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Keuper J, van Tuyl LHD, de Geit E, Rijpkema C, Vis E, Batenburg R, Verheij R. The impact of eHealth use on general practice workload in the pre-COVID-19 era: a systematic review. BMC Health Serv Res 2024; 24:1099. [PMID: 39300456 DOI: 10.1186/s12913-024-11524-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 09/02/2024] [Indexed: 09/22/2024] Open
Abstract
BACKGROUND In recent years, eHealth has received much attention as an opportunity to increase efficiency within healthcare organizations. Adoption of eHealth might consequently help to solve perceived health workforce challenges, including labor shortages and increasing workloads among primary care professionals, who serve as the first point of contact for healthcare in many countries. The purpose of this systematic review was to investigate the impact of general eHealth use and specific eHealth services use on general practice workload in the pre-COVID-19 era. METHODS The databases of CINAHL, Cochrane, Embase, IEEE Xplore, Medline ALL, PsycINFO, Web of Science, and Google Scholar were searched, using combinations of keywords including 'eHealth', 'workload', and 'general practice'. Data extraction and quality assessment of the included studies were independently performed by at least two reviewers. Publications were included for the period 2010 - 2020, before the start of the COVID-19 pandemic. RESULTS In total, 208 studies describing the impact of eHealth services use on general practice workload were identified. We found that two eHealth services were mainly investigated within this context, namely electronic health records and digital communication services, and that the largest share of the included studies used a qualitative study design. Overall, a small majority of the studies found that eHealth led to an increase in general practice workload. However, results differed between the various types of eHealth services, as a large share of the studies also reported a reduction or no change in workload. CONCLUSIONS The impact of eHealth services use on general practice workload is ambiguous. While a small majority of the effects indicated that eHealth increased workload in general practice, a large share of the effects also showed that eHealth use reduced workload or had no impact. These results do not imply a definitive conclusion, which underscores the need for further explanatory research. Various factors, including the study setting, system design, and the phase of implementation, may influence this impact and should be taken into account when general practices adopt new eHealth services. STUDY REGISTRATION NUMBER PROSPERO (International Prospective Register of Systematic Reviews) CRD42020199897; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=199897 .
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Affiliation(s)
- Jelle Keuper
- Netherlands Institute for Health Services Research (NIVEL), Otterstraat 118, Utrecht, 3513CR, Netherlands.
- Tranzo, Tilburg School of Social and Behavioral Sciences, Tilburg University, Professor Cobbenhagenlaan 125, Tilburg, 5037DB, Netherlands.
| | - Lilian H D van Tuyl
- Netherlands Institute for Health Services Research (NIVEL), Otterstraat 118, Utrecht, 3513CR, Netherlands
| | - Ellemarijn de Geit
- Netherlands Institute for Health Services Research (NIVEL), Otterstraat 118, Utrecht, 3513CR, Netherlands
| | - Corinne Rijpkema
- Netherlands Institute for Health Services Research (NIVEL), Otterstraat 118, Utrecht, 3513CR, Netherlands
- Tranzo, Tilburg School of Social and Behavioral Sciences, Tilburg University, Professor Cobbenhagenlaan 125, Tilburg, 5037DB, Netherlands
| | - Elize Vis
- Netherlands Institute for Health Services Research (NIVEL), Otterstraat 118, Utrecht, 3513CR, Netherlands
| | - Ronald Batenburg
- Netherlands Institute for Health Services Research (NIVEL), Otterstraat 118, Utrecht, 3513CR, Netherlands
- Department of Sociology, Radboud University Nijmegen, Thomas van Aquinostraat 4, Nijmegen, 6525GD, Netherlands
| | - Robert Verheij
- Netherlands Institute for Health Services Research (NIVEL), Otterstraat 118, Utrecht, 3513CR, Netherlands
- Tranzo, Tilburg School of Social and Behavioral Sciences, Tilburg University, Professor Cobbenhagenlaan 125, Tilburg, 5037DB, Netherlands
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Fouladvand S, Gomez FR, Nilforoshan H, Schwede M, Noshad M, Jee O, You J, Sosic R, Leskovec J, Chen J. Graph-based clinical recommender: Predicting specialists procedure orders using graph representation learning. J Biomed Inform 2023; 143:104407. [PMID: 37271308 DOI: 10.1016/j.jbi.2023.104407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 05/15/2023] [Accepted: 05/25/2023] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To determine whether graph neural network based models of electronic health records can predict specialty consultation care needs for endocrinology and hematology more accurately than the standard of care checklists and other conventional medical recommendation algorithms in the literature. METHODS Demand for medical expertise far outstrips supply, with tens of millions in the US alone with deficient access to specialty care. Rather than potentially months long delays to initiate diagnostic workup and medical treatment with a specialist, referring primary care supported by an automated recommender algorithm could anticipate and directly initiate patient evaluation that would otherwise be needed at subsequent a specialist appointment. We propose a novel graph representation learning approach with a heterogeneous graph neural network to model structured electronic health records and formulate recommendation/prediction of subsequent specialist orders as a link prediction problem. RESULTS Models are trained and assessed in two specialty care sites: endocrinology and hematology. Our experimental results show that our model achieves an 8% improvement in ROC-AUC for endocrinology (ROC-AUC = 0.88) and 5% improvement for hematology (ROC-AUC = 0.84) personalized procedure recommendations over prior medical recommender systems. These recommender algorithm approaches provide medical procedure recommendations for endocrinology referrals more effectively than manual clinical checklists (recommender: precision = 0.60, recall = 0.27, F1-score = 0.37) vs. (checklist: precision = 0.16, recall = 0.28, F1-score = 0.20), and similarly for hematology referrals (recommender: precision = 0.44, recall = 0.38, F1-score = 0.41) vs. (checklist: precision = 0.27, recall = 0.71, F1-score = 0.39). CONCLUSION Embedding graph neural network models into clinical care can improve digital specialty consultation systems and expand the access to medical experience of prior similar cases.
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Affiliation(s)
- Sajjad Fouladvand
- Biomedical Informatics Research, Stanford University, Stanford, CA, United States of America.
| | - Federico Reyes Gomez
- Computer Science Department, Stanford University, Stanford, CA, United States of America.
| | - Hamed Nilforoshan
- Computer Science Department, Stanford University, Stanford, CA, United States of America.
| | - Matthew Schwede
- Biomedical Informatics Research, Stanford University, Stanford, CA, United States of America.
| | - Morteza Noshad
- Biomedical Informatics Research, Stanford University, Stanford, CA, United States of America.
| | - Olivia Jee
- Primary Care and Population Health, Stanford University, Stanford, CA, United States of America.
| | - Jiaxuan You
- Computer Science Department, Stanford University, Stanford, CA, United States of America.
| | - Rok Sosic
- Computer Science Department, Stanford University, Stanford, CA, United States of America.
| | - Jure Leskovec
- Computer Science Department, Stanford University, Stanford, CA, United States of America.
| | - Jonathan Chen
- Biomedical Informatics Research, Stanford University, Stanford, CA, United States of America; Division of Hospital Medicine, Stanford University, Stanford, CA, United States of America; Clinical Excellence Research Center, Stanford University, Stanford, CA, United States of America.
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Epstein JA, Lkhagvajav Z, Young T, Bertram A, Yeh HC, Taylor CO. Will the Doctor "See" You Now? The Development and Implementation of a Targeted Telemedicine System for Primary Care. ACI OPEN 2023; 7:e71-e78. [PMID: 37900978 PMCID: PMC10610031 DOI: 10.1055/s-0043-1776038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
Objectives The coronavirus disease 2019 (COVID-19) pandemic led to a rapid adoption of telehealth. For underserved populations lacking internet access, telemedicine was accomplished by phone rather than an audio-video connection. The latter is presumed a more effective form and better approximation of an in-person visit. We sought to provide a telehealth platform to overcome barriers for underserved groups to hold video visits with their health care providers and evaluate differences between the two telehealth modalities as assessed by physicians and patients. Methods We designed a simplified tablet solution for video visits and piloted its use among patients who otherwise would have been completing audio-only visits. Patients consented to participation and were randomized in a 1:1 fashion to continue with their scheduled phone visit (control) versus being shipped a tablet to facilitate a video visit (intervention). Participants and providers completed communication and satisfaction surveys. Results Tablet and connectivity design features included removal of all functions but for the telemedicine program, LTE always-on wireless internet connectivity, absence of external equipment (cords chargers and keyboard), and no registration with a digital portal. In total, 18 patients were enrolled. Intervention patients with video-enabled devices compared to control patients agreed more strongly that they were satisfied with their visits (4.75/5 vs. 3.75/5, p = 0.02). Conclusion The delivered simplified tablet solution for video visits holds promise to improve access to video visits for underserved groups. Strategies to facilitate patient acceptance of devices are needed to expand the scope and potential impact of this effort.
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Affiliation(s)
- Jeremy A. Epstein
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Zoljargal Lkhagvajav
- Institute for Computational Medicine, Johns Hopkins University Whiting School of Engineering, Baltimore, Maryland, United States
| | - Tempest Young
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Amanda Bertram
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Hsin-Chieh Yeh
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Casey Overby Taylor
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
- Institute for Computational Medicine, Johns Hopkins University Whiting School of Engineering, Baltimore, Maryland, United States
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland, United States
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Archibald D, Grant R, Tuot DS, Liddy C, Sewell JL, Price DW, Grad R, Shipman SA, Campbell C, Guglani S, Wood TJ, Keely E. Development of eConsult reflective learning tools for healthcare providers: a pragmatic mixed methods approach. BMC PRIMARY CARE 2023; 24:15. [PMID: 36647016 PMCID: PMC9841624 DOI: 10.1186/s12875-022-01948-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 12/14/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Electronic consultation (eConsult) programs are crucial components of modern healthcare that facilitate communication between primary care providers (PCPs) and specialists. eConsults between PCPs and specialists. They also provide a unique opportunity to use real-world patient scenarios for reflective learning as part of professional development. However, tools that guide and document learning from eConsults are limited. The purpose of this study was to develop and pilot two eConsult reflective learning tools (RLTs), one for PCPs and one for specialists, for those participating in eConsults. METHODS We performed a four-phase pragmatic mixed methods study recruiting PCPs and specialists from two public health systems located in two countries: eConsult BASE in Canada and San Francisco Health Network eConsult in the United States. In phase 1, subject matter experts developed preliminary RLTs for PCPs and specialists. During phase 2, a Delphi survey among 20 PCPs and 16 specialists led to consensus on items for each RLT. In phase 3, we conducted cognitive interviews with three PCPs and five specialists as they applied the RLTs on previously completed consults. In phase 4, we piloted the RLTs with eConsult users. RESULTS The RLTs were perceived to elicit critical reflection among participants regarding their knowledge and practice habits and could be used for quality improvement and continuing professional development. CONCLUSION PCPs and specialists alike perceived that eConsult systems provided opportunities for self-directed learning wherein they were motivated to investigate topics further through the course of eConsult exchanges. We recommend the RLTs be subject to further evaluation through implementation studies at other sites.
