Evaluation of an electronic consultation service in psychiatry for primary care providers

Evaluating preferences for medication formulation and treatment model among people who use opioids non-medically: A web-based cross-sectional study

INTRODUCTION

Over the past decade, treatment for opioid use disorder has expanded to include long-acting injectable and implantable formulations of medication for opioid use disorder (MOUD), and integrated treatment models systematically addressing both behavioral and physical health. Patient preference for these treatment options has been underexplored. Gathering data on OUD treatment preferences is critical to guide the development of patient-centered treatment for OUD. This cross-sectional study assessed preferences for long-acting MOUD and integrated treatment using an online survey.

METHODS

An online Qualtrics survey assessed preferences for MOUD formulation and integrated treatment models. The study recruited participants (n = 851) in October and November 2019 through advertisements or posts on Facebook, Google AdWords, Reddit, and Amazon Mechanical Turk (mTurk). Eligible participants scored a two or higher on the opioid pain reliever or heroin scales of the Tobacco, Alcohol Prescription Medication and other Substance Use (TAPS) Tool. Structured survey items obtained patient preference for MOUD formulation and treatment model. Using stated preference methods, the study assessed preference via comparison of preferred options for MOUD and treatment model.

RESULTS

In the past year, 824 (96.8 %) participants reported non-prescribed use of opioid pain relievers (mean TAPS score = 2.72, SD = 0.46) and 552 (64.9 %) reported heroin or fentanyl use (mean TAPS score = 2.73, SD = 0.51). Seventy-four percent of participants (n = 631) reported currently or previously receiving OUD treatment, with 407 (48.4 %) receiving MOUD. When asked about preferences for type of MOUD formulation, 452 (53.1 %) preferred a daily oral formulation, 115 (13.5 %) preferred an implant, 114 (13.4 %) preferred a monthly injection and 95 (11.2 %) preferred a weekly injection. Approximately 8.8 % (n = 75) would not consider MOUD regardless of formulation. The majority of participants (65.2 %, n = 555) preferred receiving treatment in a specialized substance use treatment program distinct from their medical care, compared with receiving care in an integrated model (n = 296, 34.8 %).

CONCLUSIONS

Though most participants expressed willingness to try long-acting MOUD formulations, the majority preferred short-acting formulations. Likewise, the majority preferred non-integrated treatment in specialty substance use settings. Reasons for these preferences provide insight on developing effective educational tools for patients and suggesting targets for intervention to develop a more acceptable treatment system.

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

Importance

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

Objective

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

Evidence Review

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

Findings

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

Conclusions and Relevance

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

Health equity for persons with disabilities: a global scoping review on barriers and interventions in healthcare services

BACKGROUND

Persons with disabilities experience health inequities in terms of increased mortality, morbidity, and limitations in functioning when compared to the rest of the population. Many of the poor health outcomes experienced by persons with disabilities cannot be explained by the underlying health condition or impairment, but are health inequities driven by unfair societal and health system factors. A synthesis of the global evidence is needed to identify the factors that hinder equitable access to healthcare services for persons with disabilities, and the interventions to remove these barriers and promote disability inclusion.

METHODS

We conducted a scoping review following the methodological framework proposed by Arksey and O'Malley, Int J Soc Res Methodol 8:19-32. We searched two scholarly databases, namely MEDLINE (Ovid) and Web of Science, the websites of Organizations of Persons with Disabilities and governments, and reviewed evidence shared during WHO-led consultations on the topic of health equity for persons with disabilities. We included articles published after 2011 with no restriction to geographical location, the type of underlying impairments or healthcare services. A charting form was developed and used to extract the relevant information for each included article.

RESULTS

Of 11,884 articles identified in the search, we included 182 articles in this review. The majority of sources originated from high-income countries. Barriers were identified worldwide across different levels of the health system (such as healthcare costs, untrained healthcare workforces, issues of inclusive and coordinated services delivery), and through wider contributing factors of health inequities that expand beyond the health system (such as societal stigma or health literacy). However, the interventions to promote equitable access to healthcare services for persons with disabilities were not readily mapped onto those needs, their sources of funding and projected sustainability were often unclear, and few offered targeted approaches to address issues faced by marginalized groups of persons with disabilities with intersectional identities.

