within health professions education are often complex and multifaceted. This article describes a complexity science-informed theoretical framework that was developed for exploring how electronic consultations support learning among primary care providers, as well as within the larger organizations or systems in which they practice. This framework enables researchers to investigate learning occurring simultaneously at multiple levels (including individuals and social groups), without simplistically conflating levels or theories. The various levels of learning and associated theories are illustrated using examples from electronic consultations. This complexity science-inspired framework can be used for studying learning in complex, multilayered systems.
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Affiliation(s)
- Rachel Grant
- Faculty of Education, University of Ottawa, Ottawa, ON Canada
| | - Angus McMurtry
- Faculty of Education, University of Ottawa, Ottawa, ON Canada
| | - Douglas Archibald
- Faculty of Education, University of Ottawa, Ottawa, ON Canada
- Department of Family Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON Canada
- Bruyère Research Institute, Ottawa, ON Canada
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Job J, Nicholson C, Calleja Z, Jackson C, Donald M. Implementing a general practitioner-to-general physician eConsult service (eConsultant) in Australia. BMC Health Serv Res 2022; 22:1278. [PMID: 36280832 PMCID: PMC9589630 DOI: 10.1186/s12913-022-08663-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 10/04/2022] [Indexed: 11/23/2022] Open
Abstract
Background In response to lengthy wait times for specialist outpatient appointments, electronic consultation (eConsult) services have developed globally, providing asynchronous, secure and timely communication between general practitioner (GP) and specialist. This study aims to track adoption of a Queensland eConsultant service in two Australian Primary Health Networks (Western Queensland and Brisbane South) to understand key barriers and enablers to adoption and inform modification of the implementation strategy. Methods Our theory-informed mixed-methods evaluation assessed implementation between July 2020 and March 2022. Adoption and implementation activities were prospectively recorded in bespoke tracking spreadsheets with implementation activities coded against the Expert Recommendations for Implementing Change (ERIC) strategies. Semi-structured interviews with GPs and stakeholders informed by the Consolidated Framework for Implementation Research (CFIR) were conducted to understand determinants of implementation. Results Of the 40 practices invited to take part in the eConsultant service, 20 (50%) enrolled. Of the 97 GPs who consented, 38 sent at least one Request for Advice (RFA) to the eConsultant with a total of 112 RFA sent. Implementation was predominantly guided by eight strategies. Qualitative interviews were conducted with 11 GPs and 4 stakeholders (12 from rural/remote regions, 11 females and two sole practitioners). Interviewees felt the eConsultant service supported outpatient appointment avoidance and provided efficient, timely access to specialist support for GPs and their patients. Barriers identified to using eConsultant related to digital infrastructure, competing priorities, and keeping the service ‘front of mind’. Key enablers identified were the relative advantage of eConsultant over other options, patient benefits and COVD-19 facilitating the use of digital technology. Conclusions This evaluation highlighted service enablers as well as user priorities for broader implementation. A focus on a well-integrated digital system and availability of a variety of eConsultant specialties are seen as key strategies to embedding the eConsultant option in GP advice processes in Australia. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08663-2.
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Affiliation(s)
- Jennifer Job
- grid.1003.20000 0000 9320 7537UQ-MRI Centre for Health System Reform and Integration, Mater Research Institute, The University of Queensland, Level 8, Health Sciences Building, Royal Brisbane and Women’s Hospital Campus, Brisbane, QLD 4029 Australia
| | - Caroline Nicholson
- grid.1003.20000 0000 9320 7537UQ-MRI Centre for Health System Reform and Integration, Mater Research Institute, The University of Queensland, Level 8, Health Sciences Building, Royal Brisbane and Women’s Hospital Campus, Brisbane, QLD 4029 Australia ,Integrated Care and Innovation Translation, Mater Misericordiae Ltd, Brisbane, Australia
| | - Zoe Calleja
- grid.1003.20000 0000 9320 7537UQ-MRI Centre for Health System Reform and Integration, Mater Research Institute, The University of Queensland, Level 8, Health Sciences Building, Royal Brisbane and Women’s Hospital Campus, Brisbane, QLD 4029 Australia
| | - Claire Jackson
- grid.1003.20000 0000 9320 7537UQ-MRI Centre for Health System Reform and Integration, Mater Research Institute, The University of Queensland, Level 8, Health Sciences Building, Royal Brisbane and Women’s Hospital Campus, Brisbane, QLD 4029 Australia ,grid.1003.20000 0000 9320 7537Primary Care Faculty of Medicine, The University of Queensland, Brisbane, Australia ,grid.1003.20000 0000 9320 7537General Practice Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Maria Donald
- grid.1003.20000 0000 9320 7537UQ-MRI Centre for Health System Reform and Integration, Mater Research Institute, The University of Queensland, Level 8, Health Sciences Building, Royal Brisbane and Women’s Hospital Campus, Brisbane, QLD 4029 Australia ,grid.1003.20000 0000 9320 7537General Practice Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Australia
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Asynchronous Remote Communication as a Tool for Care Management in Primary Care: A Rapid Review of the Literature. Int J Integr Care 2022; 22:7. [PMID: 36043028 PMCID: PMC9374012 DOI: 10.5334/ijic.6489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 08/03/2022] [Indexed: 11/24/2022] Open
Abstract
Aim: To review the available evidence on asynchronous communication models between primary care professionals and patients in different countries around the world in order to analyse the added value that this model brings to patients and professionals. Design: A rapid literature review was conducted using the World Health Organisation guidance to include a variety of studies on the concept of asynchronous communications between primary care and patients in different countries. Data sources: The search for articles was carried out in PubMed and Google Academics and with the contribution of telemedicine experts from the Catalan Institute of Health. Selection of studies: The review included 271 articles. The inclusion criteria were: publications from 2010 onwards, in English, Spanish or Catalan, focused on asynchronous communications between primary care professionals and patients to improve patient management. After discarding duplicates and applying the exclusion criteria (255 articles), 16 were included for further review. Data extraction: The rapid literature review was conducted by an evaluator; detecting 5 main general themes: reduction of face-to-face visits, available services and most frequent uses, characteristics and perceptions of primary care professionals, characteristics and perceptions of users, and barriers and facilitators for the implementation of asynchronous teleconsultation. Results: A total of sixteen studies were included, including seven quantitative studies, seven qualitative studies and two mixed studies. Conclusions: The high degree of satisfaction of both users and professionals, the outbreak of COVID-19 and the effectiveness and efficiency of asynchronous remote communications are key factors for the implementation and improvement in the management of the different healthcare systems across the world.