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Affiliation(s)
- Douglas Archibald
- grid.28046.380000 0001 2182 2255Department of Family Medicine, C.T. Lamont Primary Health Care Research Centre, University of Ottawa, Ottawa, Canada ,grid.418792.10000 0000 9064 3333Bruyère Research Institute, Ottawa, Canada ,grid.28046.380000 0001 2182 2255Faculty of Education, University of Ottawa, Ottawa, Canada
| | - Rachel Grant
- grid.28046.380000 0001 2182 2255Faculty of Education, University of Ottawa, Ottawa, Canada
| | - Delphine S. Tuot
- grid.266102.10000 0001 2297 6811Department of Medicine, Division of Nephrology, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, CA USA
| | - Clare Liddy
- grid.28046.380000 0001 2182 2255Department of Family Medicine, C.T. Lamont Primary Health Care Research Centre, University of Ottawa, Ottawa, Canada ,grid.418792.10000 0000 9064 3333Bruyère Research Institute, Ottawa, Canada ,grid.412687.e0000 0000 9606 5108Ontario eConsult Centre of Excellence, The Ottawa Hospital, Ottawa, Canada
| | - Justin L. Sewell
- grid.266102.10000 0001 2297 6811Department of Medicine, Division of Gastroenterology, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, CA USA
| | - David W. Price
- grid.430503.10000 0001 0703 675XDepartment of Family Medicine, University of Colorado Anschutz School of Medicine, Aurora, CO USA ,The American Board of Family Medicine, Lexington, KY USA
| | - Roland Grad
- grid.14709.3b0000 0004 1936 8649Department of Family Medicine, McGill University, Montreal, Canada
| | - Scott A. Shipman
- grid.414000.10000 0000 8652 9597Association of American Medical Colleges, Washington, DC USA ,grid.254748.80000 0004 1936 8876Creighton University, Omaha, NE USA
| | - Craig Campbell
- grid.28046.380000 0001 2182 2255Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Sheena Guglani
- grid.418792.10000 0000 9064 3333Bruyère Research Institute, Ottawa, Canada ,grid.412687.e0000 0000 9606 5108Ontario eConsult Centre of Excellence, The Ottawa Hospital, Ottawa, Canada
| | - Timothy J. Wood
- grid.28046.380000 0001 2182 2255Department of Innovation in Medical Education, University of Ottawa, Ottawa, Canada
| | - Erin Keely
- grid.412687.e0000 0000 9606 5108Ontario eConsult Centre of Excellence, The Ottawa Hospital, Ottawa, Canada ,grid.28046.380000 0001 2182 2255Department of Medicine, University of Ottawa, Ottawa, Canada
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Chisci E, Parlani G, Gatta E, Isernia G, de Donato G, Antonello M, Simonte G, Kölbel T, Bertoglio L, Yeung KK, Donas K, Fazzini S, Dias N, Michelagnoli S. “The New Educational Project TELEVASCULAR GAMES During COVID-19 Pandemic.”. J Vasc Surg Cases Innov Tech 2022; 8:638-645. [PMID: 35873717 PMCID: PMC9296369 DOI: 10.1016/j.jvscit.2022.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 05/12/2022] [Indexed: 11/02/2022] Open
Abstract
Objective Methods Results Conclusions
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Sindhu S. Digital health care services in post COVID-19 scenario: modeling the enabling factors. INTERNATIONAL JOURNAL OF PHARMACEUTICAL AND HEALTHCARE MARKETING 2022. [DOI: 10.1108/ijphm-04-2021-0046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
The recent pandemic of COVID-19 has posed challenges for delivering essential and desirable health-care services for the masses. Digital health-care services initiated by several hospitals and health practitioners promise efficient and safe health care in the new normal post-COVID era but need a supportive enabling ecosystem. Therefore, this study aims toward identifying and modeling the key enabling factors for digital health-care services.
Design/methodology/approach
A total of nine factors were identified from the literature review and verified by the domain experts which can enable the wider acceptance of digital health-care services. The identified factors were then modeled with the help of the total interpretive structural modeling (TISM) approach and fuzzy Matrices d’Impacts Croises Multiplication Appliquée à un Classement (MICMAC) and a meaningful contextual relationship were developed for the factors.
Findings
This study reflects that the trust of patients is required for the acceptance of digital health care. Quality of patient care and affordability cum accessibility of online services will define mass engagement. Hospital staff resilience, hospital care service capacity, strategic partnerships and collaborations supported by technology and regulatory structure are the major factors defining the enabling ecosystem.
Originality/value
This study has its uniqueness in the way the TISM approach and fuzzy MICMAC are used for modeling the enabling factors toward growth and acceptance of digital health-care services in the days to come in developing nations. The focus of this study can be considered as relevant for the study interested in investigating the role of cognitive dimensions in influencing actors’ behaviors and decisions.
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[E-consultation as a tool for the relationship between Primary Care and Endocrinology. Impact of COVID-19 epidemic in its use]. J Healthc Qual Res 2022; 37:155-161. [PMID: 34866028 PMCID: PMC9847372 DOI: 10.1016/j.jhqr.2021.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 07/20/2021] [Accepted: 10/05/2021] [Indexed: 01/23/2023]
Abstract
INTRODUCTION Electronic consultation (eConsultation) can precede, complete, or replace visits to the specialist. OBJECTIVE To describe the profile of eConsultations issued from Primary Care (PC) to the Endocrinology Unit since their implementation in our hospital, to assess the response time and to evaluate changes in trends in relation to the COVID19 pandemic. A secondary objective is to evaluate the degree of satisfaction of PC specialists with this tool. MATERIAL AND METHODS An observational retrospective study of Endocrinology eConsultations conducted from June 2019 to October 2020 analysing 2periods: pre-COVID and post-COVID. The degree of satisfaction of the Family and Community Medicine specialists was assessed by means of a questionnaire. RESULTS 391 eConsultations were answered (69 pre-COVID and 322 post-COVID). The response time was less than 24h in 85% of them. A total of 35.3% were resolved without the need for visits or additional tests. Thyroid pathology was the most consulted. The incidence was significantly higher in the post-COVID period. The proportion of high resolution was significantly higher in the pre-COVID period. There were no differences in the rest of the parameters analysed in both periods. Thirty-nine point 2percent of PC specialists answered the survey. The degree of satisfaction of PC specialists was high. A total of 92.7% considered that the tool met their expectations and 90.5% were satisfied or very satisfied with its use. CONCLUSION The COVID epidemic has driven the use of eConsultation in Endocrinology, which makes it possible to precede, complete or replace visits to the specialist, with a high degree of user satisfaction.
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McGrowder DA, Miller FG, Vaz K, Anderson Cross M, Anderson-Jackson L, Bryan S, Latore L, Thompson R, Lowe D, McFarlane SR, Dilworth L. The Utilization and Benefits of Telehealth Services by Health Care Professionals Managing Breast Cancer Patients during the COVID-19 Pandemic. Healthcare (Basel) 2021; 9:1401. [PMID: 34683081 PMCID: PMC8535379 DOI: 10.3390/healthcare9101401] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 10/05/2021] [Accepted: 10/13/2021] [Indexed: 12/20/2022] Open
Abstract
Telehealth is the delivery of many health care services and technologies to individuals at different geographical areas and is categorized as asynchronously or synchronously. The coronavirus disease 2019 (COVID-19) pandemic has caused major disruptions in health care delivery to breast cancer (BCa) patients and there is increasing demand for telehealth services. Globally, telehealth has become an essential means of communication between patient and health care provider. The application of telehealth to the treatment of BCa patients is evolving and increasingly research has demonstrated its feasibility and effectiveness in improving clinical, psychological and social outcomes. Two areas of telehealth that have significantly grown in the past decade and particularly since the beginning of the COVID-19 pandemic are telerehabilitation and teleoncology. These two technological systems provide opportunities at every stage of the cancer care continuum for BCa patients. We conducted a literature review that examined the use of telehealth services via its various modes of delivery among BCa patients particularly in areas of screening, diagnosis, treatment modalities, as well as satisfaction among patients and health care professionals. The advantages of telehealth models of service and delivery challenges to patients in remote areas are discussed.
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Affiliation(s)
- Donovan A. McGrowder
- Department of Pathology, Faculty of Medical Sciences, The University of the West Indies, Kingston 7, Jamaica; (K.V.); (L.A.-J.); (L.L.); (R.T.); (D.L.); (L.D.)
| | - Fabian G. Miller
- Department of Physical Education, Faculty of Education, The Mico University College, 1A Marescaux Road, Kingston 5, Jamaica;
- Department of Biotechnology, Faculty of Science and Technology, The University of the West Indies, Kingston 7, Jamaica
| | - Kurt Vaz
- Department of Pathology, Faculty of Medical Sciences, The University of the West Indies, Kingston 7, Jamaica; (K.V.); (L.A.-J.); (L.L.); (R.T.); (D.L.); (L.D.)
| | - Melisa Anderson Cross
- School of Allied Health and Wellness, College of Health Sciences, University of Technology, Kingston 7, Jamaica;
| | - Lennox Anderson-Jackson
- Department of Pathology, Faculty of Medical Sciences, The University of the West Indies, Kingston 7, Jamaica; (K.V.); (L.A.-J.); (L.L.); (R.T.); (D.L.); (L.D.)
| | - Sophia Bryan
- Department of Basic Medical Sciences, Faculty of Medical Sciences, The University of the West Indies, Kingston 7, Jamaica;
| | - Lyndon Latore
- Department of Pathology, Faculty of Medical Sciences, The University of the West Indies, Kingston 7, Jamaica; (K.V.); (L.A.-J.); (L.L.); (R.T.); (D.L.); (L.D.)
| | - Rory Thompson
- Department of Pathology, Faculty of Medical Sciences, The University of the West Indies, Kingston 7, Jamaica; (K.V.); (L.A.-J.); (L.L.); (R.T.); (D.L.); (L.D.)
| | - Dwight Lowe
- Department of Pathology, Faculty of Medical Sciences, The University of the West Indies, Kingston 7, Jamaica; (K.V.); (L.A.-J.); (L.L.); (R.T.); (D.L.); (L.D.)
| | - Shelly R. McFarlane
- Caribbean Institute for Health Research, Faculty of Medical Sciences, The University of the West Indies, Kingston 7, Jamaica;
| | - Lowell Dilworth
- Department of Pathology, Faculty of Medical Sciences, The University of the West Indies, Kingston 7, Jamaica; (K.V.); (L.A.-J.); (L.L.); (R.T.); (D.L.); (L.D.)
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Damery S, Jones J, O'Connell Francischetto E, Jolly K, Lilford R, Ferguson J. Remote Consultations Versus Standard Face-to-Face Appointments for Liver Transplant Patients in Routine Hospital Care: Feasibility Randomized Controlled Trial of myVideoClinic. J Med Internet Res 2021; 23:e19232. [PMID: 34533461 PMCID: PMC8486986 DOI: 10.2196/19232] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 02/01/2021] [Accepted: 08/02/2021] [Indexed: 12/17/2022] Open
Abstract
Background Using technology to reduce the pressure on the National Health Service (NHS) in England and Wales is a key government target, and the NHS Long-Term Plan outlines a strategy for digitally enabled outpatient care to become mainstream by 2024. In 2020, the COVID-19 response saw the widespread introduction of remote consultations for patient follow-up, regardless of individual preferences. Despite this rapid change, there may be enduring barriers to the effective implementation of remote appointments into routine practice once the unique drivers for change during the COVID-19 pandemic no longer apply, to which pre-COVID implementation studies can offer important insights. Objective This study aims to evaluate the feasibility of using real-time remote consultations between patients and secondary care physicians for routine patient follow-up at a large hospital in the United Kingdom and to assess whether patient satisfaction differs between intervention and usual care patients. Methods Clinically stable liver transplant patients were randomized to real-time remote consultations in which their hospital physician used secure videoconferencing software (intervention) or standard face-to-face appointments (usual care). Participants were asked to complete postappointment questionnaires over 12 months. Data were analyzed on an intention-to-treat basis. The primary outcome was the difference in scores between baseline and study end by patient group for the three domains of patient satisfaction (assessed using the Visit-Specific Satisfaction Instrument). An embedded qualitative process evaluation used interviews to assess patient and staff experiences. Results Of the 54 patients who were randomized, 29 (54%) received remote consultations, and 25 (46%) received usual care (recruitment rate: 54/203, 26.6%). The crossover between study arms was high (13/29, 45%). A total of 129 appointments were completed, with 63.6% (82/129) of the questionnaires being returned. Patient satisfaction at 12 months increased in both the intervention (25 points) and usual care (14 points) groups. The within-group analysis showed that the increases were significant for both intervention (P<.001) and usual care (P=.02) patients; however, the between-group difference was not significant after controlling for baseline scores (P=.10). The qualitative process evaluation showed that—according to patients—remote consultations saved time and money, were less burdensome, and caused fewer negative impacts on health. Technical problems with the software were common, and only 17% (5/29) of patients received all appointments over video. Both consultants and patients saw remote consultations as positive and beneficial. Conclusions Using technology to conduct routine follow-up appointments remotely may ease some of the resource and infrastructure challenges faced by the UK NHS and free up clinic space for patients who must be seen face-to-face. Our findings regarding the advantages and challenges of using remote consultations for routine follow-ups of liver transplant patients have important implications for service organization and delivery in the postpandemic NHS. Trial Registration ISRCTN Registry 14093266; https://www.isrctn.com/ISRCTN14093266 International Registered Report Identifier (IRRID) RR2-10.1186/s13063-018-2953-4
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Affiliation(s)
- Sarah Damery
- Institute of Applied Health Research, Birmingham, United Kingdom
| | - Janet Jones
- Institute of Applied Health Research, Birmingham, United Kingdom
| | | | - Kate Jolly
- Institute of Applied Health Research, Birmingham, United Kingdom
| | - Richard Lilford
- Institute of Applied Health Research, Birmingham, United Kingdom
| | - James Ferguson
- National Institute for Health Research, Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, United Kingdom
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Daye D, Joseph E, Flores E, Kambadakone A, Chinn G, Bennett S, Sahani D. Point-of-Care Virtual Radiology Consultations in Primary Care: A Feasibility Study of a New Model for Patient-Centered Care in Radiology. J Am Coll Radiol 2021; 18:1239-1245. [DOI: 10.1016/j.jacr.2021.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 07/12/2021] [Indexed: 10/20/2022]
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Canterino JE, Wang K, Golden M. Provider Satisfaction with Infectious Diseases Telemedicine Consults for Hospitalized Patients During the COVID-19 Pandemic. Clin Infect Dis 2021; 74:711-714. [PMID: 34048567 PMCID: PMC8244553 DOI: 10.1093/cid/ciab479] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Indexed: 11/14/2022] Open
Abstract
During the COVID-19 pandemic, our institution transitioned ID consultations on
hospitalized patients to telemedicine. We evaluated satisfaction with
telemedicine among referring providers and ID consultants. Respondents were
satisfied with telemedicine consults for hospitalized patients, though there
were significant differences in perceptions of quality and timeliness between
consultants and referring providers.