CONCLUSION

Persons with disabilities continue to face considerable barriers when accessing healthcare services, which negatively affects their chances of achieving their highest attainable standard of health. It is encouraging to note the increasing evidence on interventions targeting equitable access to healthcare services, but they remain too few and sparce to meet the populations' needs. Profound systemic changes and action-oriented strategies are warranted to promote health equity for persons with disabilities, and advance global health priorities.

Specialists accessing specialty advice: Evaluating utilization, benefits, and impact of care of an e-consultation service

INTRODUCTION

The usual referral pathway is from a primary care provider (PCP) to a specialist; however, specialists also refer to and consult with other specialists. Electronic consultation (eConsult) allows clinicians to submit questions on behalf of patients to specialists to receive timely advice. Most eConsult studies in the past have examined questions asked from PCPs to specialists. This study investigates the utilization of specialists submitting clinical questions to other specialists through the Ontario eConsult Service and identifies use-case scenarios where specialist-to-specialist eConsult may be beneficial.

METHODS

A retrospective, descriptive, cross-sectional analysis of eConsults submitted by specialists through the Ontario eConsult Service for 24 months (March 2019 to February 2021). Utilization data is collected automatically by the service, including specialty referred to, time billed, region, and results from a closeout survey which includes the referral outcome of the eConsult and the utility to the submitting clinician.

RESULTS

4% (n = 3285) of all eConsults sent within the study period were specialist-to-specialist, with the others being sent by a PCP. The number of specialist-to-specialist eConsults grew 120% following the onset of the COVID-19 pandemic. The top three specialties that submitted eConsults were pediatrics, internal medicine, and endocrinology. The top three specialties that specialists submitted to were dermatology, neurology, and hematology. A face-to-face referral was avoided in 69% of referrals.

CONCLUSION

Evaluating the utilization patterns of specialist-to-specialist eConsults allows us to better understand and expand the scope of eConsult services, which have traditionally been thought of as a workflow between a PCP and a specialist.

Strategies used throughout the scaling-up process of eConsult - Multiple case study of four Canadian Provinces

BACKGROUND

eConsult is a model of asynchronous communication connecting primary care providers to specialists to discuss patient care. This study aims to analyze the scaling-up process and identify strategies used to support scaling-up efforts in four provinces in Canada.

METHODS

We conducted a multiple case study with four cases (ON, QC, MB, NL). Data collection methods included document review (n = 93), meeting observations (n = 65) and semi-structured interviews (n = 40). Each case was analyzed based on Milat's framework.

RESULTS

The first scaling-up phase was marked by the rigorous evaluation of eConsult pilot projects and the publication of over 90 scientific papers. In the second phase, provinces implemented provincial multi-stakeholder committees, institutionalized the evaluation, and produced documents detailing the scaling-up plan. During the third phase, efforts were made to lead proofs of concept, obtain the endorsement of national and provincial organizations, and mobilize alternate sources of funding. The last phase was mainly observed in Ontario, where the creation of a provincial governance structure and strategies were put in place to monitor the service and manage changes.

CONCLUSIONS

Various strategies need to be used throughout the scaling-up process. The process remains challenging and lengthy because health systems lack clear processes to support innovation scaling-up.

Does virtual consultation between primary and specialised care improve healthcare quality? A scoping review of healthcare quality domains assessment

BACKGROUND

Virtual consultation has been proposed as a promising tool to improve the coordination and quality of healthcare between primary and specialised care. However, despite its potential facilitators, the evidence on the usefulness of virtual consultation for improving healthcare quality domains is fragmented and unclear. This scoping review aims to assess the impact of virtual consultation on different healthcare quality domains.

MATERIAL AND METHODS

We conducted a scoping review with a rigorous search strategy on PubMed, EMBASE and Cochrane Library databases. The inclusion criteria were original articles, reviews, meta-analyses or letters to the editor, published between 1 January 2017 and 24 June 2022, and available in English, Spanish or French. For each of the articles selected, we identified the addressed healthcare quality domains, their facilitators and barriers, areas of improvement and data gaps. We have adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Review reporting standards.