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Abu Libdeh A, Flanigan J, Heinan K. Experience with Pediatric Neurology e-Consults from a Specialist Perspective at an Academic Center. J Child Neurol 2022; 37:373-379. [PMID: 35300549 DOI: 10.1177/08830738221077760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION E-consults improve access to specialty expertise and increase satisfaction for patients and Primary Care Providers (PCPs). Pediatric neurology may be perceived as less amenable to e-consults compared to other specialties. METHODS We performed a retrospective analysis of e-consults performed by pediatric neurologists at the University of Virginia. We reviewed the electronic medical records and analyzed the content of e-consults, recommendations from specialists, and subsequent actions by PCPs. RESULTS Between April 2019 and April 2021, 58 e-consults were performed by pediatric neurologists. Most common indications included spells, headache, and tremor. In 56.9% of cases, the answer was provided without recommending a face-to-face (FTF) visit. For patients seen in clinic, e-consults reduced wait time and facilitated the clinic visit. DISCUSSION E-consults are a suitable option for pediatric neurology, and they help with the workflow. Further education is needed to improve utility of e-consults in pediatric neurology.
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Affiliation(s)
- Amal Abu Libdeh
- Department of Neurology, 2358University of Virginia, Charlottesville, VA, US
| | - Joseph Flanigan
- Department of Neurology, 2358University of Virginia, Charlottesville, VA, US
| | - Kristen Heinan
- Department of Neurology, 2358University of Virginia, Charlottesville, VA, US
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Malcolm EJ, Brandon Z, Wilson LE, Shoup JP, King HA, Lewinski A, Greiner MA, Malone S, Miller J, Keenan RT, Tarrant TK, Phinney D, Cho A, Bosworth HB, Shah K. eConsults' Impact on Care Access and Wait Times in Rheumatology. J Clin Rheumatol 2022; 28:147-154. [PMID: 35067514 DOI: 10.1097/rhu.0000000000001825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND/OBJECTIVE A growing number of health systems have implemented eConsults to improve access to specialty advice, but few studies have described their use in rheumatology or impact on visit wait times. We evaluated the uptake of an eConsult program and its impact on wait times for in-person rheumatology visits. METHODS In this quality improvement project, we analyzed electronic health record data from 4 intervention clinics and 4 comparison clinics, 12 months before and after implementation of an eConsult program. We compared median wait time for rheumatology appointments using a pre-post difference-in-differences analysis and quantile regression, adjusting for patient age, race, sex, clinic pair, and primary insurance payer. We also interviewed 11 primary care providers from the intervention clinics and conducted a rheumatology provider focus group (n = 4) to elucidate experiences with the program. RESULTS Rheumatologists recommended management in primary care or referral to another specialty for 41% of eConsults, reducing initial demand for in-person visits. The median wait times dropped in the intervention and the comparison clinics (42 and 25 days, respectively). Intervention clinic median wait time dropped 17 days more than comparison clinics, and this was nonstatistically significant (p = 0.089). eConsults fit provider care tasks best for triage or initial workup for diagnosis, and less well when tests required interpretation, or when back and forth communication was needed to manage the patient's condition. CONCLUSIONS Implementation of eConsults for rheumatology was associated with reduced wait times for rheumatology appointments and supported primary care providers in the triage and workup for a substantial portion of patients.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Julie Miller
- From the Duke University School of Medicine, Durham
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Use of telemedicine for initial outpatient subspecialist consultative visit: A national survey of general pediatricians and pediatric subspecialists. HEALTHCARE (AMSTERDAM, NETHERLANDS) 2022; 10:100600. [PMID: 34875456 PMCID: PMC8881319 DOI: 10.1016/j.hjdsi.2021.100600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 11/15/2021] [Accepted: 11/23/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Evidence-based strategies are needed to support appropriate use of telemedicine for initial outpatient subspecialty consultative visits. To inform such strategies we performed a survey of general pediatricians and pediatric subspecialists about use of telemedicine for patients newly referred for pediatric subspecialty care. METHODS We developed and fielded an e-mail and postal survey of a national sample of 840 general pediatricians and 840 pediatric subspecialists in May and June 2020. RESULTS Of 266 completed surveys (17% response rate), 204 (76%) thought telemedicine should be offered for some and 29 (11%) thought telemedicine should be offered for all initial subspecialist visits. Most respondents who indicated telemedicine should be offered for some initial consultations believed this decision should be made by subspecialty attendings (176/204, 86%). Respondents prioritized several data elements to inform this decision, including clinical information and family-based contextual information (e.g., barriers to in-person care, interest in telemedicine, potential communication barriers). Factors perceived to reduce appropriateness of telemedicine for subspecialty consultation included need for interpreter services and prior history of frequent no-shows. Responses from generalists and subspecialists rarely differed significantly. CONCLUSIONS Survey results suggest potential opportunities to support the appropriate use of telemedicine for initial outpatient pediatric subspecialty visits through structured transfer of specific clinical and contextual information at the time of referral and through strategies to mitigate perceived communication or engagement barriers. IMPLICATION Pediatric physician beliefs about telemedicine for initial outpatient subspecialty consultative visits may inform future interventions to support appropriate telemedicine use. LEVEL OF EVIDENCE Survey of a national sample of clinicians.