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Affiliation(s)
- Joseph E Canterino
- Department of Medicine, Yale University School of Medicine, New Haven, United States
| | - Kaicheng Wang
- Yale Center for Analytic Sciences,Yale School of Public Health, New Haven, United States
| | - Marjorie Golden
- Department of Medicine, Yale University School of Medicine, New Haven, United States
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Cui S, Sedney CL, Daffner SD, Large MJ, Davis SK, Crossley L, France JC. Effects of telemedicine triage on efficiency and cost-effectiveness in spinal care. Spine J 2021; 21:779-784. [PMID: 33434648 DOI: 10.1016/j.spinee.2021.01.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 12/11/2020] [Accepted: 01/06/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Ambulatory spine referral triage must be optimized to improve both quality of care and access to specialists. PURPOSE To evaluate cost savings in an existing model of telemedicine/electronic-triage for ambulatory spine referrals. STUDY DESIGN/SETTING Retrospective review. Institutional spine center. PATIENT SAMPLE All patients/referrals made to the institutional spine center of a tertiary medical center from 2011 to 2014 were included in the data analysis. OUTCOME MEASURES Cost savings and efficiency was evaluated based upon intake to appointment time, rate of referral to surgeons versus nonoperative providers, additional testing required, and extrapolated cost savings based on estimated avoidance of unnecessary office visits and travel. METHODS All ambulatory spine referrals electronically triaged (E-triaged) from 2011 to 2014 were analyzed. The E-triage database was mined for data from intake until triage completion. Hospital electronic medical record system was mined for data on initial clinic visit, tests ordered, follow-up appointments, and presence of surgical encounters. Financial savings from avoiding unnecessary visits were estimated. RESULTS There were 16,174 records created from 2011 to 2014, of which 10,832 were E-triaged by spine surgeons. E-triage generated 3,718 nonoperative provider visits within our healthcare system. The "saved" surgical consult that was avoided resulted in total estimated savings of $793,835 to the patient population; 4,446 patients were deemed surgical and were offered appointments with a spine surgeon. CONCLUSIONS Appropriate triage of ambulatory spine referrals improves access and quality of care. E-triage resulted in $800,000 cost savings. Further studies are required to fully evaluate the effects of an E-triage system on ambulatory spinal care.
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Affiliation(s)
- Shari Cui
- Department of Orthopaedics, West Virginia University, PO Box 9196, Morgantown, WV 26506-9196, USA.
| | - Cara L Sedney
- Department of Neurosurgery, West Virginia University, PO Box 9183, Morgantown, WV 26506-9183, USA
| | - Scott D Daffner
- Department of Orthopaedics, West Virginia University, PO Box 9196, Morgantown, WV 26506-9196, USA
| | - Michelle J Large
- JW Ruby Memorial Hospital, Strategic Analytics, PO Box 8181, Morgantown, WV 26505, USA
| | - Sherri K Davis
- Department of Orthopaedics, West Virginia University, PO Box 9196, Morgantown, WV 26506-9196, USA
| | - Leslie Crossley
- JW Ruby Memorial Hospital, Rockefeller Neuroscience Institute, PO Box 8258, Morgantown, WV 26506, USA
| | - John C France
- Department of Orthopaedics, West Virginia University, PO Box 9196, Morgantown, WV 26506-9196, USA
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Understanding How to Improve the Use of Clinical Coordination Mechanisms between Primary and Secondary Care Doctors: Clues from Catalonia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18063224. [PMID: 33804691 PMCID: PMC8003988 DOI: 10.3390/ijerph18063224] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 03/10/2021] [Accepted: 03/11/2021] [Indexed: 01/27/2023]
Abstract
Clinical coordination between primary (PC) and secondary care (SC) is a challenge for health systems, and clinical coordination mechanisms (CCM) play an important role in the interface between care levels. It is therefore essential to understand the elements that may hinder their use. This study aims to analyze the level of use of CCM, the difficulties and factors associated with their use, and suggestions for improving clinical coordination. A cross-sectional online survey-based study using the questionnaire COORDENA-CAT was conducted with 3308 PC and SC doctors in the Catalan national health system. Descriptive bivariate analysis and logistic regression models were used. Shared Electronic Medical Records were the most frequently used CCM, especially by PC doctors, and the one that presented most difficulties in use, mostly related to technical problems. Some factors positively associated with frequent use of various CCM were: working full-time in integrated areas, or with local hospitals. Interactional and organizational factors contributed to a greater extent among SC doctors. Suggestions for improving clinical coordination were similar between care levels and related mainly to the improvement of CCM. In an era where management tools are shifting towards technology-based CCM, this study can help to design strategies to improve their effectiveness.
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Eddine IS, Zedan HS. Telehealth Role During the COVID-19 Pandemic: Lessons Learned from Health Care Providers in Saudi Arabia. Telemed J E Health 2021; 27:1249-1259. [PMID: 33448900 DOI: 10.1089/tmj.2020.0489] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Coronavirus disease 2019 (COVID-19) was originally recognized in December 2019 as a case of lung infection in Wuhan, China. COVID-19 has affected the capability of health care experts to treat patients face to face. One initiative to improve the efficacy and convenience of patient care despite the physical distancing limitations has been the application of "virtual clinics" (VCs) as a treatment modality. This study was aimed to investigate the use of VCs as a tool of telehealth during the COVID-19 pandemic in Saudi Arabia. Methods: This study was conducted in the ambulatory care setting at King Abdullah Specialized Children Hospital in Riyadh. Respondents were selected from different groups of health care providers. The study was a hospital-based cross-sectional design using an electronic survey. Results: In total, 277 surveys were collected. Principal findings showed the deployment of VCs by 67.2% (n = 186) of providers. Among these providers, 54.3% were female, and only 18.8% of providers were aged >54 years. 98.1% of the respondents have started running VCs since the COVID-19 outbreak, with 47.2% of respondents running between 51 and 100 VCs per month, and the majority (74%) were spending 6-15 min per patient visit. Chronically ill patients constituted 57.7% of the patient's population served. Almost 95% of respondents used electronic prescriptions during their VCs. Most providers (98.1%) used the telephone/mobile as a means of communication with the patient during these VCs. A total of 75.5% of VCs were integrated with electronic health records such as appointment scheduling (77.9%), and 88.3% of the providers were satisfied with their VCs. The major opportunity seen by providers was reducing appointment waiting times (73.4%). The major success metric seen in VCs was increased patient satisfaction as reported by providers (67.9%). In contrast, the major challenge seen was the lack of face-to-face interaction and physical examination (86.8%). Conclusion: VCs are one way of centering the health system around the patient, but careful attention is needed to integrate these services with the current health care delivery system in place and ensure quality care to the patients.
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Affiliation(s)
- Inaam Shehabe Eddine
- Department of Oncology, Ministry of National Guard Health Affairs-Central Region-King Abdullah Specialized Children's Hospital, Riyadh, Saudi Arabia
| | - Haya S Zedan
- Department of Public Health, College of Health Sciences, Saudi Electronic University, Riyadh, Saudi Arabia
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Pfeil JN, Rados DV, Roman R, Katz N, Nunes LN, Vigo Á, Harzheim E. A telemedicine strategy to reduce waiting lists and time to specialist care: A retrospective cohort study. J Telemed Telecare 2020; 29:10-17. [DOI: 10.1177/1357633x20963935] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction The demand for specialty care is rising worldwide. In the state of Rio Grande do Sul, Brazil, more than 150,000 people were waiting for specialist consultations in 2013. A telemedicine programme (RegulaSUS) developed referral protocols, audited waitlisted cases, authorised/prioritised referrals by risk and discuss deferred cases primary-care physician. This study assesses the effectiveness of RegulaSUS. Methods A retrospective cohort analysis with contemporaneous controls was performed from June 2014 to June 2016. Six medical specialties included in RegulaSUS (50,185 patients) were compared to 50,124 control patients waitlisted according to the usual routine (scheduled for specialty consultation at the next available date). The groups were matched (1:1) by semester and year of waitlisting and by the specialty demand-to-supply ratio. Primary outcomes were referral-to-consultation time and number of waitlisted patients. Results The mean referral-to-consultation time was 584.8 days in the intervention group and 607.0 days in controls ( p<0.001). For specialties regulated by RegulaSUS, the mean referral-to-consultation time was 237.6 days for higher-risk patients. At the end of the observation, 26,708 control patients had been unlisted compared to 31,050 patients in the intervention group (reduction of 53.5% vs. 61.9%, respectively; p<0.001). The number of cancelled referrals was lower in the control group ( n=14,403; 28.7%) than in the intervention group ( n=16,387; 32.7%; p<0.001). Discussion Telemedicine support for primary care effectively decreased the time to specialty consultation, reduced the number of waitlisted patients and allowed sicker patients to reach a specialist faster.
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Affiliation(s)
- Juliana N Pfeil
- Núcleo de Telessaúde Técnico Científico do Rio Grande do Sul (TelessaúdeRS-UFRGS), Porto Alegre, RS, Brazil
| | - Dimitris V Rados
- Núcleo de Telessaúde Técnico Científico do Rio Grande do Sul (TelessaúdeRS-UFRGS), Porto Alegre, RS, Brazil
| | - Rudi Roman
- Núcleo de Telessaúde Técnico Científico do Rio Grande do Sul (TelessaúdeRS-UFRGS), Porto Alegre, RS, Brazil
| | - Natan Katz
- Núcleo de Telessaúde Técnico Científico do Rio Grande do Sul (TelessaúdeRS-UFRGS), Porto Alegre, RS, Brazil
| | - Luciana N Nunes
- Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Álvaro Vigo
- Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Erno Harzheim
- Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
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Abstract
BACKGROUND The demand for pediatric orthopaedic surgery consultation has grown rapidly, leading to longer wait times for elective consultation in some regions. Some specialties are addressing this increased demand through electronic consultation services. We wanted to examine the impact of pediatric orthopaedic e-consultations in Canada's Eastern Ontario region. METHODS We developed a cross-sectional study of all the cases directed to a pediatric orthopaedic surgery specialist using the Champlain Building Access to Specialists through eConsultation (BASE) eConsult service over a 2-year period and examined their impact on in-person referrals, time of e-consultation and primary care satisfaction as well as types of clinical questions that were asked. RESULTS Electronic consultations avoided in-person appointments in 68% of the submitted cases. The median response by specialists received by the primary care providers (PCPs) was <20 hours. A total of 69% of consultations involve >1 type of clinical questions, most commonly about basic trauma/fracture care and management recommendations. Ninety-seven percent of the PCPs found the overall value for the care of the patients to be good or excellent. CONCLUSIONS This cross-sectional study demonstrates the effective and timely use of eConsult in pediatric orthopaedic surgery. It also shows a significant reduction in the number of in-person consultations required and demonstrates a high satisfaction rate by PCPs using the service. CLINICAL RELEVANCE In addition to the efficacy and time-sensitive care provided to the patients, the study shows that, professionally, 89% of PCPs found this service to be excellent or good. The broader implications of electronic consultation on overall quality of care, population health, and patient satisfaction requires further investigation.
