Evaluation of an Electronic Consultation Service in Obstetrics and Gynecology in Ontario

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

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.

Family Physician-to-Hospital Specialist Electronic Consultation and Access to Hospital Care: A Systematic Review

Importance

Globally, health care systems face challenges in managing health care costs while maintaining access to hospital care, quality of care, and a good work balance for caregivers. Electronic consultations (e-consultations)-defined as asynchronous, consultative communication between family physicians and hospital specialists-may offer advantages to face these challenges.

Objective

To provide a quantitative synthesis of the association of e-consultation with access to hospital care and the avoidance of hospital referrals.

Evidence Review

A systematic search through PubMed, MEDLINE, and Embase was conducted. Eligible studies included original research studies published from January 2010 to March 2023 in English, Dutch, or German that reported on outcomes associated with access to hospital care and the avoidance of hospital referrals. Reference lists of included articles were searched for additional studies. Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) scores were assigned to assess quality of evidence.

Findings

The search strategy resulted in 583 records, of which 72 studies were eligible for data extraction after applying exclusion criteria. Most studies were observational, focused on multispecialty services, and were performed in either Canada or the US. Outcomes on access to hospital care and the avoidance of referrals indicated that e-consultation was associated with improved access to hospital care and an increase in avoided referrals to the hospital specialist, although outcomes greatly differed across studies. GRADE scores were low or very low across studies.

Conclusions and Relevance

In this systematic review of the association of e-consultation with access to hospital care and the avoidance of hospital referrals, results indicated that the use of e-consultation has greatly increased over the years. Although e-consultation was associated with improved access to hospital care and avoidance of hospital referrals, it was hard to draw a conclusion about these outcomes due to heterogeneity and lack of high-quality evidence (eg, from randomized clinical trials). Nevertheless, these results suggest that e-consultation seems to be a promising digital health care implementation, but more rigorous studies are needed; nonrandomized trial designs should be used, and appropriate outcomes should be chosen in future research on this topic.

Demand-oriented design of telemedical services in gynecologic oncology

BACKGROUND

The medical field is in the midst of a massive expansion in telemedical services. However, it is not possible to say to what extent telemedical offerings can be designed to meet needs in the German healthcare system. This study provides insights into demand-oriented care using telemedical services for gynecological patients.

METHODS

A total of 262 patients who received systemic therapy for gynecological oncology were surveyed anonymously using a questionnaire regarding their acceptance of telemedicine from February 2021 to April 2021.

RESULTS

Insufficient computer skills were associated with less acceptance of telemedicine treatment by gynecological oncology patients and presented a barrier. However, the patient's level of education was not related to the level of acceptance. Long travel distances from medical facilities and some types of patient occupations significantly increased the acceptance of telemedicine services. A high level of education, on the other hand, was not associated with the approval of telemedical approaches. Long journeys and work commitments increased the acceptance of telemedical visits.

CONCLUSIONS

The results of this study show that the factors investigated have an influence on the acceptance of telemedical offerings by patients. Barriers such as insufficient computer skills must be taken into account when implementing telemedicine services. Telemedicine can provide physical and economic relief for patients if telemedical planning is tailored to their needs.

Mapping Health Professions Education: Using Complexity Science to Make Sense of Learning Through Electronic Consultations

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.

The Use of Electronic Consultations in Outpatient Surgery Clinics: Synthesized Narrative Review

BACKGROUND

Electronic consultations (eConsults) are an increasingly used form of telemedicine that allows a nonspecialist clinician to seek specialist advice remotely without direct patient-specialist communication. Surgical clinics may see benefits from such forms of communication but face challenges with the need for intervention planning.

OBJECTIVE

We aimed to use the Quadruple Aim Framework to integrate published knowledge of surgical outpatient eConsults with regard to efficacy, safety, limitations, and evolving use in the era of COVID-19.

METHODS

We systematically searched for relevant studies across four databases (Ovid MEDLINE, Embase, Scopus, and Web of Science) on November 4, 2021, with the following inclusion criteria: English language, published in the past 10 years, and data on the outcomes of outpatient surgical eConsults.