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Rea CJ, Toomey SL, Rosen M, Le T, Shah S. Understanding Caregiver Perspectives on an Electronic Consultation and Referral System. Clin Pediatr (Phila) 2022; 61:270-279. [PMID: 35090366 DOI: 10.1177/00099228221074856] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study examined caregiver impressions of an electronic consultation and referral (ECR) system. Participants included 56 caregivers of primary care patients referred through the ECR system. Semistructured interviews and surveys were conducted between August 2018 and April 2019. Transcripts were coded and themes developed using thematic content analysis. A total of 51% of caregivers stated that they would prefer to see their child's primary care provider (PCP) for a specialty issue if they could receive the same quality of care. All caregivers who received an electronic consult (n = 28) said that they would utilize that process again. Three themes emerged: (1) caregivers expect immediate action prior to or instead of a specialty referral; (2) caregiver preferences for PCP versus specialist are mediated by both child and provider characteristics; (3) caregiver attitudes toward the ECR system are influenced by external considerations and experiences with the system. Results suggest caregivers value enhanced communication and immediate access to specialty input facilitated by the ECR system.
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Affiliation(s)
- Corinna J Rea
- Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Sara L Toomey
- Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | | | - Tiffany Le
- Boston Children's Hospital, Boston, MA, USA
| | - Snehal Shah
- Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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Anderson E, Vimalananda VG, Orlander JD, Cutrona SL, Strymish JL, Bokhour BG, Rinne ST. Implications of Electronic Consultations for Clinician Communication and Relationships: A Qualitative Study. Med Care 2021; 59:808-815. [PMID: 34116530 PMCID: PMC8360667 DOI: 10.1097/mlr.0000000000001575] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Strong relationships and effective communication between clinicians support care coordination and contribute to care quality. As a new mechanism of clinician communication, electronic consultations (e-consults) may have downstream effects on care provision and coordination. OBJECTIVE The objective of this study was to understand primary care providers' and specialists' perspectives on how e-consults affect communication and relationships between clinicians. RESEARCH DESIGN Qualitative study using thematic analysis of semistructured interviews. SUBJECTS Six of 8 sites in the VISN 1 (Veterans Integrated Service Network) in New England were chosen, based on variation in organization and received e-consult volume. Seventy-three respondents, including 60 clinicians in primary care and 3 high-volume specialties (cardiology, pulmonology, and neurology) and 13 clinical leaders at the site and VISN level, were recruited. MEASURES Participants' perspectives on the role and impact of e-consults on communication and relationships between clinicians. RESULTS Clinicians identified 3 types of e-consults' social affordances: (1) e-consults were praised for allowing specialist advice to be more grounded in patient data and well-documented, but concerns about potential legal liability and increased transparency of communication to patients and others were also noted; (2) e-consults were perceived as an imperfect modality for iterative communication, especially for complex conversations requiring shared deliberation; (3) e-consults were understood as a factor influencing clinician relationships, but clinicians disagreed on whether e-consults promote or undermine relationship building. CONCLUSIONS Clinicians have diverse concerns about the implications of e-consults for communication and relationships. Our findings may inform efforts to expand and improve the use of e-consults in diverse health care settings.