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Lee M, Leonard C, Greene P, Kenney R, Whittington MD, Kirsh S, Ho PM, Sayre G, Simonetti J. Perspectives of VA Primary Care Clinicians Toward Electronic Consultation-Related Workload Burden: A Qualitative Analysis. JAMA Netw Open 2020; 3:e2018104. [PMID: 33125494 PMCID: PMC7599439 DOI: 10.1001/jamanetworkopen.2020.18104] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
IMPORTANCE Electronic consultation (e-consultation) is increasingly being adopted to expand access to specialty care and reduce health care costs. Little is known about clinicians' perceptions of using e-consultations, which may be associated with program adoption. OBJECTIVE To identify perceptions of primary care clinicians in the US Veterans Health Administration (VHA) system about e-consultation and workload. DESIGN, SETTING, AND PARTICIPANTS A qualitative study using semistructured interviews was conducted from September 2017 through March 2018 in a national sample of VHA primary care clinics in the US. Participants were primary care clinicians who had at least 300 total patient encounters from July 2016 to June 2017, including at least 1 e-consultation request. A convenience sample of participants was recruited using email invitations. Deductive and inductive content analysis were used to identify themes. Data were analyzed from October 2017 to April 2018. EXPOSURES Use of e-consultation. MAIN OUTCOMES AND MEASURES Primary care clinician perspectives regarding e-consultation and their workload. RESULTS A total of 34 primary care clinicians enrolled working across 27 VHA clinical sites were included; 9 (26%) were between ages 40-49 years; 23 (68%) were female. Three themes were identified. First, the process of entering, tracking, and following up on e-consultations added a time burden to primary care clinicians. Second, e-consultation was perceived to shift diagnostic and follow-up responsibilities from specialists to primary care clinicians. Third, e-consultations were thought to improve the timeliness and quality of care provided despite a perceived increase in workload. CONCLUSIONS AND RELEVANCE In this study, participants perceived e-consultation as valuable for patient care but also as an increase in their workload. Further work is warranted to quantify the workload increase on clinician burnout, job satisfaction, and turnover.
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Affiliation(s)
- Marcie Lee
- Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora
| | - Chelsea Leonard
- Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora
| | - Preston Greene
- Department of Health Services, University of Washington, Seattle
| | - Rachael Kenney
- Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora
| | - Melanie D. Whittington
- Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora
| | - Susan Kirsh
- Office of Specialty Care and Specialty Care Transformation, Washington, DC
| | - P. Michael Ho
- Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora
- Division of Cardiology, University of Colorado School of Medicine, Aurora
| | - George Sayre
- Department of Health Services, University of Washington, Seattle
- Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
| | - Joseph Simonetti
- Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora
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Abstract
PURPOSE OF REVIEW Diabetes mellitus is a leading chronic disease worldwide. Access to diabetes care varies widely and is influenced by multiple factors including social, geographic, and economic conditions. The use of technology to expand healthcare may bridge these barriers and improve access. Our aim was to review the evidence for the role of telehealth to expand access to quality diabetes care. RECENT FINDINGS There is evidence that application of technology-based programs to deliver healthcare are both feasible and effective. These programs are accepted by both patients and providers, can reduce healthcare costs, and may redress inequalities in healthcare access. Technology-based care models can improve disease management, enhance efficiency and clinical decision-making, promote patient self-management skills, and promote patient centered care. Future research should focus on implementation of technology-based healthcare delivery programs on a larger scale.
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Affiliation(s)
- Anusha Verravanallur Appuswamy
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, SUNY Upstate Medical University, 750 East Adams Street, Syracuse, NY, 13210, USA
| | - Marisa E Desimone
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, SUNY Upstate Medical University, 750 East Adams Street, Syracuse, NY, 13210, USA.
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Ackerman SL, Gleason N, Shipman SA. Comparing Patients' Experiences with Electronic and Traditional Consultation: Results from a Multisite Survey. J Gen Intern Med 2020; 35:1135-1142. [PMID: 32076987 PMCID: PMC7174441 DOI: 10.1007/s11606-020-05703-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 10/18/2019] [Accepted: 01/30/2020] [Indexed: 01/18/2023]
Abstract
BACKGROUND There have been no large-scale studies to date of patients' experiences with electronic consultation (eConsult) between primary and specialty care. OBJECTIVE Compare experiences with eConsult and referral for in-person specialist consultation. DESIGN Online survey 2-6 weeks following eConsult or referral at 9 US academic medical centers. PARTICIPANTS Adult patients with no more than one eConsult or referral order from a primary care provider (PCP) in the prior month. Over 9 months, 29,291 email invitations were sent (88% referral; 12% eConsult). MAIN MEASURES Trust in and satisfaction with PCP; consult type awareness; agreement with decision to seek specialist input; timeliness of care; mode of PCP-patient eConsult communication; satisfaction with specialist's recommendations; future preference for eConsult or referral. KEY RESULTS A 27.6% response rate yielded 8087 respondents (88.4% referral; 11.6% eConsult). Many did not know that their PCP had placed a referral (32.8% unaware) or eConsult (52.9%), and eConsult awareness was significantly higher among patients reporting better health (OR 1.62, 95% CI 1.18-2.23). Most (81.4% eConsult; 82.0% referral) were satisfied with the specialist's recommendations. Those who had a good primary care experience were more likely to be satisfied (eConsult: OR 10.63, 95% CI 2.95-38.32; referral: OR 2.87, 95% CI 1.86-4.44). For a similar problem in the future, 78% of eConsult and 32% percent of referral patients preferred eConsult. CONCLUSIONS This multisite study demonstrates that many patients find virtual consultation to be an acceptable strategy for the management of their medical condition and that trust and confidence in one's PCP are crucial ingredients for a satisfying eConsult experience. The lack of awareness of eConsult among many patients who were beneficiaries of the service warrants an increased effort to include patients in eConsult decision-making and communication. Further research is needed to assess eConsult acceptability and satisfaction in more diverse patient populations.
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Affiliation(s)
- Sara L Ackerman
- Department of Social and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, USA.
| | - Nathaniel Gleason
- Division of General Internal Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Scott A Shipman
- Association of American Medical Colleges, Washington, DC, USA
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Anderson D, Porto A, Koppel J, Macri G, Wright M. Impact of Endocrinology eConsults on Access to Endocrinology Care for Medicaid Patients. Telemed J E Health 2020; 26:1383-1390. [PMID: 32023182 DOI: 10.1089/tmj.2019.0238] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Access to endocrinologists is a particular challenge for medically underserved populations. Introduction: Electronic consultations (eConsults) are a promising tool to help address this problem. Materials and Methods: This retrospective cohort study compared two groups: (1) Medicaid patients referred to an endocrinologist 1 year before the implementation of eConsults and (2) those referred in the 1 year after implementation. Data included patient demographics, dates of referral requests, appointment dates, eConsult response dates and times, diagnosis codes, and consultants' recommendations. Provider perspectives of eConsults were determined by using a survey. Results: Before eConsult implementation, only 138 out of 365 (37.8%) of referrals to endocrinology were completed. Postimplementation, 281 out of 469 (59.9%) of referrals were completed either by a confirmed face-to-face visit with an endocrinologist or by an eConsult, of whom 194 (41.4%) did not require a face-to-face visit. Thyroid conditions were the most common reason for a consult, accounting for roughly 40% of all consults. Overall, 32 out of 36 (89%) primary care providers (PCPs) indicated that they were satisfied with eConsults and 19 out of 36 (53%) felt that the process did not create additional work or burden for them. Discussion: These findings demonstrate that eConsult use can help address poor access to specialty care for Medicaid-insured patients. eConsults were able to significantly decrease the need for face-to-face visits and enabled PCPs to address specialty-related issues in primary care. Conclusions: Widespread adoption of eConsults could be a potential solution for major challenges that our health care system faces today.
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Affiliation(s)
| | | | - Jonathan Koppel
- Frank H. Netter MD School of Medicine, Quinnipiac University, North Haven, Connecticut, USA
| | | | - Megan Wright
- Weitzman Institute, Middletown, Connecticut, USA
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Ackerman SL, Dowdell K, Clebak KT, Quinn M, Shipman SA. Patients Assess an eConsult Model's Acceptability at 5 US Academic Medical Centers. Ann Fam Med 2020; 18:35-41. [PMID: 31937531 PMCID: PMC7227466 DOI: 10.1370/afm.2487] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 06/29/2019] [Accepted: 07/19/2019] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Electronic consultation (eConsult), involving asynchronous primary care clinician-to-specialist consultation, is being adopted at a growing number of health systems. Most evaluations of eConsult programs have assessed clinical and financial impacts and clinician acceptability. Less attention has been focused on patients' opinions. We set out to understand patient perspectives and preferences for hypothetical eConsult use at 5 US academic medical centers in the process of adopting an eConsult model. METHODS We invited adult primary care patients to participate in focus groups. Participants were introduced to the eConsult model, considered its potential benefits and drawbacks, judged the acceptability of a hypothetical copay, and expressed their preferences for future involvement in eConsult decision making and communication. Thematic analysis was used for data interpretation. RESULTS One focus group was conducted at each of the 5 sites with a total of 52 participants. Focus groups responded positively to the idea of eConsult, with quicker access to specialty care and convenience identified as key benefits. Approval was particularly high among those with a trusted primary care clinician. Preference for involvement in eConsult decision making and communication varied and enthusiasm about eConsult waned when a hypothetical copay was introduced. Concerns included potential misuse of eConsult and exclusion of the patient's illness narrative in the eConsult exchange. CONCLUSIONS Primary care patients expressed strong support for eConsult, particularly when used by a trusted primary care clinician, in addition to voicing several concerns. Patient involvement in eConsult outreach and education efforts could help to enhance the model's effectiveness and acceptability.
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Affiliation(s)
- Sara L Ackerman
- Department of Social and Behavioral Sciences, University of California San Francisco, San Francisco, California
| | - Kim Dowdell
- Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Karl T Clebak
- Department of Family and Community Medicine, Penn State College of Medicine, Hershey, Pennsylvania
| | - Meagban Quinn
- American Association of Medical Colleges, Washington, DC
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Mold F, Hendy J, Lai YL, de Lusignan S. Electronic Consultation in Primary Care Between Providers and Patients: Systematic Review. JMIR Med Inform 2019; 7:e13042. [PMID: 31793888 PMCID: PMC6918214 DOI: 10.2196/13042] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 06/11/2019] [Accepted: 08/07/2019] [Indexed: 12/27/2022] Open
Abstract
Background Governments and health care providers are keen to find innovative ways to deliver care more efficiently. Interest in electronic consultation (e-consultation) has grown, but the evidence of benefit is uncertain. Objective This study aimed to assess the evidence of delivering e-consultation using secure email and messaging or video links in primary care. Methods A systematic review was conducted on the use and application of e-consultations in primary care. We searched 7 international databases (MEDLINE, EMBASE, CINAHL, Cochrane Library, PsycINFO, EconLit, and Web of Science; 1999-2017), identifying 52 relevant studies. Papers were screened against a detailed inclusion and exclusion criteria. Independent dual data extraction was conducted and assessed for quality. The resulting evidence was synthesized using thematic analysis. Results This review included 57 studies from a range of countries, mainly the United States (n=30) and the United Kingdom (n=13). There were disparities in uptake and utilization toward more use by younger, employed adults. Patient responses to e-consultation were mixed. Patients reported satisfaction with services and improved self-care, communication, and engagement with clinicians. Evidence for the acceptability and ease of use was strong, especially for those with long-term conditions and patients located in remote regions. However, patients were concerned about the privacy and security of their data. For primary health care staff, e-consultation delivers challenges around time management, having the correct technological infrastructure, whether it offers a comparable standard of clinical quality, and whether it improves health outcomes. Conclusions E-consultations may improve aspects of care delivery, but the small scale of many of the studies and low adoption rates leave unanswered questions about usage, quality, cost, and sustainability. We need to improve e-consultation implementation, demonstrate how e-consultations will not increase disparities in access, provide better reassurance to patients about privacy, and incorporate e-consultation as part of a manageable clinical workflow.