RESULTS

1284 manuscripts were retrieved. Finally, 235 papers were included in this review, most of which were original, descriptive studies. The most evaluated quality domain was effectiveness (223 articles). Safety and patient-centred care were the least evaluated. Simultaneous assessment of more than one domain was observed in 117 papers, being effectiveness and timeliness the most frequent combination. Our analysis revealed that virtual consultation is in development and underused. This tool has the potential to improve access to specialised care and enhance coordination between professionals.

CONCLUSIONS

Virtual consultation has the potential to provide effective, efficient, equitable and timely attention. However, its contribution to safety and patient-centered care needs further evaluation. Our review emphasises the need for more rigorous research and standardised quality assessment criteria to obtain robust evidence on the usefulness of virtual consultation for improving healthcare quality domains.

Formalizing the curbside: digitally enhancing access to specialty care

Asynchronous medical care has increased in utilization, patient interest, and industry demand. While E-consults have been discussed extensively in the literature, there are rare examples of a multispecialty implementation within a large health system. Here, we describe our experience in implementing an internal E-consult program for asynchronous, nonurgent communication between ambulatory specialists and primary care providers in our large multispecialty regional health system. To ensure adoption of the program, patient, specialist, and primary care physician concerns were systematically addressed. The program commenced in February 2022 with three high referral rate specialties: cardiology, orthopedics, and dermatology. In the 12 months after implementation, 2243 total E-consults were ordered among 505 ordering providers. Dermatology received the most consultations, and we have expanded to 19 specialties and subspecialties available in the program in the first year. Our E-consult implementation experienced substantial growth in a short time period, demonstrating the viability of E-consult utilization for increasing asynchronous access to ambulatory specialists' expertise in a large healthcare system.

Psychiatric consultation: Characteristics, satisfaction, and perceived opportunities among referrers to a 1-time service

OBJECTIVE

To further understand and optimize primary care provider (PCP) referrals to a 1-time psychiatric consultation service by developing profiles of PCP referrers, assessing PCP satisfaction with the service, and determining intervention opportunities.

DESIGN

Secondary analysis of a referral database and subsequent cross-sectional survey of referrers.

SETTING

Winnipeg, Man.

PARTICIPANTS

All family physicians who had made at least 1 referral in 2017 to the Centralized Psychiatric Consultation Service for Adults, a 1-time consultation service.

MAIN OUTCOME MEASURES

Referral frequency, individual and practice characteristics, satisfaction with the Centralized Psychiatric Consultation Service for Adults, and subjective drivers of referral activity were assessed. Interest in a range of intervention opportunities to increase mental health knowledge and support were also examined.

RESULTS

Of the 403 family physicians who referred patients to the consultation service in 2017, a total of 111 (27.5%) responded to the survey. Among all referrers, 287 (71.2%) were low referrers (1 to 4 referrals), 65 (16.1%) were moderate referrers (5 to 9 referrals), and 51 (12.7%) were high referrers (≥10 referrals). Solo practice (P=.04) and no access to collaborative mental health services (P<.001) were significantly associated with being a high referrer. Roughly 26.3% of low referrers, 29.2% of moderate referrers, and 15.4% of high referrers were satisfied with wait times for the service. Higher referrers did not identify a lack of comfort with providing psychiatric care as a driver of referrals; more indicated that they had a high volume of patients with mental health needs, that there was a lack of access to alternative services, and that patients sometimes requested referral. Overall, more than 40% of respondents expressed interest in a mental health care navigator, hard-copy resource information, and rapid access to consultation advice via telephone or an electronic platform. There was less interest in other proposed interventions.

CONCLUSION

We found referrers to the Centralized Psychiatric Consultation Service for Adults to be clustered based on specific practice characteristics, as well as provider-patient factors. Overall, satisfaction with the service was fair and PCPs were not highly interested in a variety of proposed interventions. Future studies should explore how useful 1-time consultation services are for solo-practising PCPs and how best to support these and other PCPs in their management of patients with mental health needs.

Technology-Based Approaches for Supporting Perinatal Mental Health

PURPOSE OF REVIEW

This review explores advances in the utilization of technology to address perinatal mood and anxiety disorders (PMADs). Specifically, we sought to assess the range of technologies available, their application to PMADs, and evidence supporting use.