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Affiliation(s)
- Ekaterina Anderson
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford
- Department of Population and Quantitative Health Sciences, Division of Health Informatics and Implementation Science, University of Massachusetts Medical School, Worcester
| | - Varsha G. Vimalananda
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford
- Section of Endocrinology, Diabetes, and Metabolism, Boston University School of Medicine
| | - Jay D. Orlander
- Medical Service, VA Boston Healthcare System
- Evans Department of Medicine, Boston University School of Medicine
| | - Sarah L. Cutrona
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford
- Department of Population and Quantitative Health Sciences, Division of Health Informatics and Implementation Science, University of Massachusetts Medical School, Worcester
| | - Judith L. Strymish
- Medical Service and Section of Infectious Diseases, VA Boston Healthcare System, Boston
- Harvard Medical School, Cambridge
| | - Barbara G. Bokhour
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford
- Department of Population and Quantitative Health Sciences, Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, Worcester
| | - Seppo T. Rinne
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford
- Section of Pulmonary, Allergy, Sleep, and Critical Care Medicine, Boston University School of Medicine, Boston, MA
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Rankine J, Yeramosu D, Matheo L, Sequeira GM, Miller E, Ray KN. Optimizing e-Consultations to Adolescent Medicine Specialists: Qualitative Synthesis of Feedback From User-Centered Design. JMIR Hum Factors 2021; 8:e25568. [PMID: 34383665 PMCID: PMC8380586 DOI: 10.2196/25568] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 01/21/2021] [Accepted: 05/24/2021] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND e-Consultations between primary care physicians and specialists are a valuable means of improving access to specialty care. Adolescents and young adults (AYAs) face unique challenges in accessing limited adolescent medicine specialty care resources, which contributes to delayed or forgone care. e-Consultations between general pediatricians and adolescent medicine specialists may alleviate these barriers to care. However, the optimal application of this model in adolescent medicine requires careful attention to the nuances of AYA care. OBJECTIVE This study aims to qualitatively analyze feedback obtained during the iterative development of an e-consultation system for communication between general pediatricians and adolescent medicine specialists tailored to the specific health care needs of AYAs. METHODS We conducted an iterative user-centered design and evaluation process in two phases. In the first phase, we created a static e-consultation prototype and storyboards and evaluated them with target users (general pediatricians and adolescent medicine specialists). In the second phase, we incorporated feedback to develop a functional prototype within the electronic health record and again evaluated this with general pediatricians and adolescent medicine specialists. In each phase, general pediatricians and adolescent medicine specialists provided think-aloud feedback during the use of the prototypes and semistructured exit interviews, which was qualitatively analyzed to identify perspectives related to the usefulness and usability of the e-consultation system. RESULTS Both general pediatricians (n=12) and adolescent medicine specialists (n=12) perceived the usefulness of e-consultations for AYA patients, with more varied perceptions of potential usefulness for generalist and adolescent medicine clinicians. General pediatricians and adolescent medicine specialists discussed ways to maximize the usability of e-consultations for AYAs, primarily by improving efficiency (eg, reducing documentation, emphasizing critical information, using autopopulated data fields, and balancing specificity and efficiency through text prompts) and reducing the potential for errors (eg, prompting a review of autopopulated data fields, requiring physician contact information, and prompting explicit discussion of patient communication and confidentiality expectations). Through iterative design, patient history documentation was streamlined, whereas documentation of communication and confidentiality expectations were enhanced. CONCLUSIONS Through an iterative user-centered design process, we identified user perspectives to guide the refinement of an e-consultation system based on general pediatrician and adolescent medicine specialist feedback on usefulness and usability related to the care of AYAs. Qualitative analysis of this feedback revealed both opportunities and risks related to confidentiality, communication, and the use of tailored documentation prompts that should be considered in the development and use of e-consultations with AYAs.
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Affiliation(s)
- Jacquelin Rankine
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Deepika Yeramosu
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Loreta Matheo
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Gina M Sequeira
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States.,Division of Adolescent Medicine, Seattle Children's Hospital, Seattle, WA, United States
| | - Elizabeth Miller
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Kristin N Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
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Gaye M, Mehrotra A, Byrnes-Enoch H, Chokshi D, Wallach A, Rodriguez L, Barnett ML. Association of eConsult Implementation With Access to Specialist Care in a Large Urban Safety-Net System. JAMA HEALTH FORUM 2021; 2:e210456. [PMID: 35977310 PMCID: PMC8796905 DOI: 10.1001/jamahealthforum.2021.0456] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 03/17/2021] [Indexed: 12/16/2022] Open
Abstract
Question What was the association of implementation of an eConsult program with access to specialty care in a large safety-net hospital system in the US? Findings In this study, 13% of submitted specialty referral requests were resolved electronically and, among requests requiring an in-person visit, appointment scheduling rates increased and wait times to an appointment decreased following eConsult implementation, while visit rates were unchanged. These improvements were mitigated during a hospital-level electronic health record transition. Meaning Wide-scale implementation of an eConsult program was associated with reduced wait times for patients in an urban safety-net health system with specialty care needs. Importance Accessing specialty care continues to be a persistent problem for patients who use safety-net health systems. To address this access barrier, hospital systems have begun to implement electronic referral systems using eConsults, which allow clinicians to submit referral requests to specialty clinics electronically and enable specialty reviewers to resolve referrals, if appropriate, through electronic dialogue without an in-person visit. Objective Measure the effect of implementing an eConsult program on access to specialty care. Design, Setting, and Participants Using an interrupted time series design with data from 2016 to 2020, this study analyzed 50 260 referral requests submitted during the year before and the year after eConsult implementation at 19 New York City Health + Hospitals (NYC H+H) specialty clinics that spanned 7 NYC H+H hospital facilities and 6 unique specialties. Exposures Referral request was submitted to a specialty clinic in the year following eConsult implementation. Main Outcomes and Measures Main outcomes included the fraction of referral requests resolved without an in-person visit following eConsult implementation; and, among requests triaged to have an in-person visit, the fraction of referrals with a successfully scheduled appointment, mean wait time to a specialty appointment, and the fraction of referral requests with a completed specialty visit. Changes associated with eConsult implementation were estimated using multivariate linear regression adjusting for patient age, gender, and specialty clinic fixed effects. Results Across 19 NYC H+H specialty clinics, 26 731 referral requests were submitted in the year before and 23 529 referrals were submitted in the year after eConsult implementation. Following eConsult implementation, 13% of all requests were resolved electronically. Among requests requiring a follow-up visit, the fraction with an appointment successfully scheduled increased by 15.8%, from 66.5% to 82.3% (P < .001). The mean time to an appointment decreased from 61.0 days pre-eConsult to 54.1 days post-eConsult, an adjusted 8.2-day shorter wait time (or 13.3% reduction) following eConsult adoption (P < .001). The percentage of referrals with a completed follow-up visit with a specialist within 90 days of the request did not change (38.4% vs 37.9%, P = .07). Changes in outcomes were mitigated during months when most clinics underwent an electronic health record transition after implementing eConsult. Conclusions and Relevance In this quality improvement study, implementation of eConsults at a large multi-specialty safety-net system was associated with improvements in appointment scheduling rates and wait times. Despite an additional electronic health record transition, eConsults are a promising health care delivery tool for increasing access to specialty care.