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Affiliation(s)
- Freda Mold
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom
| | - Jane Hendy
- Brunel Business School, Brunel University London, Uxbridge, United Kingdom
| | - Yi-Ling Lai
- Faculty of Business and Law, University of Portsmouth, Portsmouth, United Kingdom
| | - Simon de Lusignan
- Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, United Kingdom
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Electronic Consultations in Allergy/Immunology. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2594-2602. [DOI: 10.1016/j.jaip.2019.05.039] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 05/08/2019] [Accepted: 05/18/2019] [Indexed: 11/20/2022]
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Gilani S, Bommakanti K, Friedman L. Electronic Consults in Otolaryngology: A Pilot Study to Evaluate the Use, Content, and Outcomes in an Academic Health System. Ann Otol Rhinol Laryngol 2019; 129:170-174. [PMID: 31625409 DOI: 10.1177/0003489419882726] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To categorize the primary reasons for electronic consults (eConsults) to otolaryngology from primary care physicians (PCPs). To determine how many patients avoided subsequent in-person otolaryngology office visits. METHODS This is a retrospective analysis of a pilot study that took place between 2016 and 2017 regarding eConsults to adult otolaryngology placed by primary care physicians at the University of California, San Diego (UCSD) Medical Center. The complaints were categorized as related to the following: ear, nose, throat or neck. Initial recommendations were classified as (1) providing education only (no intervention), (2) suggesting medical therapy provided by the PCP, or (3) suggesting surgical intervention. Univariate statistics and multinomial logistic regression were used to analyze the association of problem type with the need for follow-up in the otolaryngology offices. The data was analyzed for differences in patient age and gender. RESULTS The study population included 64 patients (average age 54.6 years, 60.9% male). Within this group, 41% of consults were for ear complaints, 15% for nose complaints, 28% had throat-related complaints, and 16% had neck-related complaints. In-person follow-up was not required for 82.8% of the consults. Overall, 76.9% of ear, 100% of nose, 88.9% of throat, and 70.0% of neck complaints did not require in-person visits. CONCLUSIONS eConsults to otolaryngology were primarily for ear concerns. Of the eConsults, 82.4% did not require in-person follow-up. We therefore conclude that the use of eConsults prevented substantial office visits that would not otherwise be necessary. Efforts should be made to promote the widespread use of eConsults, which may to the more efficient use of resources.
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Affiliation(s)
- Sapideh Gilani
- Department of Surgery, Division of Head and Neck Surgery, University of California San Diego, San Diego, CA, USA
| | - Krishna Bommakanti
- University of California San Diego School of Medicine, La Jolla, CA, USA
| | - Lawrence Friedman
- Department of Internal Medicine, University of California San Diego, San Diego, CA, USA
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Deeds SA, Dowdell KJ, Chew LD, Ackerman SL. Implementing an Opt-in eConsult Program at Seven Academic Medical Centers: a Qualitative Analysis of Primary Care Provider Experiences. J Gen Intern Med 2019; 34:1427-1433. [PMID: 31197734 PMCID: PMC6667576 DOI: 10.1007/s11606-019-05067-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 01/31/2019] [Accepted: 04/11/2019] [Indexed: 01/20/2023]
Abstract
BACKGROUND Electronic consultation (eConsult), which involves primary care provider (PCP)-to-specialist asynchronous consultation, is increasingly used in health care systems to streamline care and to improve patient access. The Association of American Medical Colleges (AAMC) formed a collaborative to support the implementation of an electronic medical record (EMR)-based, opt-in eConsult program across multiple academic medical centers (AMCs). In this model, PCPs can elect to send either an eConsult or a traditional referral. OBJECTIVE We sought to understand the PCP experience with eConsult to identify facilitators of and barriers to the successful adoption of the model. DESIGN AND PARTICIPANTS We conducted 35 semi-structured interviews and 6 focus groups with a range of primary care providers at 7 AMCs participating in the AAMC collaborative. APPROACH Interviews were recorded and transcribed or detailed field notes were taken. We used the constant comparative method to identify recurring themes within and across sites, and resolve interpretive discrepancies. KEY RESULTS We identified three major themes related to the eConsult program: (1) eConsult increases the comprehensiveness of primary care and fills PCPs' knowledge gaps through case-based learning. (2) Factors that influence PCPs to order an eConsult rather than a traditional referral include patient preference, case complexity, and need for expert guidance. (3) Implementation challenges included increasing PCPs' awareness of the program, addressing PCPs' concerns about increased workload, recruiting engaged specialist consultants, and ensuring high quality eConsult responses. Implementation success relied on PCP ownership of the consultation process, mitigating unintended consequences, ongoing education about the program, and mechanisms for providing feedback to clinicians. CONCLUSIONS Our findings demonstrate that an opt-in eConsult program at AMCs has the potential to increase PCP knowledge and enhance the comprehensiveness of primary care. For these benefits to be realized, program implementation requires sustained efforts to overcome barriers to use and establish norms guiding eConsult communication.
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Affiliation(s)
- Stefanie A Deeds
- Department of Medicine, Veterans Affairs Puget Sound Healthcare System, Division of General Internal Medicine , University of Washington School of Medicine, Seattle, WA, USA.
| | - Kimberly J Dowdell
- Department of Medicine, Division of General, Geriatric, Palliative & Hospital Medicine, University of Virginia, Charlottesville, VA, USA
| | - Lisa D Chew
- Department of Medicine, Harborview Medical Center, Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA, 98195, USA
| | - Sara L Ackerman
- Department of Social & Behavioral Sciences, School of Nursing, University of California, San Francisco, San Francisco, CA, USA
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Chudner I, Goldfracht M, Goldblatt H, Drach-Zahavy A, Karkabi K. Video or In-Clinic Consultation? Selection of Attributes as Preparation for a Discrete Choice Experiment Among Key Stakeholders. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2019; 12:69-82. [PMID: 29948961 DOI: 10.1007/s40271-018-0318-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
INTRODUCTION Video consultations (VCs) provide increased accessibility of primary care to remote areas and overall improved care for chronic patients. They also contribute to higher patient satisfaction and improved resource management. Despite these benefits, VC integration into the health system is complex and slow. Understanding the VC-related preferences of three key stakeholders-patients, primary care physicians (PCPs) and policy makers (PMs)-is crucial for achieving optimal implementation. OBJECTIVE The aim of this study was to select relevant attributes and levels for a discrete choice experiment (DCE) of stakeholders' choice-VC or traditional in-clinic consultation (I-CC) in primary care. METHODS Ten semi-structured focus group interviews and 24 semi-structured individual interviews were conducted. Data analysis was performed inductively, using a thematic content analysis method. An attribute-ranking exercise was then conducted based on the results gleaned from the interviews. RESULTS The most important attributes when choosing either VC or I-CC, for both patients and PMs, were: (1) time to next available appointment; (2) time in line before consultation; (3) relationship to PCP; and (4) quality of consultation. For PCPs, the most important attributes were: (1) time in line before consultation; (2) patient's self-management ability; (3) consultation purpose; (4) quality of consultation. CONCLUSIONS This qualitative study identified attributes and levels for a DCE quantitative stage among three key stakeholder groups. It adds to the literature of examples of developing DCE attributes, and to literature about the stakeholder benefits in the area of telemedicine in healthcare.
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Affiliation(s)
- Irit Chudner
- Family Medicine Department, The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel.
| | - Margalit Goldfracht
- Family Medicine Department, The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Hadass Goldblatt
- Department of Nursing, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel
| | - Anat Drach-Zahavy
- Department of Nursing, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel
| | - Khaled Karkabi
- Family Medicine Department, The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
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Afable MK, Gupte G, Simon SR, Shanahan J, Vimalananda V, Kim EJ, Strymish J, Orlander JD. Innovative Use Of Electronic Consultations In Preoperative Anesthesiology Evaluation At VA Medical Centers In New England. Health Aff (Millwood) 2019; 37:275-282. [PMID: 29401018 DOI: 10.1377/hlthaff.2017.1087] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Electronic consultations (e-consults) improve access to specialty care without requiring face-to-face patient visits. We conducted a mixed-methods descriptive study to understand the variability in e-consult use across anesthesiology departments in the Veterans Affairs New England Healthcare System (VANEHS). In the period 2012-15, the system experienced a rapid increase in the use of anesthesiology e-consults: 5,023 were sent in 2015, compared with 103 in 2012. Uptake across sites varied from near-universal use of e-consults for preoperative assessment to use for only selected low-risk patients or no use. Interviews with stakeholders revealed considerable differences in the perceived impact of e-consults on workflow and patient-centeredness. Clinicians at sites with high use of e-consults noted that they improved workflow efficiency. In comparison, clinicians at sites with low use preferentially valued face-to-face visits for some or all patients. The adoption of a health information technology innovation can alter the process of care delivery, depending on perceptions of its value by key stakeholders.
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Affiliation(s)
- Melissa K Afable
- Melissa K. Afable ( ) is a project manager in the Department of Quality, Safety, and Value at Partners HealthCare System, in Boston, Massachusetts. When this work was conducted, she was a project manager for health policy, law, and management at Boston University School of Public Health and at the Center for Healthcare Organization and Implementation Research, Veterans Affairs (VA) Boston Healthcare System, in Boston
| | - Gouri Gupte
- Gouri Gupte is an assistant professor of health policy, law, and management at Boston University School of Public Health and director of performance improvement at Cambridge Health Alliance, in Massachusetts
| | - Steven R Simon
- Steven R. Simon is an associate professor of medicine at Harvard Medical School and Brigham and Women's Hospital and chief of the Geriatrics and Extended Care Service, VA Boston Healthcare System
| | - Jessica Shanahan
- Jessica Shanahan is an anesthesiologist in the Department of Anesthesia, VA Boston Healthcare System
| | - Varsha Vimalananda
- Varsha Vimalananda is an assistant professor in the Section of Endocrinology, Diabetes, and Metabolism, Boston University School of Medicine, and a research health scientist at the Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Medical Center, in Bedford, Massachusetts
| | - Eun Ji Kim
- Eun Ji Kim is an assistant professor of medicine at Zucker School of Medicine at Hofstra/Northwell in Manhasset, New York. When this work was conducted, she was a fellow in the Section of General Internal Medicine, Boston University School of Medicine
| | - Judith Strymish
- Judith Strymish is an assistant professor of infectious diseases at Harvard Medical School and the VA Boston Healthcare System
| | - Jay D Orlander
- Jay D. Orlander is a professor of medicine, Section of General Medicine, at Boston University School of Medicine and associate chief of Medical Service, VA Boston Healthcare System
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Olayiwola JN, Knox M, Dubé K, Lu EC, Woldeyesus T, James IE, Willard‐Grace R, Tuot D. Understanding the Potential for Patient Engagement in Electronic Consultation and Referral Systems: Lessons From One Safety Net System. Health Serv Res 2018; 53:2483-2502. [PMID: 28940495 PMCID: PMC6051985 DOI: 10.1111/1475-6773.12776] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE To understand patient, primary care clinician (PCC), and subspecialist perspectives on potential, unexplored roles for patients in electronic consultation and referral (eCR) systems. DATA SOURCES Primary focus group and survey data collected April-November 2015. Zuckerberg San Francisco General Hospital (ZSFG) is part of an integrated public health delivery system. Its mature eCR system was first implemented in 2005. STUDY DESIGN This mixed-methods study synthesizes patient, subspecialist, and PCC perspectives through two patient focus groups in English, Spanish, and Cantonese (n = 6); subspecialist focus groups (n = 2); and an electronic survey of all PCCs (n = 222/634, 35 percent response). DATA COLLECTION/EXTRACTION METHODS Focus groups were audio-recorded and transcribed. Two researchers coded the transcripts to identify recurrent themes. Survey data were analyzed using summary and bivariate statistics. PRINCIPAL FINDINGS Patients expressed minimal desire to directly engage in eCR, instead of emphasizing their PCC's role in advocating, informing, and finding health solutions. Subspecialists requested more consistent communication to patients about the electronic consultation process. Most PCCs (52 percent) supported patient engagement in the eCR process, particularly patient ability to track consult status and securely message with subspecialists. CONCLUSIONS Results suggest a continuum of opportunities for patients and their caregivers to engage in eCR systems.