RESULTS

A total of 363 studies were screened for eligibility, of which 33 (9.1%) were included. Most of the included studies were from the United States (23/33, 70%) and Canada (7/33, 21%), with a predominant multidisciplinary focus (9/33, 27%). Most were retrospective audits (16/33, 48%), with 15% (5/33) of the studies having a prospective component.

CONCLUSIONS

The surgical eConsult studies indicated a possible benefit for population health, promising safety results, enhanced patient and clinician experience, and cost savings compared with the traditional face-to-face surgical referral pathway. Their use appeared to be more favorable in some surgical subspecialties, and the overall efficacy was similar to that of medical subspecialties. Limited data on their long-term safety and use during the COVID-19 pandemic were identified, and this should be the focus of future research.

Barriers and Benefits of the Scheduled Telephone Referral Model (DETELPROG): A Qualitative Approach

The recently developed scheduled mobile-telephone referral model (DETELPROG) has achieved especially important results in reducing waiting days for patients, but it has been decided to explore what barriers and positive aspects were detected by both primary care physicians (PCPs) and hospital attending physicians (HAPs) regarding its use. For this, a qualitative descriptive study was carried out through six semi-structured interviews and two focus groups in a sample of eleven PCPs and five HAPs. Interviews were carried out from September 2019 to February 2020. Data were analysed by creating the initial categories, recording the sessions, transcribing the information, by doing a comprehensive reading of the texts obtained, and analysing the contents. The results show that DETELPROG gives the PCP greater prominence as a patient’s health coordinator by improving their relationship and patient safety; it also improves the relationship between PCP and HAP, avoiding unnecessary face-to-face referrals and providing safety to the PCP when making decisions. The barriers for DETELPROG to be used by PCP were defensive medicine, patients’ skepticism in DETELPROG, healthcare burden, and inability to focus on the patient or interpret a sign, symptom, or diagnostic test. For HAP, the barriers were lack of confidence in the PCP and complexity of the patient. As a conclusion, DETELPROG referral model provides a lot of advantages and does not pose any new barrier to face-to-face referral or other non-face-to-face referral models, so it should be implemented in primary care.

Experiences in Electronic Consultation (eConsult) Service in Gynecology from a Quaternary Academic Medical Center

To evaluate an academic institution’s implementation of a gynecologic electronic consultation (eConsult) service, including the most common queries, turnaround time, need for conversion to in-person visits, and to demonstrate how eConsults can improve access and convenience for patients and providers. This is a descriptive and retrospective electronic chart review. We obtained data from the UCSF eConsult and Smart Referral program manager. The medical system provided institution-wide statistics. Three authors reviewed and categorized gynecologic eConsults for the last fiscal year. The senior author resolved conflicts in coding. The eConsult program manager provided billing information and provider reimbursement. A total of 548 eConsults were submitted to the gynecology service between July 2017 and June 2020 (4.5% of institutional eConsult volume). Ninety-five percent of the eConsults were completed by a senior specialist within our department. Abnormal pap smear management, abnormal uterine bleeding, and contraception questions were the most common queries. Over half (59.3%) of all inquiries were answered on the same day as they were received, with an average of 9% declined. Gynecology was the 10th largest eConsult provider at our institution in 2020. The present investigation describes one large university-based experience with eConsults in gynecology. Results demonstrate that eConsults permit appropriate, efficient triaging of time-sensitive conditions affecting patients especially in the time of the COVID-19 pandemic. eConsult services provide the potential to improve access, interdisciplinary communication, and patient and provider satisfaction.

Electronic consultations (E-consults) and their outcomes: a systematic review

OBJECTIVE

Electronic consultations (e-consults) are clinician-to-clinician communications that may obviate face-to-face specialist visits. E-consult programs have spread within the US and internationally despite limited data on outcomes. We conducted a systematic review of the recent peer-reviewed literature on the effect of e-consults on access, cost, quality, and patient and clinician experience and identified the gaps in existing research on these outcomes.

MATERIALS AND METHODS

We searched 4 databases for empirical studies published between 1/1/2015 and 2/28/2019 that reported on one or more outcomes of interest. Two investigators reviewed titles and abstracts. One investigator abstracted information from each relevant article, and another confirmed the abstraction. We applied the GRADE criteria for the strength of evidence for each outcome.