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Affiliation(s)
- Marema Gaye
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | | | - Dave Chokshi
- New York City Department of Health and Mental Hygiene, New York, New York
- Department of Population Health, New York University Grossman School of Medicine, New York, New York
- Department of Medicine, New York University Grossman School of Medicine, New York, New York
| | - Andrew Wallach
- Department of Medicine, New York University Grossman School of Medicine, New York, New York
- Office of Ambulatory Care, New York City Health + Hospitals, New York, New York
| | - Laura Rodriguez
- Office of Ambulatory Care, New York City Health + Hospitals, New York, New York
| | - Michael L. Barnett
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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Rikin S, Epstein EJ, Gendlina I. Rapid implementation of Inpatient eConsult Programme addresses new challenges for patient care during COVID-19 pandemic. BMJ INNOVATIONS 2021; 7:271-277. [PMID: 34192016 PMCID: PMC7944413 DOI: 10.1136/bmjinnov-2020-000557] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 12/17/2020] [Accepted: 02/24/2021] [Indexed: 12/29/2022]
Abstract
INTRODUCTION At the early epicentre of the COVID-19 crisis in the USA, our institution saw a surge in the demand for inpatient consultations for areas impacted by COVID-19 (eg, infectious diseases, nephrology, palliative care) and shortages in personal protective equipment (PPE). We aimed to provide timely specialist input for consult requests during the COVID-19 pandemic by implementing an Inpatient eConsult Programme. METHODS We used the reach, effectiveness, adoption, implementation and maintenance implementation science framework and run chart analysis to evaluate the reach, adoption and maintenance of the Inpatient eConsult Programme compared with traditional in-person consults. We solicited qualitative feedback from frontline physicians and specialists for programme improvements. RESULTS During the study period, there were 46 available in-person consult orders and 21 new eConsult orders. At the peak of utilisation, 42% of all consult requests were eConsults, and by the end of the study period, utilisation fell to 20%. Qualitative feedback revealed subspecialties best suited for eConsults (infectious diseases, nephrology, haematology, endocrinology) and influenced improvements to the ordering workflow, documentation, billing and education regarding use. DISCUSSION When offered inpatient eConsult requests as an alternative to in-person consults in the context of a surge in patients with COVID-19, frontline physicians used eConsult requests and decreased use of in-person consults. As the demand for consults decreased and PPE shortages were no longer a major concern, eConsult utilisation decreased, revealing a preference for in-person consultations when possible. CONCLUSIONS Lessons learnt can be used to develop and implement inpatient eConsults to meet context-specific challenges at other institutions.
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Affiliation(s)
- Sharon Rikin
- Department of Medicine, Montefiore Medical Center, Bronx, New York, USA
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Eric J Epstein
- Department of Medicine, Montefiore Medical Center, Bronx, New York, USA
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Inessa Gendlina
- Department of Medicine, Montefiore Medical Center, Bronx, New York, USA
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
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15
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Leyton C, Zhang C, Rikin S. Evaluation of the Effects of the COVID-19 Pandemic on Electronic Consultation Use in Primary Care. Telemed J E Health 2021; 28:66-72. [PMID: 33794114 DOI: 10.1089/tmj.2020.0547] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Background: Little is known about electronic consultation (e-consult) utilization during the COVID-19 pandemic when health systems rapidly implemented and scaled telehealth alternatives to in-person care. It is also unknown if e-consult utilization during the pandemic replaced or merely deferred the need for a specialty appointment. We evaluated if primary care providers' (PCPs) e-consult utilization and specialists' recommendations for specialty appointments changed after the transition to telemedicine during the COVID-19 pandemic. Methods: This cohort study used an interrupted time series analysis of e-consult utilization in a large, urban academic health care system between December 1, 2019, and June 27, 2020; the post-telemedicine time period began March 15, 2020. The primary outcome measure was the odds of an e-consult ordered during a PCP appointment; the secondary outcome measure was the odds of a specialist recommending a specialty appointment in an e-consult. Results: During 193,263 PCP appointments, 1,318 e-consults were placed to internal medicine subspecialties. Compared to the pre-telemedicine time period, the odds of a PCP ordering an e-consult increased (OR 1.04, 95% CI [1.02-1.07]) and the odds of specialists recommending specialty appointments increased (OR 1.11, 95% CI [1.06-1.15]). Conclusions: E-consult use increased following the transition to telemedicine in the context of the COVID-19 pandemic, suggesting that PCPs consider the e-consult a valuable tool for patient care when there is limited availability of specialty appointments. However, recommendations for specialty appointments following an e-consult also increased, suggesting that the e-consult may not replace the need for a specialty appointment.