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Affiliation(s)
- Jacqueline Nwando Olayiwola
- Center for Excellence in Primary CareDepartment of Family & Community MedicineUniversity of CaliforniaSan FranciscoCA94110
| | - Margae Knox
- Center for Excellence in Primary CareDepartment of Family & Community MedicineUniversity of CaliforniaSan FranciscoCA94110
| | - Kate Dubé
- University of California, BerkeleyBerkeleyCA
| | - Emily Chen‐Yuan Lu
- Department of Family & Community MedicineUniversity of California, San FranciscoSan FranciscoCA
| | - Tem Woldeyesus
- Department of Family & Community MedicineUniversity of California, San FranciscoSan FranciscoCA
| | - Iguehi E. James
- Division of EndocrinologyZuckerberg San Francisco General HospitalCenter for Innovation in Access and QualityUniversity of California, San FranciscoSan FranciscoCA
| | - Rachel Willard‐Grace
- Center for Excellence in Primary CareDepartment of Family & Community MedicineUniversity of CaliforniaSan FranciscoCA94110
| | - Delphine Tuot
- Division of NephrologyeReferral at Zuckerberg San Francisco General Hospital (ZSFG)Center for Innovation in Access and Quality at ZSFGUCSF Center for Vulnerable Populations at ZSFGUniversity of California, San FranciscoSan FranciscoCA
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Lee MS, Ray KN, Mehrotra A, Giboney P, Yee HF, Barnett ML. Primary Care Practitioners' Perceptions of Electronic Consult Systems: A Qualitative Analysis. JAMA Intern Med 2018; 178:782-789. [PMID: 29801079 PMCID: PMC6145753 DOI: 10.1001/jamainternmed.2018.0738] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Safety-net health systems across the country are implementing electronic consult (eConsult) systems in which primary care practitioners (PCPs) submit all requests for specialty assistance electronically to be reviewed and discussed with specialists. Evidence suggests that eConsult systems can make significant improvements in specialty access, but the outcomes of these systems for frontline PCPs is poorly understood. OBJECTIVE To understand PCP perceptions of the results of eConsult initiation on PCP workflow, specialist access, and patient care. DESIGN, SETTING, AND PARTICIPANTS Qualitative interviews were conducted from December 1, 2016, to April 15, 2017, with 40 safety-net PCPs in Los Angeles County who use the Los Angeles County Department of Health Services (DHS) eConsult system. Interviewees were recruited to include diversity in PCP type, practice setting, and employer (DHS employed vs DHS affiliated). Participants were interviewed about their perceptions of clinical workflow, access to specialists, relationships with specialists, and referral decision making. MAIN OUTCOMES AND MEASURES Perceptions of the results of eConsult, including positive and negative themes and remaining perceived gaps in specialty care. RESULTS Of the 40 participants, 27 (68%) were women; 24 (60%) PCPs performed 5 or more eConsults per week. Primary care practitioners' perceptions of eConsult clustered around 4 main themes: access and timeliness of specialty care, shift of work to PCPs, relationships with specialists, and eConsult interface issues. Many PCPs praised the improved timeliness of specialist input with eConsult, as well as the added clinical and educational value of dialogue with specialists, particularly compared with the limitations of the prior referral process. However, PCPs also consistently perceived that eConsult shifted some of the work of specialty care to them. Many PCPs believed that this extra burden was worth the effort given the benefits of eConsult, such as improved timeliness of care and ability to manage specialty conditions. In contrast, others were frustrated by the increased administrative burden, broadened clinical responsibility, and restructuring of specialty care delivery. CONCLUSIONS AND RELEVANCE While associated with improved specialty care access, eConsult systems simultaneously created new challenges for PCPs, such as an increased burden of work in providing specialty care. Primary care practitioners varied in their enthusiasm for these workflow changes with diverging perceptions of the same processes. Our findings provide insights on challenges future primary care transformation efforts may face.
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Affiliation(s)
- Michelle S Lee
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Kristin N Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Paul Giboney
- Los Angeles County Department of Health Services, Los Angeles, California
| | - Hal F Yee
- Los Angeles County Department of Health Services, Los Angeles, California
| | - Michael L Barnett
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
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Kim EJ, Orlander JD, Afable M, Pawar S, Cutrona SL, Simon SR, Strymish J, Vimalananda VG. Cardiology electronic consultation (e-consult) use by primary care providers at VA medical centres in New England. J Telemed Telecare 2018; 25:370-377. [PMID: 29754562 DOI: 10.1177/1357633x18774468] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Eun Ji Kim
- 1 Division of General Internal Medicine, Zucker School of Medicine at Hofstra/Northwell, USA
| | - Jay D Orlander
- 2 Medical Service, VA Boston Healthcare System, USA.,3 Evans Department of Medicine, Boston University School of Medicine, USA
| | - Melissa Afable
- 4 Center for Healthcare Organization and Implementation Research, Partners Healthcare, USA
| | - Sumeet Pawar
- 5 Department of Cardiology, Yale School of Medicine, USA
| | - Sarah L Cutrona
- 6 Center for Healthcare Organization and Implementation Research (CHOIR), Bedford VA Medical Center, USA.,7 Department of Quantitative Health Science, University of Massachusetts Medical School, USA
| | - Steven R Simon
- 8 Geriatrics and Extended Care Service, VA Boston Healthcare System, Boston, MA, USA.,9 Harvard Medical School, USA
| | - Judith Strymish
- 2 Medical Service, VA Boston Healthcare System, USA.,9 Harvard Medical School, USA
| | - Varsha G Vimalananda
- 3 Evans Department of Medicine, Boston University School of Medicine, USA.,6 Center for Healthcare Organization and Implementation Research (CHOIR), Bedford VA Medical Center, USA
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Chisci E, de Donato G, Fargion A, Ventoruzzo G, Parlani G, Setacci C, Ercolini L, Michelagnoli S. One-year experience of a regional service model of teleconsultation for planning and treatment of complex thoracoabdominal aortic disease. J Vasc Surg 2018; 67:974-983. [DOI: 10.1016/j.jvs.2017.11.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 11/21/2017] [Indexed: 11/26/2022]
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Joschko J, Liddy C, Moroz I, Reiche M, Crowe L, Afkham A, Keely E. Just a click away: exploring patients' perspectives on receiving care through the Champlain BASETM eConsult service. Fam Pract 2018; 35:93-98. [PMID: 28968806 DOI: 10.1093/fampra/cmx073] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Excessive wait times for specialist care can have a substantial negative impact on health outcomes. The Champlain BASETM (Building Access to Specialists through eConsultation) eConsult service based in Ottawa, Canada has demonstrated the ability to improve patients' access to specialist care. OBJECTIVE We interviewed patients who were treated using eConsult in order to explore their attitudes towards the service and their experiences of receiving care via the service. METHODS We conducted a thematic analysis of patient interviews using a constant comparative approach. Patients whose primary care providers used the eConsult service in their care were contacted by telephone between June 2015 and January 2016 and completed 15-min semi-structured interviews. RESULTS Of 43 contacted participants, 30 completed interviews (70%). Over half of all respondents (n = 16) reported receiving a follow-up call or appointment within 1 week, and 26 stated that eConsult was useful in their case. Participants unanimously agreed that eConsult was an acceptable way to access specialist care, and 29 stated that they would ask their primary care provider to use eConsult on their behalf in the future. Three themes emerged from the thematic analysis of patient comments: access, acceptability of eConsult and strengthened role of the primary care provider. CONCLUSIONS Patients expressed acceptance for eConsult as a model for improving access to specialist care, had largely positive experiences with it as a model of care delivery, and supported its use in their future care.
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Affiliation(s)
- Justin Joschko
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada
| | - Clare Liddy
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Isabella Moroz
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada
| | - Marnie Reiche
- Winchester District Memorial Hospital, Ottawa, ON, Canada
| | - Lois Crowe
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada
| | - Amir Afkham
- Winchester District Memorial Hospital, Ottawa, ON, Canada.,The Champlain Local Health Integration Network, Ottawa, ON, Canada
| | - Erin Keely
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Division of Endocrinology/Metabolism, The Ottawa Hospital, Ottawa, ON, Canada
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The impact of electronic consultation on a Canadian tertiary care pediatric specialty referral system: A prospective single-center observational study. PLoS One 2018; 13:e0190247. [PMID: 29320539 PMCID: PMC5761872 DOI: 10.1371/journal.pone.0190247] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 12/11/2017] [Indexed: 11/19/2022] Open
Abstract
Background Champlain BASE™ (Building Access to Specialists through eConsultation) is a web-based asynchronous electronic communication service that allows primary-care- practitioners (PCPs) to submit “elective” clinical questions to a specialist. For adults, PCPs have reported improved access and timeliness to specialist advice, averted face-to-face specialist referrals in up to 40% of cases and high provider satisfaction. Objective To determine whether the expansion of eConsult to a pediatric setting would result in similar measures of improved healthcare system process and high provider acceptance reported in adults. Design Prospective observational cohort study. Setting Single Canadian tertiary-care academic pediatric hospital (June 2014–16) servicing 1.2 million people. Participants 1. PCPs already using eConsult. 2.Volunteer pediatric specialists provided services in addition to their regular workload. 3.Pediatric patients (< 18 years-old) referred for none-acute care conditions. Main outcomes and measures Specialty service utilization and access, impact on PCP course-of-action and referral-patterns and survey-based provider satisfaction data were collected. Results 1064 eConsult requests from 367 PCPs were answered by 23 pediatric specialists representing 14 specialty-services. The top three specialties represented were: General Pediatrics 393 cases (36.9%), Orthopedics 162 (15.2%) and Psychiatry 123 (11.6%). Median specialist response time was 0.9 days (range <1 hour-27 days), most consults (63.2%) required <10minutes to complete and 21/21(100%) specialist survey-respondents reported minimal workload burden. For 515/1064(48.4%) referrals, PCPs received advice for a new or additional course of action; 391/1064(36.7%) referrals resulted in an averted face-to-face specialist visit. In 9 specialties with complete data, the median wait-time was significantly less (p<0.001) for an eConsult (1 day, 95%CI:0.9–1.2) compared with a face-to-face referral (132 days; 95%CI:127–136). The majority (>93.3%) of PCPs rated eConsult as very good/excellent value for both patients and themselves. All specialist survey-respondents indicated eConsult should be a continued service. Conclusions and relevance Similar to adults, eConsult improves PCP access and timeliness to elective pediatric specialist advice and influences their care decisions, while reporting high end-user satisfaction. Further study is warranted to assess impact on resource utilization and clinical outcomes.
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Schettini P, Shah KP, O’Leary CP, Patel MP, Anderson JB, Cho AH, Long AL, Bosworth HB, Cameron CB. Keeping care connected: e-Consultation program improves access to nephrology care. J Telemed Telecare 2017; 25:142-150. [DOI: 10.1177/1357633x17748350] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction Health systems are seeking innovative solutions to improve specialty care access. Electronic consultations (eConsults) allow specialists to provide formal clinical recommendations to primary care providers (PCPs) based on patient chart review, without a face-to-face visit. Methods We implemented a nephrology eConsult pilot program within a large, academic primary care practice to facilitate timely communication between nephrologists and PCPs. We used primary care referral data to compare wait times and completion rates between traditional referrals and eConsults. We surveyed PCPs to assess satisfaction with the program. Results For traditional nephrology referrals placed during the study period (July 2016–March 2017), there was a 51-day median appointment wait time and a 40.9% referral completion rate. For eConsults, there was a median nephrologist response time of one day and a 100% completion rate; 67.5% of eConsults did not require a subsequent face-to-face specialty appointment. For eConsults that were converted to an in-person visit, the median wait time and completion rate were 40 days and 73.1%, respectively. Compared to traditional referrals placed during the study period, eConsults converted to in-person visits were more likely to be completed ( p = 0.001). Survey responses revealed that PCPs were highly satisfied with the program and consider the quick turnaround time as the greatest benefit. Discussion Our eConsult pilot program reduced nephrology wait times and significantly increased referral completion rates. In large integrated health systems, eConsults have considerable potential to improve access to specialty care, reduce unnecessary appointments, and optimize the patient population being seen by specialists.