RESULTS

We found only modest empirical evidence for effectiveness of e-consults on important outcomes. Most studies are observational and within a single health care system, and comprehensive assessments are lacking. For those outcomes that have been reported, findings are generally positive, with mixed results for clinician experience. These findings reassure but also raise concern for publication bias.

CONCLUSION

Despite stakeholder enthusiasm and encouraging results in the literature to date, more rigorous study designs applied across all outcomes are needed. Policy makers need to know what benefits may be expected in what contexts, so they can define appropriate measures of success and determine how to achieve them.

Evaluating the use of telemedicine in gynaecological practice: a systematic review

OBJECTIVES

The aim of this systematic review is to examine the use of telemedicine in the delivery and teaching of gynaecological clinical practice. To our knowledge, no other systematic review has assessed this broad topic.

DESIGN

Systematic review of all studies investigating the use of telemedicine in the provision of gynaecological care and education. The search for eligible studies followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and focused on three online databases: PubMed, Science Direct and SciFinder.

ELIGIBILITY CRITERIA

Only studies within gynaecology were considered for this review. Studies covering only obstetrics and with minimal information on gynaecology, or clinical medicine in general were excluded. All English language, peer-reviewed human studies were included. Relevant studies published up to the date of final submission of this review were considered with no restrictions to the publication year.

DATA EXTRACTIONS AND SYNTHESIS

Data extracted included author details, year of publication and country of the study, study aim, sample size, methodology, sample characteristics, outcome measures and a summary of findings. Data extraction and qualitative assessment were performed by the first author and crossed checked by the second author. Quality assessment for each study was assessed using the Newcastle-Ottawa scale.

RESULTS

A literature search carried out in August 2020 yielded 313 records published between 1992 and 2018. Following a rigorous selection process, only 39 studies were included for this review published between 2000 and 2018. Of these, 19 assessed gynaecological clinical practice, eight assessed gynaecological education, one both, and 11 investigated the feasibility of telemedicine within gynaecological practice. 19 studies were classified as good, 12 fair and eight poor using the Newcastle-Ottawa scale. Telecolposcopy and abortion care were two areas where telemedicine was found to be effective in potentially speeding up diagnosis as well as providing patients with a wide range of management options. Studies focusing on education demonstrated that telementoring could improve teaching in a range of scenarios such as live surgery and international teleconferencing.

CONCLUSIONS

The results of this review are promising and demonstrate that telemedicine has a role to play in improving clinical effectiveness and education within gynaecology. Its applications have been shown to be safe and effective in providing remote care and training. In the future, randomised controlled studies involving larger numbers of patients and operators with measurable outcomes are required in order to be able to draw reliable conclusions.

Optimization of transmural care by implementation of an online expert panel to assess treatment strategy in patients suffering from colorectal cancer liver metastases: A prospective analysis

INTRODUCTION

Centralization of oncological care results in a growing demand for specialized consultations and referrals. Improved telemedicine solutions are needed to facilitate access to specialist care and select patients eligible for referral. The purpose of this quality improvement initiative was to optimize transmural care for patients suffering from colorectal cancer liver metastases through implementation of an online expert panel.

METHODS

A digital communication platform was developed to share medical data, including high-quality diagnostic imaging of patients suffering from colorectal cancer liver metastases. Feasibility of local treatment strategies was assessed by a panel of liver specialists to select patients for referral. After implementation, an observational cohort study was conducted to evaluate quality improvement in transmural care using revised Standards for Quality Improvement Reporting Excellence guidelines.

RESULTS

From September 2016-September 2018, eight hospitals were connected to the platform, covering a population of 3 m. In total, 123 cases were assessed, of which 54 (43.9%) were prevented from needless physical referral. Assessment of treatment strategy by an online expert panel significantly reduced the average lead time during multidisciplinary team meetings from 3.73 min to 2.12 min per patient (p < 0.01).

CONCLUSIONS

Implementation of an online expert panel is an innovative, accessible and user-friendly way to provide cancer-specific expertise to regional hospitals. E-consultation of such panels may result in more efficient multidisciplinary team meetings and prevent fragile patients from needless referral. Sustainability of these panels however is subject to structural financial compensation, so a cost-effectiveness analysis is warranted.