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Affiliation(s)
- Christopher Leyton
- Department of Medicine, Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, New York, USA
| | - Chenshu Zhang
- Department of Medicine, Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, New York, USA
| | - Sharon Rikin
- Department of Medicine, Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, New York, USA
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16
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Smith M, Vuernick E, Anderson D, Mulrooney M, Harel O, Allotey P. Pharmacist eConsult service for primary care medication optimization and safety. J Am Pharm Assoc (2003) 2021; 61:351-359. [PMID: 33678565 DOI: 10.1016/j.japh.2021.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 12/14/2020] [Accepted: 01/05/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND There is a critical need in primary care to proactively prevent, identify, and resolve poor medication-related outcomes. However, more than 80% of primary care practices do not have clinical pharmacists as members of expanded care teams. The emergence of eConsult services in primary care settings presents an opportunity for primary care providers (PCPs) to consult with clinical pharmacists as "on-demand" pharmacotherapy specialists. OBJECTIVES The objectives were to (1) determine the use of a clinical pharmacist in an existing eConsult network, (2) characterize the use and type of clinical pharmacist eConsults sent by PCPs, and (3) measure the implementation percentage of pharmacist recommendations by PCPs. METHODS The study was conducted in a federally qualified health center using an existing eConsult platform. A clinical pharmacist was contracted to receive eConsults and was expected to respond within 2 business days. PCPs were introduced to the pharmacist eConsult service through presentations that reviewed the clinical pharmacist's education/training, suitable pharmacist eConsult topics, and workflow for sending a pharmacist eConsult. RESULTS A total of 57 eConsults containing 123 individual questions were answered. Advanced practice nurses (APRNs) sent 3 times the number of eConsults and individual questions per eConsult compared with physicians (P < 0.0001). Most eConsult questions from APRNs related to adverse drug events/drug interactions (44%), drug or dosage changes to reach therapeutic goals (18%), and renal/hepatic dosage adjustments (13%). However, physician eConsult questions were primarily targeted on patient-specific drug or dosage adjustments (62%) and comprehensive medication regimen reviews (17%). A total of 74% of the pharmacist eConsult responses had at least 50% of the recommendations implemented by PCPs. CONCLUSION This study revealed the use of a pharmacist eConsult service for medication-related questions in an existing eConsult network for PCPs. As more practices enroll in value-based plans, pharmacist eConsults can improve the quality and safety of prescribing and chronic medication management.
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Liddy C, Sethuram C, Mihan A, Moroz I, Keely E. Primary Care Providers' Perspectives on the Ontario eConsult Program. Telemed J E Health 2020; 27:1039-1045. [PMID: 33252320 DOI: 10.1089/tmj.2020.0338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Electronic consultation (eConsult) allows asynchronous virtual communication between primary care providers (PCPs) and specialists regarding patient care. Introduction: The Ontario eConsult Program enables timely and equitable access to specialist advice for Ontarians. This study examines clinicians' perspectives and experiences with the program. Materials and Methods: We conducted an anonymous survey of PCPs registered for the Ontario eConsult Program. The survey ran from June to August 2019 and included questions on PCPs' experiences with the service, opinions on remuneration, and recommendations for enhancement. Results: One thousand two hundred fifty-six PCPs completed the survey (response rate of 16%). Seventy-eight percent had submitted an eConsult, of whom 67% were active users (i.e., had submitted ≥3 eConsults in the past 6 months). The majority of PCPs stated that their user experience was very good (57%) or good (31%), 74% agreed that eConsult improved their referral decision making, and 73% agreed that eConsult increased their ability to manage a broader array of diagnoses. Thirty-seven percent felt adequately compensated for using eConsult, 30% wanted higher rates of remuneration, and 31% were not compensated or were unaware of the fee code. Discussion: The majority of PCPs who use eConsult had positive experiences with the service. Nevertheless, improvements to further streamline the service's use, particularly through electronic medical record integration, were broadly cited as a desirable improvement. Conclusions: PCPs expressed an overall positive experience with the Ontario eConsult Program, citing prompt response times and improved care delivery as chief benefits.