RECENT FINDINGS

We identified a variety of technologies with promising capacity for direct intervention, prevention, and augmentation of clinical care for PMADs. These included wearable technology, electronic consultation, virtual and augmented reality, internet-based cognitive behavioral therapy, and predictive analytics using machine learning. Available evidence for these technologies in PMADs was almost uniformly positive. However, evidence for use in PMADs was limited compared to that in general mental health populations. Proper attention to PMADs has been severely limited by issues of accessibility, affordability, and patient acceptance. Increased use of technology has the potential to address all three of these barriers by facilitating modes of communication, data collection, and patient experience.

Telematriciamento em saúde mental na pandemia de COVID-19

Problema: A demanda em saúde mental na Atenção Primária à Saúde (APS) é alta, e a capacitação das equipes para a detecção e o tratamento desses pacientes é fundamental, sendo o matriciamento, modelo de cuidado colaborativo desenvolvido no contexto brasileiro, uma ferramenta importante para a efetividade do cuidado em saúde mental na APS. Em março de 2020, com o isolamento social consequente à pandemia pelo novo coronavírus, houve necessidade de reorganização dos serviços. O objetivo deste artigo é descrever a experiência de telematriciamento e reorganização do apoio matricial em saúde mental em unidade da APS do município do Rio de Janeiro, nos primeiros meses de pandemia. Método: O Centro Municipal de Saúde Heitor Beltrão localiza-se na Zona Norte do Rio de Janeiro. Nos anos de 2017 a 2019, o matriciamento ocorreu por meio de consultas conjuntas, discussão de casos e grupo de psicotrópicos. No início da pandemia, o trabalho foi reorganizado em duas frentes: teleconsultas conjuntas síncronas e organização da lista de usuários com transtornos mentais. Resultados: Foram realizadas 50 teleconsultas conjuntas no período de 12 semanas, com média de 4,16 consultas/semana, sendo os diagnósticos mais frequentes transtornos depressivos e ansiosos seguidos de transtornos de personalidade e por uso de substâncias. O novo formato permitiu a manutenção do acesso de usuários da saúde mental ao serviço, a absorção de novos casos, a melhoria de acesso a usuários do grupo de risco para infecção por coronavírus e a continuidade do processo formativo em saúde com aquisição de novas competências e modernização do trabalho. As principais limitações foram a falta de equipamentos disponíveis e a dificuldade de acesso à internet. Conclusão: Esta experiência, desenvolvida em razão da pandemia de COVID-19, descreve os desafios e benefícios da utilização do telematriciamento e da criação da lista de usuários da saúde mental. Poderá auxiliar profissionais e gestores de outros serviços a desenvolver adaptações mais adequadas às realidades locais.  

The Practice of Psychiatric E-Consultation: Current State and Future Directions

OBJECTIVE

This article summarizes the existing literature on psychiatric electronic consultation (e-consultation or e-consult) to provide guidance on psychiatric e-consult practice and suggest next steps in research on psychiatric e-consults.

METHOD

A narrative review was conducted using relevant search terms in PubMed and Google Scholar.

RESULTS AND DISCUSSION

The psychiatric e-consult is a method of asynchronous consultation between primary care providers and psychiatric specialists that is associated with primary care provider satisfaction and promotes access to specialist guidance in mental health care. Major themes in the literature include contextual factors that affect implementation of psychiatric e-consult services, outcomes associated with psychiatric e-consults, and specific practical considerations that may affect psychiatric e-consult technique.

CONCLUSIONS

Psychiatric e-consults may help address the widespread lack of access to specialty psychiatric care. Further studies are needed to examine clinical outcomes based on psychiatry e-consults.

Evaluation of an Electronic Consultation Service for COVID-19 Care

PURPOSE

COVID-19 has increased the need for innovative virtual care solutions. Electronic consultation (eConsult) services allow primary care practitioners to pose clinical questions to specialists using a secure remote application. We examined eConsult cases submitted to a COVID-19 specialist group in order to assess usage patterns, impact on response times and referrals, and the content of clinical questions being asked.

METHODS

This was a mixed-methods analysis of eConsult cases submitted between March and September 2020 in Ontario, Canada to 2 services. We performed a descriptive analysis of the average response time and the total time spent by the specialist for eConsults. Primary care practitioners completed a post-eConsult questionnaire that asked about the outcome of the eConsult. We performed an inductive and deductive content analysis of a subset of cases to identify common themes among the clinical questions asked.