Electronic Consultation Between Primary Care Providers and Radiologists

OBJECTIVE. The purpose of this study was to assess the use of an electronic consultation platform to connect primary care providers and radiologists and provide opportunities for valuable consultation regarding diagnostic imaging in patients, as well as to identify opportunities for targeted education surrounding high-yield radiology topics. MATERIALS AND METHODS. A retrospective review was performed of consultations conducted using the electronic platform from September 2012 to January 2017. Consultations were classified by subspecialty (neuroradiology, thoracic, abdominal, musculoskeletal, or pediatric radiology), question type (workup, surveillance, education, specialist referral query, discharge, or other), anatomy, and pathology. Feedback surveys were completed by primary care providers after each consultation to evaluate timeliness, value, and impact on patient care. RESULTS. A total of 302 consultations were reviewed. Subspecialty breakdown was as follows: abdominal, 94/302 (31%); neuroradiology, 74/302 (25%); musculoskeletal, 61/302 (20%); thoracic, 56/302 (19%); and pediatric, 17/302 (6%). The majority of consultations pertained to patient workup (112/302 [37%]), surveillance of imaging findings (95/302 [31%]), and provider education (48/302 [16%]). Cystic lesions (38/302 [13%]), pain (24/302 [8%]), and bone lesions (21/302 [7%]) were the most queried conditions. Patient management was altered in 167 cases (55%), and unnecessary testing was avoided in 84 (28%). Providers rated the perceived value of the electronic consultation system as excellent in 227 cases (75%). CONCLUSION. The electronic consultation system allowed primary care providers to easily consult with radiologists, was perceived as high value by primary care providers, resulted in altered patient management, and avoided unnecessary imaging tests. We identified follow-up imaging of cystic lesions and imaging workup of pain in patients as opportunities for continuing medical education for primary care providers.

Overcoming Barriers to Accessing Obstetric Care in Underserved Communities

Changes in the current workforce of obstetrician-gynecologists and other health care providers of obstetric care, as well as changes in the delivery of health care services, prompt health care leaders to consider alternative strategies for approaching the essential shortage of obstetric care providers and facilities. Geographic variations in health care needs and resources require a tailored approach by individual communities and local health care providers. New and emerging technologies can support a range of innovative solutions to health care access limitations. This article describes an alternative model for remote obstetric care and quality review in Santa Fe, New Mexico, that is applicable to any community facing limited access to full-spectrum obstetric care.

Barriers and facilitators for implementation of electronic consultations (eConsult) to enhance access to specialist care: a scoping review

INTRODUCTION

Electronic consultation (eConsult)-provider-to-provider electronic asynchronous exchanges of patient health information at a distance-is emerging as a potential tool to improve the interface between primary care providers and specialists. Despite growing evidence that eConsult has clinical benefits, it is not widely adopted. We investigated factors influencing the adoption and implementation of eConsult services.

METHODS

We applied established methods to guide the review, and the recently published Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews to report our findings. We searched five electronic databases and the grey literature for relevant studies. Two reviewers independently screened titles and full texts to identify studies that reported barriers to and/or facilitators of eConsult (asynchronous (store-and-forward) use of telemedicine to exchange patient health information between two providers (primary and secondary) at a distance using secure infrastructure). We extracted data on study characteristics and key barriers and facilitators were analysed thematically and classified using the Quadruple Aim framework taxonomy. No date or language restrictions were applied.

RESULTS

Among the 2579 publications retrieved, 130 studies met eligibility for the review. We identified and summarised key barriers to and facilitators of eConsult adoption and implementation across four domains: provider, patient, healthcare system and cost. Key barriers were increased workload for providers, privacy concerns and insufficient reimbursement for providers. Main facilitators were remote residence location, timely responses from specialists, utilisation of referral coordinators, addressing medicolegal concerns and incentives for providers to use eConsult.

CONCLUSION

There are multiple barriers to and facilitators of eConsult adoption across the domains of Quadruple Aim framework. Our findings will inform the development of practice tools to support the wider adoption and scalability of eConsult implementation.