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Affiliation(s)
- Clare Liddy
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, Canada.,Ontario eConsult Centre of Excellence, The Ottawa Hospital, Ottawa, Canada
| | - Claire Sethuram
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Canada
| | - Ariana Mihan
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Canada
| | - Isabella Moroz
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Canada
| | - Erin Keely
- Ontario eConsult Centre of Excellence, The Ottawa Hospital, Ottawa, Canada.,Department of Medicine, University of Ottawa, Ottawa, Canada.,Division of Endocrinology/Metabolism, The Ottawa Hospital, Ottawa, Canada
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18
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Rikin S, Zhang C, Lipsey D, Deluca J, Epstein EJ, Berger M, Tomer Y, Arnsten JH. Impact of an Opt-In eConsult Program on Primary Care Demand for Specialty Visits: Stepped-Wedge Cluster Randomized Implementation Study. J Gen Intern Med 2020; 35:832-838. [PMID: 32779140 PMCID: PMC7652962 DOI: 10.1007/s11606-020-06101-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 07/30/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND eConsult programs have been instituted to increase access to specialty expertise. Opt-in choice eConsult programs maintain primary care physician (PCP) autonomy to decide whether to utilize eConsults versus traditional specialty referrals, but little is known about how this intervention may impact PCP eConsult adoption and traditional referral demand. OBJECTIVE We assessed the feasibility of implementing an opt-in choice eConsult program and examined whether this intervention reduces demand for in-person visits for primary care patients requiring specialty expertise. DESIGN Stepped-wedge, cluster randomized trial conducted from July 2018 to June 2019. PARTICIPANTS Sixteen primary care practices in a large, urban academic health care system. INTERVENTION Our intervention was an opt-in choice eConsult available in addition to traditional specialty referral; our implementation strategy included in-person training, audit and feedback, and incentive payments. MAIN MEASURES Our implementation outcome measure was the eConsult rate: weekly proportion of eConsults per PCP visit at each site. Our intervention outcome measure was traditional referral rate: weekly proportion of referrals per PCP visit at each site. We also assessed PCP experiences with questionnaires. KEY RESULTS Of 305,915 in-person PCP visits, there were 31,510 traditional referrals to specialties participating in the eConsult program, and 679 eConsults. All but one primary care site utilized the opt-in choice eConsult program, with a weekly rate of 0.05 eConsults per 100 PCP visits by the end of the study period. The weekly rate of traditional referrals was 11 per 100 PCP visits at the end of the study period; this represents a significant increase in traditional referral rate after implementation of eConsults. PCPs were generally satisfied with the eConsult program and valued prompt provider-to-provider communication. CONCLUSIONS Implementation of an opt-in choice eConsult program resulted in widespread PCP adoption; however, this did not decrease the demand for traditional referrals. Future studies should evaluate different strategies to incentivize and increase eConsult utilization while maintaining PCP choice.
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Affiliation(s)
- Sharon Rikin
- Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA.
| | - Chenshu Zhang
- Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Daniel Lipsey
- Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Joseph Deluca
- Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Eric J Epstein
- Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Matt Berger
- Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Yaron Tomer
- Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Julia H Arnsten
- Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
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Asabor EN, Bunick CG, Cohen JM, Perkins SH. Patient and physician perspectives on teledermatology at an academic dermatology department amid the COVID-19 pandemic. J Am Acad Dermatol 2020; 84:158-161. [PMID: 32946971 PMCID: PMC7491373 DOI: 10.1016/j.jaad.2020.09.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 09/10/2020] [Accepted: 09/11/2020] [Indexed: 11/01/2022]
Affiliation(s)
- Emmanuella Ngozi Asabor
- Yale School of Medicine, Yale University, New Haven, Connecticut; Department of Epidemiology of Microbial Diseases, Yale School of Public Health, Yale University, New Haven, Connecticut
| | - Christopher G Bunick
- Department of Dermatology, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Jeffrey M Cohen
- Department of Dermatology, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Sara H Perkins
- Department of Dermatology, Yale School of Medicine, Yale University, New Haven, Connecticut.
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20
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Zallman L, Fisher CF, Ladner S, Mengistu K, Rapaport AB, Bor D, He Z, Sawady J, Stavert R, Nardin R, Bajracharya A, Pels R, Sayah A. Inter-clinician eConsults without programmatic incentives or requirements: a qualitative study of primary care provider perspectives. Fam Pract 2020; 37:525-529. [PMID: 32112080 DOI: 10.1093/fampra/cmaa016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Inter-clinician electronic consultation (eConsult) programmes are becoming more widespread in the USA as health care systems seek innovative ways of improving specialty access. Existing studies examine models with programmatic incentives or requirements for primary care providers (PCPs) to participate. OBJECTIVE We aimed to examine PCP perspectives on eConsults in a system with no programmatic incentive or requirement for PCPs to use eConsults. METHODS We conducted seven focus groups with 41 PCPs at a safety-net community teaching health care system in Eastern Massachusetts, USA. RESULTS Focus groups revealed that eConsults improved PCP experience by enabling patient-centred care and enhanced PCP education. However, increased workload and variations in communication patterns added challenges for PCPs. Patients were perceived as receiving timelier and more convenient care. Timelier care combined with direct documentation in the patient record was perceived as improving patient safety. Although cost implications were less clear, PCPs perceived costs as being lowered through fewer unnecessary visits and laboratories. CONCLUSIONS Our findings suggest that eConsult systems with no programmatic incentives or requirements for PCPs have the potential to improve care.
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Affiliation(s)
- Leah Zallman
- Cambridge Health Alliance, Cambridge, MA, USA.,Institute for Community Health, Malden, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Carolyn F Fisher
- Institute for Community Health, Malden, MA, USA.,Tufts School of Medicine, Boston, MA, USA
| | | | | | - Alison B Rapaport
- Cambridge Health Alliance, Cambridge, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - David Bor
- Cambridge Health Alliance, Cambridge, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Zhiheng He
- Cambridge Health Alliance, Cambridge, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Joel Sawady
- Cambridge Health Alliance, Cambridge, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Robert Stavert
- Cambridge Health Alliance, Cambridge, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Rachel Nardin
- Cambridge Health Alliance, Cambridge, MA, USA.,Harvard Medical School, Boston, MA, USA
| | | | - Richard Pels
- Cambridge Health Alliance, Cambridge, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Assaad Sayah
- Cambridge Health Alliance, Cambridge, MA, USA.,Harvard Medical School, Boston, MA, USA
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21
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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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Abstract
Obstructive sleep apnea (OSA) telehealth management may improve initial and chronic care access, time to diagnosis and treatment, between-visit care, e-communications and e-education, workflows, costs, and therapy outcomes. OSA telehealth options may be used to replace or supplement none, some, or all steps in the evaluation, testing, treatments, and management of OSA. All telehealth steps must adhere to OSA guidelines. OSA telehealth may be adapted for continuous positive airway pressure (CPAP) and non-CPAP treatments. E-data collection enhances uses for individual and group analytics, phenotyping, testing and treatment selections, high-risk identification and targeted support, and comparative and multispecialty therapy studies.