RESULTS

A total of 208 primary care practitioners submitted 289 eConsult cases. The median specialist response time was 0.6 days (range = 3 minutes to 15 days); the average time spent by specialists per case was 16 minutes (range = 5 to 59 minutes). In 69 cases (24%), the eConsult enabled avoidance of a face-to-face referral. Content analysis of 51 cases identified 5 major themes: precautions for high-risk and special populations, diagnostic clarification and/or need for COVID-19 testing, guidance on self-isolation and return to work, guidance on personal protective equipment, and management of chronic symptoms.

CONCLUSIONS

This study demonstrates the considerable potential of eConsults during a pandemic as our service was quickly implemented across Ontario and resulted in primary care practitioners' rapid and low-barrier access to specialist input.

Health complaints in individual visiting primary health care: population-based national electronic health records of Iran

Background

The mission of medical schools is a sustainable commitment to orient education, research, and services based on the priorities and expectations of society. The most common complaints of patients from comprehensive health service centers (CHSCs) based on the data from electronic health records were assessed in order to determine primary health care (PHC) priorities for the educational planning of medical students in Iran.

Methods

A population-based national study was designed to assess clinical complaints of patients in all age groups who were referred to CHSCs at least once to be visited by physicians. All the data in the census were extracted from electronic health records in PHC system during 2015–2020, classified by the International Classification of Primary Care 2^nd edition (ICPC-2e-English), and statistically analyzed. The total number of complaints that were recorded in the system was 17,430,139.

Results

59% of the referring patients were women. The highest number of referrals was related to the age group of 18–59 years (56.9%), while the lowest belonged to the elderly people (13.3%). In all age and sex groups, the first ten complaints of patients with three top priorities in each category included process (follow-up, consultation, and results exam), digestive (toothache and gum complaint, abdominal pain, and diarrhea), respiratory (cough, sore throat, and runny nose), general (fever, pain, and weakness and fatigue), musculoskeletal (back pain, leg complaint, and knee injuries), endocrine and nutritional (weight gain, Feeding problem, and weight loss), cardiovascular (hypertension, palpitations, and Postural hypotension), neurological (headache, dizziness, and paralysis), sexual dysfunction (vaginal complaint, discharge, and irregular menstruation), and dermatological (pruritus, rash, and inflammation) problems.

Conclusion

High priorities in referring to PHC had a key role in assessing the country's health needs. Since this study was in line with the national pattern of complaints and patients' profile, the present findings can be helpful to amend policy-making, educational planning and curricula development in medical schools.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07880-z.

Expanding the scope of an eConsult service: acceptability and feasibility of an optometry–ophthalmology pilot project

OBJECTIVE

To determine the feasibility and acceptability of connecting optometrists to ophthalmologists on an eConsult service.

DESIGN

Descriptive analysis of utilization data and an anonymous survey.

PARTICIPANTS

All eConsult cases sent by optometrists between March 2019 and February 2020 (utilization data); optometrists and ophthalmologists participating in the eConsult Vision Pilot Project (survey).

METHODS

Utilization data for the study period were collected automatically and underwent descriptive analysis. Participating optometrists and ophthalmologists received an email invitation to a survey assessing the project.

RESULTS

Thirteen optometrists from 5 clinics in the southeast region and 7 ophthalmologists were recruited to participate in the pilot project. Optometrists sent 109 eConsults in a 13-month period, representing 33% of all cases submitted to ophthalmology through the eConsult service provincially (March 2019-March 2020). Sixty-eight percent of respondents to an anonymous online survey valued the recruitment and engagement of eye care professionals from the same health region. The influence of the eConsult service was reported to have a "somewhat positive" (27%) to "very positive" (50%) influence on the relationship between the two professional groups.

CONCLUSION

The eConsult Vision Pilot Project fills a gap in service and provides an opportunity for patients to get access to specialty advice. We demonstrated that allowing optometrists to solicit specialist advice from ophthalmologists was acceptable and feasible.