Evolving Toward Shared HIV Care Using the Champlain BASE eConsult Service

Background. Electronic consultation (eConsultation) is a potential strategy to improve access to specialist expertise and facilitate collaborative care models. The Champlain BASE eConsult service allows for asynchronous communication between primary care providers (PCP) and specialists on a secure, web-based system. HIV experts accessible include HIV physician specialists, HIV pharmacists, and social workers with expertise in HIV. Objective. This study aims to describe the use, value, and utility of this eConsultation service in the care of people living with HIV and to characterize the common question types and clinical topics asked by PCPs. Methods. We analyzed the data from eConsults sent to the HIV specialty group in Ontario’s Champlain Local Health Integration Network between February 2015 and December 2017. Usage data and close-out survey responses were analyzed using descriptive statistics, eConsults were classified using a predefined list of validated taxonomy, and a thematic analysis was performed on the consultation logs to identify common clinical themes. Results. Among the 46 eConsults, the most common question type related to drug treatment (58.7%, n = 27) and management (19.6%, n = 9). The main clinical themes involved the care of significant complexities in people living with HIV, such as comorbidities and drug interactions, and suggestions of coordinated patient care. As well, eConsult was used for advice regarding pre-exposure prophylaxis for HIV-negative patients at risk of HIV infection. PCPs highly valued the eConsult service (average rating 4.8/5). Conclusion. Overall, this study demonstrates that eConsult provides an efficient and valuable service to PCPs caring for patients living with or at risk for HIV by improving access to HIV specialists and facilitating the delivery of team-based comprehensive care.

A pilot eConsultation service in Eastern Ontario: bridging clinical genetics and primary care

With the rising demand for clinical genetics services, it is a challenge for clinical geneticists to meet the needs of patients and referring primary care providers in a timely way, using current models of genetics health care delivery. One method of providing primary care providers with greater access to clinical genetics expertise is through an electronic consultation (eConsult) service. We describe here a pilot project of a clinical genetics eConsult service that our genetics centre in Eastern Ontario, Canada provided, using the Champlain Building Access to Specialists through eConsultation (BASE)^TM web-based application. We analyzed 111 genetics eConsults submitted by primary care providers to a single clinical geneticist over a 28-month time period. More than half (54%) of the eConsult questions were regarding (1) hereditary cancer and (2) genetic syndromes, with the remainder encompassing a wide variety of clinical genetics topics. We avoided a referral to the Genetics clinic for an in-person appointment for 30% of the eConsult cases, based on a contemplated referral rate to Genetics clinic of 72% prior to eConsult and a planned referral rate to Genetics clinic of 42% following all eConsults. Primary care providers rated the eConsult service of high value to themselves and also to their patients. This pilot service supports the potential of an eConsultation service to create a stronger and more dynamic link between clinical genetics and primary care providers, which may lead to better patient care.

Cardiology electronic consultation (e-consult) use by primary care providers at VA medical centres in New England

INTRODUCTION

E-consultations (e-consults) were implemented at VA medical centers to improve access to specialty care. Cardiology e-consults are among the most commonly requested, but little is known about how primary care providers (PCPs) use cardiology e-consults to access specialty care.

METHODS

This is a retrospective analysis of 750 patients' medical charts with cardiology e-consults requested by medical providers (October 2013-September 2015) in the VA New England Healthcare System. We described the patients and referring provider characteristics, and e-consult questions. We reviewed cardiologists' responses and examined their recommendations.

RESULTS

Among the 424 e-consults requested from PCPs, 92.7% were used to request answers to clinical questions, while 7.3% were used for administrative purposes. Among the 393 e-consults with clinical questions, 60 e-consults were regarding preoperative management; these questions most commonly addressed general risk assessment (n = 44), anti-coagulation/anti-platelet management (n = 33), and EKG interpretation (n = 20). Cardiologists provided answers for the majority (89.6%) of clinical questions. Among the e-consults in which cardiologists did not provide answers or clinical guidance (n = 41), the reasons included missing or insufficient clinical information (n = 18), medical complexity (n = 6), and deferment to the patient's non-VA primary cardiologist (n = 7). Cardiologists recommended that the patients be seen as face-to-face consults for 7.9% of e-consults.

DISCUSSION

Primary care providers are the most frequent requesters of cardiology e-consults, using them primarily to obtain input on clinical questions. Cardiologists did not provide answers for one in ten, owing principally to insufficient available clinical information. Educating PCPs and standardizing the template for requesting e-consultation may help to reduce the number of unanswered e-consults.