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Affiliation(s)
| | - Kevin P Shah
- Duke Primary Care, Duke University Health System, Durham, NC, USA
| | | | | | - John B Anderson
- Duke Primary Care, Duke University Health System, Durham, NC, USA
| | - Alex H Cho
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Andrea L Long
- Duke Health Technology Solutions (DHTS), Durham, NC, USA
| | - Hayden B Bosworth
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Durham Veterans Affairs Medical Center, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - C Blake Cameron
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
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Aller MB, Vargas I, Coderch J, Vázquez ML. Doctors' opinion on the contribution of coordination mechanisms to improving clinical coordination between primary and outpatient secondary care in the Catalan national health system. BMC Health Serv Res 2017; 17:842. [PMID: 29273045 PMCID: PMC5741878 DOI: 10.1186/s12913-017-2690-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 11/07/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinical coordination is considered a health policy priority as its absence can lead to poor quality of care and inefficiency. A key challenge is to identify which strategies should be implemented to improve coordination. The aim is to analyse doctors' opinions on the contribution of mechanisms to improving clinical coordination between primary and outpatient secondary care and the factors influencing their use. METHODS A qualitative descriptive study in three healthcare networks of the Catalan national health system. A two-stage theoretical sample was designed: in the first stage, networks with different management models were selected; in the second, primary care (n = 26) and secondary care (n = 24) doctors. Data were collected using semi-structured interviews. Final sample size was reached by saturation. A thematic content analysis was conducted, segmented by network and care level. RESULTS With few differences across networks, doctors identified similar mechanisms contributing to clinical coordination: 1) shared EMR facilitating clinical information transfer and uptake; 2) mechanisms enabling problem-solving communication and agreement on clinical approaches, which varied across networks (joint clinical case conferences, which also promote mutual knowledge and training of primary care doctors; virtual consultations through EMR and email); and 3) referral protocols and use of the telephone facilitating access to secondary care after referrals. Doctors identified organizational (insufficient time, incompatible timetables, design of mechanisms) and professional factors (knowing each other, attitude towards collaboration, concerns over misdiagnosis) that influence the use of mechanisms. DISCUSSION Mechanisms that most contribute to clinical coordination are feedback mechanisms, that is those based on mutual adjustment, that allow doctors to exchange information and communicate. Their use might be enhanced by focusing on adequate working conditions, mechanism design and creating conditions that promote mutual knowledge and positive attitudes towards collaboration.
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Affiliation(s)
- Marta-Beatriz Aller
- Health Policy and Health Services Research Group; Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Avinguda Tibidabo 21, 08022 Barcelona, Spain
| | - Ingrid Vargas
- Health Policy and Health Services Research Group; Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Avinguda Tibidabo 21, 08022 Barcelona, Spain
| | - Jordi Coderch
- Grup de Recerca en Serveis Sanitaris i Resultats en Salut; Serveis de Salut Integrats Baix Empordà, Hospital, 17-19 Edif. Fleming, 17230 Palamós, Spain
| | - Maria-Luisa Vázquez
- Health Policy and Health Services Research Group; Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Avinguda Tibidabo 21, 08022 Barcelona, Spain
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Fort MP, Namba LM, Dutcher S, Copeland T, Bermingham N, Fellenz C, Lantz D, Reusch JJ, Bayliss EA. Implementation and Evaluation of the Safety Net Specialty Care Program in the Denver Metropolitan Area. Perm J 2017; 21:16-022. [PMID: 28241908 DOI: 10.7812/tpp/16-022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES In response to limited access to specialty care in safety-net settings, an integrated delivery system and three safety-net organizations in the Denver, CO, metropolitan area launched a unique program in 2013. The program offers safety-net providers the option to electronically consult with specialists. Uninsured patients may be seen by specialists in office visits for a defined set of services. This article describes the program, identifies aspects that have worked well and areas that need improvement, and offers lessons learned. METHODS We quantified electronic consultations (e-consults) between safety-net clinicians and specialists, and face-to-face specialist visits between May 2013 and December 2014. We reviewed and categorized all e-consults from November and December 2014. In 2015, we interviewed 21 safety-net clinicians and staff, 12 specialists, and 10 patients, and conducted a thematic analysis to determine factors facilitating and limiting optimal program use. RESULTS In the first 20 months of the program, safety-net clinicians at 23 clinics made 602 e-consults to specialists, and 81 patients received face-to-face specialist visits. Of 204 primary care clinicians, 103 made e-consults; 65 specialists participated in the program. Aspects facilitating program use were referral case managers' involvement and the use of clear, concise questions in e-consults. Key recommendations for process improvement were to promote an understanding of the different health care contexts, support provider-to-provider communication, facilitate hand-offs between settings, and clarify program scope. CONCLUSION Participants perceived the program as responsive to their needs, yet opportunities exist for continued uptake and expansion. Communitywide efforts to assess and address needs remain important.
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Affiliation(s)
- Meredith P Fort
- Research Assistant Professor in the Department of Health Systems, Management and Policy and the Centers for American Indian and Alaska Native Health at the University of Colorado Denver in Aurora.
| | - Lynnette M Namba
- Senior Community Health Specialist in the Community Benefit and Relations Department at Kaiser Permanente Colorado in Denver.
| | - Sarah Dutcher
- Community Health Center Advocate and a former Senior Manager in the Quality Initiatives Division of the Colorado Community Health Network in Denver.
| | - Tracy Copeland
- Project Coordinator for Community Care in the Community Benefit and Relations Department at Kaiser Permanente Colorado in Denver.
| | - Neysa Bermingham
- Former Access to Care Manager in the Community Benefit and Relations Department at Kaiser Permanente Colorado in Denver.
| | - Chris Fellenz
- Physician Lead for Safety Net Partnerships and Access to Care in the Community Benefit and Relations Department at Kaiser Permanente Colorado in Denver.
| | - Deborah Lantz
- Clinical Services Director for the Department of Neurology and Community Patient Access for Kaiser Permanente Colorado in Denver.
| | - John J Reusch
- Cardiologist with the Colorado Permanente Medical Group in Denver.
| | - Elizabeth A Bayliss
- Clinician Investigator for the Institute for Health Research of Kaiser Permanente Colorado in Denver and a Professor of Family Medicine at the University of Colorado School of Medicine.
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O'Toole A, Joo J, DesGroseilliers JP, Liddy C, Glassman S, Afkham A, Keely E. The association between question type and the outcomes of a Dermatology eConsult service. Int J Dermatol 2017; 56:836-841. [DOI: 10.1111/ijd.13628] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2016] [Revised: 02/01/2017] [Accepted: 03/15/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Ashley O'Toole
- Division of Dermatology; Department of Medicine; University of Ottawa and The Ottawa Hospital; Ottawa Ontario Canada
| | - Jiyeh Joo
- Faculty of Medicine; University of Ottawa; Ottawa Ontario Canada
| | - Jean-Pierre DesGroseilliers
- Division of Dermatology; Department of Medicine; University of Ottawa and The Ottawa Hospital; Ottawa Ontario Canada
| | - Clare Liddy
- Department of Family Medicine; University of Ottawa; Ottawa Ontario Canada
- C.T. Lamont Primary Healthcare Research Centre; Elisabeth Bruyère Research Institute; Ottawa Ontario Canada
| | - Steven Glassman
- Division of Dermatology; Department of Medicine; University of Ottawa and The Ottawa Hospital; Ottawa Ontario Canada
| | - Amir Afkham
- Senior Project Manager; Champlain Local Health Integration Network; Ottawa Ontario Canada
| | - Erin Keely
- Division of Endocrinology/Metabolism; Department of Medicine; University of Ottawa and The Ottawa Hospital; Ottawa Ontario Canada
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Abbott DE, Voils CL, Fisher DA, Greenberg CC, Safdar N. Socioeconomic disparities, financial toxicity, and opportunities for enhanced system efficiencies for patients with cancer. J Surg Oncol 2017; 115:250-256. [PMID: 28105638 DOI: 10.1002/jso.24528] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 11/10/2016] [Accepted: 11/14/2016] [Indexed: 12/20/2022]
Abstract
Cancer care continues to stress the US healthcare system with increases in life expectancy, cancer prevalence, and survivors' complex needs. These challenges are compounded by socioeconomic, racial, and cultural disparities that are associated with poor clinical outcomes. One innovative and resource-wise strategy to address this demand on the system is expanded use of telehealth. This paradigm has the potential to decrease healthcare and patient out-of-pocket costs and improve patient adherence to recommended treatment and/or surveillance.
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Affiliation(s)
- Daniel E Abbott
- William S. Middleton Memorial Veterans Hospital, Cincinnati, Ohio.,Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Corrine L Voils
- Durham Veteran's Affairs Medical Center, Durham, North Carolina.,Department of Medicine, Duke University, Durham, North Carolina
| | - Deborah A Fisher
- Durham Veteran's Affairs Medical Center, Durham, North Carolina.,Department of Medicine, Duke University, Durham, North Carolina
| | - Caprice C Greenberg
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Nasia Safdar
- William S. Middleton Memorial Veterans Hospital, Cincinnati, Ohio.,Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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Price EL, Sewell JL, Chen AH, Sarkar U. Minding the Gaps: Assessing Communication Outcomes of Electronic Preconsultation Exchange. Jt Comm J Qual Patient Saf 2017; 42:341-54. [PMID: 27456415 DOI: 10.1016/s1553-7250(16)42048-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Effective communication between referring and specialty providers is key to optimizing patient safety. Communication was assessed in an electronic referral system by review of referrals to a public urban health care system's gastroenterology clinic that were not scheduled for appointments. METHODS All electronic referrals to a publicly funded, urban health care system's adult gastroenterology clinic from November 1, 2009, to November 30, 2010, were reviewed that did not result in scheduling of appointments. An assessment was made of whether in-person visits were unnecessary by preconsultation exchange or whether the referrals remained unscheduled for other reasons. For the latter group, reasons why the referrals remained unscheduled were examined, and medical records were reviewed for actual patient harm when sufficient information was present in the chart or for potential harm when no further information about the referral complaint was available. RESULTS Eighty-six (32%) of 266 not-scheduled referrals were resolved via preconsultation exchange. For another 96 (36%), patients were not ultimately considered to require appointments or were scheduled via other routes. Nine patients received unplanned care while awaiting scheduling decisions, 5 of whom had harm that was related to referral complaints, although scheduling of appointments may not have avoided this harm. Of 75 patients for whom further information was not available about the referral complaints, most were not seen back in primary care, and 55 (73%) had potential for major harm. CONCLUSION Few adverse outcomes in electronic referrals not scheduled for in-person gastroenterology visits were found, and none were clearly due to communication lapses in the referral process. Contributors to the potential for harm in referrals that were unintentionally left unscheduled included discontinuity of care and lack of patient or provider follow-up.
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Caffery LJ, Farjian M, Smith AC. Telehealth interventions for reducing waiting lists and waiting times for specialist outpatient services: A scoping review. J Telemed Telecare 2016; 22:504-512. [PMID: 27686648 DOI: 10.1177/1357633x16670495] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 08/30/2016] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Liam J Caffery
- Centre for Online Health, The University of Queensland, Australia
| | | | - Anthony C Smith
- Centre for Online Health, The University of Queensland, Australia
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Wrenn K, Catschegn S, Cruz M, Gleason N, Gonzales R. Analysis of an electronic consultation program at an academic medical centre: Primary care provider questions, specialist responses, and primary care provider actions. J Telemed Telecare 2016; 23:217-224. [DOI: 10.1177/1357633x16633553] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Introduction Electronic consultations (eConsults) increase access to specialty care, but little is known about the types of questions primary care providers (PCPs) ask through eConsults, and how they respond to specialist recommendations. Methods This is a retrospective descriptive analysis of the first 200 eConsults completed in the UCSF eConsult program. Participating PCPs were from eight adult primary care sites at the University of California, San Francisco (UCSF), USA. Medicine subspecialties participating were Cardiology, Endocrinology, Gastroenterology/hepatology, Hematology, Infectious diseases, Nephrology, Pulmonary medicine, Rheumatology, and Sleep medicine. We categorized eConsult questions into “diagnosis,” “treatment,” and/or “monitoring.” We performed medical record reviews to determine the percentage of specialist recommendations PCPs implemented, and the proportion of patients with a specialist visit in the same specialty as the eConsult, emergency department visit, or hospital admission during the subsequent six months. Results PCP questions related to diagnosis in 71% of cases, treatment in 46%, and monitoring in 21%. Specialist responses related to diagnosis in 76% of cases, treatment in 64%, and monitoring in 40%. PCPs ordered 79% of all recommended laboratory tests, 86% of recommended imaging tests and procedures, 65% of recommended new medications, and 73% of recommended medication changes. In the six months after the eConsult, 14% of patients had a specialist visit within the UCSF system in the same specialty as the eConsult. Discussion eConsults provide guidance to PCPs across the spectrum of patient care. PCPs implement specialists’ recommendations in the large majority of cases, and few patients subsequently require in-person specialty care related to the reason for the eConsult.