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23
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Verma R, Krishnamurti T, Ray KN. Parent Perspectives on Family-Centered Pediatric Electronic Consultations: Qualitative Study. J Med Internet Res 2020; 22:e16954. [PMID: 32084626 PMCID: PMC7180509 DOI: 10.2196/16954] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 01/19/2020] [Accepted: 01/26/2020] [Indexed: 01/09/2023] Open
Abstract
Background Electronic consultations, which use store-and-forward transfer of clinical information between a primary care physician and a specialist, improve access to specialty care. Adoption of electronic consultations is beginning in pediatric health care systems, but little is known about parent perspectives, informational needs, and preferences for interaction with this new model of care. Objective This study aimed to examine parent perspectives about electronic consultations, including perceived benefits and risks, anticipated informational needs, and preferences for parent engagement with electronic consultations. Methods We recruited caregivers of pediatric patients (aged 0-21 years) attending visits at an academic primary care center. Caregivers were eligible if their child had ever been referred for in-person specialty care. Caregivers participated in a semistructured interview about electronic consultations, including general perspectives, desired information, and preferences for parental engagement. Interviews were transcribed and qualitatively analyzed to identify parent perspectives on electronic consultations in general, information parents would like to receive about electronic consultations, and perspectives on opportunities to enhance parent engagement with electronic consultations. Results Interviewees (n=20) anticipated that electronic consultations would reduce the time burden of specialty care on families and that these had the potential to improve the integrity and availability of clinical information, but interviewees also expressed concern about data confidentiality. The most detailed information desired by interviewees about electronic consultations related to data security, including data confidentiality, availability, and integrity. Interviewees expressed concern that electronic consultations could exclude parents from their child’s health care decisions. Interviewees saw value in the potential ability to track the consultation status or to participate in the consultation dialogue, but they were more ambivalent about the idea of read-only access to consultation documentation. Conclusions Parents identified the potential risks and benefits of pediatric electronic consultations, with implications for communication with families about electronic consultations and for incorporation of features to enhance parent engagement.
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Affiliation(s)
- Rhea Verma
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Tamar Krishnamurti
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Kristin N Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
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24
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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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Wood BR, Bender JA, Jackson S, Rosengaus L, Pottinger PS, Gottlieb GS, Dhanireddy S, Harrington RD, Pruzhanskaya Y, Chew LD, Scott JD. Electronic Consults for Infectious Diseases in a United States Multisite Academic Health System. Open Forum Infect Dis 2020; 7:ofaa101. [PMID: 32328507 PMCID: PMC7166117 DOI: 10.1093/ofid/ofaa101] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 03/19/2020] [Indexed: 01/09/2023] Open
Abstract
We launched Infectious Disease electronic consultations (eConsults) in 2018. During the first 15.5 months, primary care practitioners submitted 328 eConsults; the most frequent reasons were a positive culture or polymerase chain reaction (PCR) result, syphilis, and latent tuberculosis. Practitioners commonly requested advice on antimicrobial choice, clinical evaluation, and indications for treatment. Internal phone consultations decreased after eConsult implementation.
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Affiliation(s)
- Brian R Wood
- Department of Medicine, University of Washington, Seattle, Washington, USA.,Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - Jessica A Bender
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Sara Jackson
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Leah Rosengaus
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Paul S Pottinger
- Department of Medicine, University of Washington, Seattle, Washington, USA.,Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - Geoffrey S Gottlieb
- Department of Medicine, University of Washington, Seattle, Washington, USA.,Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA.,Department of Global Health, University of Washington, Seattle, Washington, USA.,Center for Emerging and Re-Emerging Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - Shireesha Dhanireddy
- Department of Medicine, University of Washington, Seattle, Washington, USA.,Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - Robert D Harrington
- Department of Medicine, University of Washington, Seattle, Washington, USA.,Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
| | | | - Lisa D Chew
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - John D Scott
- Department of Medicine, University of Washington, Seattle, Washington, USA.,Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
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Electronic primary care to specialist referral: A pilot project to evaluate referral expedience and efficacy. J Am Assoc Nurse Pract 2020; 33:318-323. [PMID: 32097191 DOI: 10.1097/jxx.0000000000000377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 12/02/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Delayed referrals to specialists often result in increased morbidity and mortality. LOCAL PROBLEM A time delay in specialist care access of over 1 month identified a gap in efficient care provision in a rural south central United States outreach clinic within a multispecialty group affiliated with a hospital system. METHODS A pilot project with a mixed-methods design that compared the established referral process with direct primary provider referral to a specialist's electronic medical record (EMR) schedule. Authors conducted the study over 16 weeks using a convenience sample size of 74 patients. INTERVENTIONS Direct primary care nurse practitioner provider to specialist EMR schedule referral based on specialty referral needs. RESULTS All electronically referred patients were seen by specialists in less than 1 month. CONCLUSIONS All electronic specialist referrals were completed more expediently than those referred by the standard process and patients reported an efficient and satisfactory process.
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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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