Using Clinical Questions Asked by Primary Care Providers Through eConsults to Inform Continuing Professional Development

INTRODUCTION

Continuing professional development (CPD) offerings should address the educational needs of health care providers. Innovative programs, such as electronic consultations (eConsults), provide unique educational opportunities for practice-based needs assessment. The purpose of this study is to assess whether CPD offerings match the needs of physicians by coding and comparing session content to clinical questions asked through eConsults.

METHODS

This study analyzes questions asked by primary care providers between July 2011 and January 2015 using a service that allows specialists to provide consultation over a secure web-based server. The content of these questions was compared with the CPD courses offered in the area in which these primary care providers are practicing over a similar period (2012-2014). The clinical questions were categorized by the content area. The percentage of questions asked about each content area was calculated for each of the 12 specialties consulted. CPD course offerings were categorized using the same list of content areas. Percentage of minutes dedicated to each content area was calculated for each specialty. The percentage of questions asked and the percentage of CPD course minutes for each content area were compared.

RESULTS

There were numerous congruencies and discrepancies between the proportion of questions asked about a given content area and the CPD minutes dedicated to it.

DISCUSSION

Traditional needs assessment may underestimate the need to address topics that are frequently the subject of eConsults. Planners should recognize eConsult questions as a valuable source of practice-associated challenges that can identify professional development needs of physicians.

Improving access to urologists through an electronic consultation service

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.

Improving access to otolaryngology-head and neck surgery expert advice through eConsultations

OBJECTIVES/HYPOTHESIS

Prolonged wait times have become common. Electronic consultations (eConsults) have been shown in previous studies to reduce unnecessary face-to-face consultations to specialists, but no prior study has investigated the feasibility or efficacy of eConsults in an otolaryngology-head and neck surgery (OTO-HNS) practice.

STUDY DESIGN

Prospective observational study.

METHODS

The Champlain BASE eConsult system is a secure web portal allowing primary care physicians (PCPs) to communicate asynchronously with specialists about a patient, without requiring a formal face-to-face consult. The data from all eConsults sent through this portal to OTO-HNS practices between July 2011 and January 2015 were collected and analyzed.

RESULTS

Response time was rapid; over 40% of eConsults received a response within 24 hours, and nearly all eConsults were answered within 7 calendar days. The median response time was nearly 29 times faster than traditional face-to-face consultation. Unnecessary face-to-face referrals were avoided in 33.4% of all eConsults, and in nearly 50% of cases where the PCP initially planned a formal referral. PCPs reported adopting a new or additional course of action over 50% of the time following an eConsult. Eighty-eight percent of PCPs reported the service to be valuable for their patients, and 92% found it valuable for themselves. eConsults require only a limited time commitment from specialists, with over 75% taking less than 10 minutes to complete.

CONCLUSIONS

eConsultation is a cost-effective system that can lead to decreased wait times, improved communication between PCPs and otolaryngologists, and help guide the development of targeted continuing professional development modules for PCPs.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:350-355, 2018.

Telehealth interventions for reducing waiting lists and waiting times for specialist outpatient services: A scoping review

We undertook a scoping review of the published literature to identify and summarise key findings on the telehealth interventions that influence waiting times or waiting lists for specialist outpatient services. Searches were conducted to identify relevant articles. Articles were included if the telehealth intervention restructured or made the referral process more efficient. We excluded studies that simply increased capacity. Two categories of interventions were identified - electronic consultations and image-based triage. Electronic consultations are asynchronous, text-based provider-to-provider consultations. Electronic consultations have been reported to obviate the need for face-to-face appointments between the patient and the specialist in between 34-92% of cases. However, it is often reported that electronic consultations are appropriate in less than 10% of referrals for outpatient care. Image-based triage has been used successfully to reduce unnecessary or inappropriate referrals and was used most often in dermatology, ophthalmology and otolaryngology (ENT). Reported reduction rates for face-to-face appointments by specialty were: dermatology 38-88%, ophthalmology 16-48% and ENT 89%. Image-based triage can be twice as effective as non-image based triage in reducing unnecessary appointments. Telehealth interventions can effectively be used to reduce waiting lists and improve the coordination of specialist services, and should be considered in conjunction with clinical requirements.