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Affiliation(s)
- Katherine Wrenn
- Division of General Internal Medicine, University of California, San Francisco, USA
| | - Sereina Catschegn
- Division of General Internal Medicine, University of California, San Francisco, USA
| | - Marisa Cruz
- Division of General Internal Medicine, University of California, San Francisco, USA
| | - Nathaniel Gleason
- Division of General Internal Medicine, University of California, San Francisco, USA
| | - Ralph Gonzales
- Division of General Internal Medicine, University of California, San Francisco, USA
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Liddy C, Drosinis P, Deri Armstrong C, McKellips F, Afkham A, Keely E. What are the cost savings associated with providing access to specialist care through the Champlain BASE eConsult service? A costing evaluation. BMJ Open 2016; 6:e010920. [PMID: 27338880 PMCID: PMC4932271 DOI: 10.1136/bmjopen-2015-010920] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE This study estimates the costs and potential savings associated with all eConsult cases completed between 1 April 2014 and 31 March 2015. DESIGN Costing evaluation from the societal perspective estimating the costs and potential savings associated with all eConsults completed during the study period. SETTING Champlain health region in Eastern Ontario, Canada. POPULATION Primary care providers and specialists registered to use the eConsult service. MAIN OUTCOME MEASURES Costs included (1) delivery costs; (2) specialist remuneration; (3) costs associated with traditional (face-to-face) referrals initiated as a result of eConsult. Potential savings included (1) costs of traditional referrals avoided; (2) indirect patient savings through avoided travel and lost wages/productivity. Net potential societal cost savings were estimated by subtracting total costs from total potential savings. RESULTS A total of 3487 eConsults were completed during the study period. In 40% of eConsults, a face-to-face specialist visit was originally contemplated but avoided as result of eConsult. In 3% of eConsults, a face-to-face specialist visit was not originally contemplated but was prompted as a result of the eConsult. From the societal perspective, total costs were estimated at $207 787 and total potential savings were $246 516. eConsult led to a net societal saving of $38 729 or $11 per eConsult. CONCLUSIONS Our findings demonstrate potential cost savings from the societal perspective, as patients avoided the travel costs and lost wages/productivity associated with face-to-face specialist visits. Greater savings are expected once we account for other costs such as avoided tests and visits and potential improved health outcomes associated with shorter wait times. Our findings are valuable for healthcare delivery decision-makers as they seek solutions to improve care in a patient-centred and efficient manner.
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Affiliation(s)
- Clare Liddy
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Paul Drosinis
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada
| | | | - Fanny McKellips
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Amir Afkham
- The Champlain Local Health Integration Network, Ottawa, Ontario, Canada
| | - Erin Keely
- Division of Endocrinology and Metabolism, The Ottawa Hospital—Riverside Campus, Ottawa, Ontario, Canada
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Liddy C, Drosinis P, Keely E. Electronic consultation systems: worldwide prevalence and their impact on patient care-a systematic review. Fam Pract 2016; 33:274-85. [PMID: 27075028 DOI: 10.1093/fampra/cmw024] [Citation(s) in RCA: 114] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Many health organizations are exploring the potential of electronic consultation (eConsult) services to address excessive wait times for specialist care. OBJECTIVE To understand the effectiveness, population impact and costs associated with implementation of eConsult services. METHODS We conducted a systematic review using a narrative synthesis approach. We searched Medline and Embase from inception to August 2014 (English/French). Included studies focused on communication between primary care providers and specialist physicians through an asynchronous, directed communication over a secure electronic medium. We assessed study quality with a modified version of the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies. We synthesized the results using the Triple Aim framework. RESULTS A total of 36 studies were included. Most were set in the USA and focused on single-specialty services (most commonly dermatology). Population health outcomes included patient populations, adoption/utilization and provider attitudes. Providers cited timely advice from specialists, good medical care, confirmation of diagnoses and educational benefits. No clinical outcomes were reported. Patient experience of care was generally positive, with quick specialist response times (4.6 hours to 3.9 days), avoided referrals (12-84%) and satisfaction ranging from 78% to 93%. System costs were reported in only seven studies using different outcome measures and settings, limiting comparability. CONCLUSION Though eConsult systems are highly acceptable for patients and providers and deliver improved access to specialist advice, gaps remain regarding eConsult's impact on population health and system costs. To achieve optimized health system performance, eConsult services must include specialty services as determined by community needs and further explore cost-effectiveness.
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Affiliation(s)
- Clare Liddy
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Department of Family Medicine and
| | - Paul Drosinis
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario
| | - Erin Keely
- Department of Medicine, University of Ottawa, Ottawa, Ontario and Division of Endocrinology/Metabolism, The Ottawa Hospital, Ottawa, Ontario, Canada
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Fogel A, Khamisa K, Afkham A, Liddy C, Keely E. Ask the eConsultant: Improving access to haematology expertise using an asynchronous eConsult system. J Telemed Telecare 2016; 23:421-427. [DOI: 10.1177/1357633x16644095] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction The Champlain BASE (Building Access to Specialists through eConsultation) eConsultation service was designed to address the limited access to specialist care in Canada, which can lead to long waiting times and, subsequently, negative patient outcomes. Our primary objective was to perform an in-depth analysis of the use, content, and perceived value of haematology electronic consults (eConsults) submitted by primary care providers (PCPs) to the eConsult service. Methods We conducted a cross-sectional study using descriptive statistics to examine post-eConsult surveys for PCPs and other collected data including PCP designation, time for specialist to complete the eConsult, specialist response time, perceived value of the eConsult by the PCP, and the need for a face-to-face referral following the eConsult. A medically-trained author reviewed all haematology eConsults from April 2011 to January 2015, and categorized them by clinical topic and question type using validated taxonomies. Results Haematology accounted for 436 out of 5601 (7.8%) total eConsults, making it the third most popular service utilized. In 66% of haematology eConsults, a face-to-face consultation was not needed. Anaemia, neutropenia, and hyperferritinemia were the most common clinical queries. Most eConsult question types concerned the management of haematological disorders or the interpretation of laboratory tests. Most eConsults were answered within three days, using less than 15 minutes of the specialists’ time. PCPs highly valued the service. Discussion This initiative increases access to haematology care and has the potential to reduce the long waiting times for non-urgent traditional consultation, along with the benefit of cost savings to the healthcare system.
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Affiliation(s)
- Adam Fogel
- Faculty of Medicine, University of Ottawa, Canada
| | - Karima Khamisa
- Department of Medicine, University of Ottawa, Canada
- Division of Hematology, The Ottawa Hospital, Canada
| | - Amir Afkham
- Champlain Local Health Integration Network, Canada
| | - Clare Liddy
- CT Lamont Primary Health Care Research Centre, Bruyère Research Institute, Canada
- Department of Family Medicine, University of Ottawa, Canada
| | - Erin Keely
- Department of Medicine, University of Ottawa, Canada
- Division of Endocrinology/Metabolism, The Ottawa Hospital, Canada
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Liddy C, Smyth C, Poulin PA, Joschko J, Rebelo M, Keely E. Improving Access to Chronic Pain Services Through eConsultation: A Cross-Sectional Study of the Champlain BASE eConsult Service. PAIN MEDICINE 2016; 17:1049-1057. [DOI: 10.1093/pm/pnw038] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Olayiwola JN, Anderson D, Jepeal N, Aseltine R, Pickett C, Yan J, Zlateva I. Electronic Consultations to Improve the Primary Care-Specialty Care Interface for Cardiology in the Medically Underserved: A Cluster-Randomized Controlled Trial. Ann Fam Med 2016; 14:133-40. [PMID: 26951588 PMCID: PMC4781516 DOI: 10.1370/afm.1869] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Communication between specialists and primary care clinicians is suboptimal, and access to referrals is often limited, which can lead to lower quality, inefficiency, and errors. An electronic consultation (e-consultation) is an asynchronous, non-face-to-face consultation between a primary care clinician and a specialist using a secure electronic communication platform. The purpose of this study was to conduct a randomized controlled trial of e-consultations to test its efficacy and effectiveness in reducing wait times and improving access to specialty care. METHODS Primary care clinicians were randomized into a control (9 traditional) or an intervention (17 e-consultation) arm for referrals to cardiologists. Primary care clinicians were recruited from 12 practice sites in a community health center in Connecticut with mainly medically underserved patients. Two end points were analyzed with a Cox proportional hazards model where the hazard of either a visit or an e-consultation was linked to study arm, sex, race, and age. RESULTS Thirty-six primary care clinicians participated in the study, referring 590 patients. In total, 69% of e-consultations were resolved without a visit to a cardiologist. After adjusting for covariates, median days to a review for an electronic consultation vs a visit for control patients were 5 and 24, respectively. A review of 6-month follow-up data found fewer cardiac-related emergency department visits for the intervention group. CONCLUSION E-consultation referrals improved access to and timeliness of care for an underserved population, reduced overall specialty utilization, and streamlined specialty referrals without any increase in adverse cardiovascular outcomes. e-consultations are a potential solution for improving access to specialty care.
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Affiliation(s)
- J Nwando Olayiwola
- Center for Excellence in Primary Care, San Francisco General Hospital, San Francisco, California Department of Family and Community Medicine, University of California San Francisco, San Francisco, California
| | - Daren Anderson
- Weitzman Institute, Community Health Center, Inc, Middletown, Connecticut
| | - Nicole Jepeal
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Robert Aseltine
- Division of Behavioral Sciences and Community Health, University of Connecticut Health Center, Farmington, Connecticut
| | - Christopher Pickett
- Pat and Jim Calhoun Cardiology Center, University of Connecticut Health Center, Farmington, Connecticut
| | - Jun Yan
- Department of Statistics, University of Connecticut, Storrs, Connecticut
| | - Ianita Zlateva
- Weitzman Institute, Community Health Center, Inc, Middletown, Connecticut
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Bidmead E, Marshall A. A case study of stakeholder perceptions of patient held records: the Patients Know Best (PKB) solution. Digit Health 2016; 2:2055207616668431. [PMID: 29942567 PMCID: PMC6001208 DOI: 10.1177/2055207616668431] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 07/29/2016] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Patients Know Best (PKB) provides a patient portal with integrated, patient-controlled digital care records. Patient-controlled personal health records facilitate coordinated management of chronic disease through improved communications among, and about, patients across professional and organisational boundaries. An NHS foundation trust hospital has used PKB to support self-management in patients with inflammatory bowel disease; this paper presents a case study of usage. METHODS The stakeholder empowered adoption model provided a framework for consulting variously placed stakeholders. Qualitative interviews with clinical stakeholders and a patient survey. RESULTS Clinicians reported PKB to have enabled a new way of managing stable patients, this facilitated clinical and cost effective use of specialist nurses; improved two-way communications, and more optimal use of outpatient appointments and consultant time. The portal also facilitated a single, rationalised pathway for stable patients, enabling access to information and pro-active support. For patients, the system was a source of support when unwell and facilitated improved communication with specialists. Three main barriers to adoption were identified; these related to concerns over security, risk averse attitudes of users and problems with data integration. CONCLUSIONS Patient-controlled personal health records offer significant potential in supporting self-management. Digital connection to healthcare can help patients to understand their condition better and access appropriate, timely clinical advice.
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Affiliation(s)
- Elaine Bidmead
- Cumbrian Centre for Health Technologies
(CaCHeT), University of Cumbria, Carlisle, UK
| | - Alison Marshall
- Cumbrian Centre for Health Technologies
(CaCHeT), University of Cumbria, Lancaster, UK
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Tejera Segura B, Bustabad S. Una nueva forma de comunicación entre reumatología y atención primaria: la consulta virtual. ACTA ACUST UNITED AC 2016; 12:11-4. [DOI: 10.1016/j.reuma.2015.01.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Revised: 11/14/2014] [Accepted: 01/08/2015] [Indexed: 10/24/2022]
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