Clinical Trends Over the First Year of a Psychiatric Electronic Consult Service

BACKGROUND

Electronic consultations (e-consultations) offer rapid, direct, and documented communication through the electronic medical record between primary care physicians (PCPs) and specialists. Psychiatric e-consultations are increasingly being implemented across hospital networks with the recommendation for face-to-face psychiatric evaluation periodically being made by the consulted psychiatrist. It remains to be seen what clinical factors lead the consultant to make this type of recommendation and whether the question asked by the PCP and the diagnosis of the patient has any bearing.

OBJECTIVES

To determine which psychiatric diagnoses are most commonly electronically consulted on, what types of questions are being asked by primary care providers to electronically consulted psychiatrists, and what questions and which diagnoses result in an electronically consulted psychiatrist to recommend further in-person evaluation.

METHODS

A retrospective chart review of an e-consultation service was conducted. One hundred sixty-four charts were reviewed. Data were collected on the psychiatric diagnosis, type of question posed by the PCP to the psychiatrist, the number of recommendations for an in-person evaluation made, and the percentages of the diagnoses and questions that were associated with a recommendation for in-person evaluation.

RESULTS

Two hundred twenty-three diagnoses were consulted on. The most common diagnoses were anxiety disorders (34.5%, N = 77), depressive disorders (32.3%, N = 72), and bipolar disorders (13.5%, N = 30). One hundred eighty-one questions were asked by PCPs. One hundred fifty-one (83.4%) questions regarded pharmacological management. Of the 164 charts, 40 (24.4%) e-consultations resulted in the psychiatrist recommending an in-person evaluation. The in-person evaluation recommendation rates did not change with increasing provider familiarity as the inaugural year went on. Three (7.5%) patients who were recommended for an outpatient psychiatry evaluation were scheduled to be seen by the consulted psychiatrist. Depressive (N = 12) and anxiety disorders (N = 13) were both recommended for in-person follow-up 17% of the time. Bipolar disorder was recommended for follow-up 53% (N = 16) of the time. Of the 181 question types posed by PCPs, 34 (22.5%) pharmacological management questions were recommended for in-person follow-up.

CONCLUSIONS

Certain diagnoses and question types appear to influence the likelihood that an electronically consulted psychiatrist will recommend a face-to-face evaluation. It also suggests that e-consultation services can be particularly serviceable for certain diagnoses, that is, depression and anxiety, as well as certain question types, that is, pharmacological management. This information can guide PCPs and psychiatrists about which patients are best suited for an e-consultation versus an in-person referral from the outset.

Clinical Questions Asked by Long-Term Care Providers Through eConsult: A Retrospective Study

Introduction

eConsult allows primary care providers (PCPs) to access timely specialist advice and informs patient care. To understand the use of eConsult in long-term care (LTC) settings, we examined the clinical content and types of questions asked by LTC PCPs.

Methods

A descriptive, retrospective study of eConsults submitted through the Champlain BASE™ eConsult Service between January 1, 2017, and December 31, 2018, by LTC PCPs was conducted. Cases were classified using validated taxonomies. Descriptive statistics were generated for content and question type classifications, service utilization data, and close-out survey responses.

Results

22 LTC PCPs submitted 113 eConsults. They sought advice about drug treatment (58%), diagnosis (44%), and management (38%) in a breadth of clinical areas, often skin-related (39%). Long-term care PCPs frequently asked more than one question type (42%). They received advice within 1 week (91%) and rated eConsult as very helpful and educational. Three case examples are presented.

Conclusion

This study demonstrates the type of advice LTC PCPs are seeking through eConsult and its usefulness in this setting. Long-term care stakeholders are encouraged to consider implementing eConsult in other regions, as a means to improve access to timely specialist advice, support clinical decision-making, and improve residents’ quality of life.

Primary Care Psychiatry eConsults at a Rural Academic Medical Center: Descriptive Analysis

BACKGROUND

Primary care providers serve a crucial role in addressing the mental health needs of many patients. However, there are times when input from a psychiatric specialist may be helpful in supporting the mental health care provided in primary care. Psychiatry eConsults can serve as a valuable tool in providing specialist advice for primary care physicians when direct referral to specialty care is not readily available.

OBJECTIVE

The goal of this study is to evaluate the content and implementation of psychiatric eConsults by primary care providers in a rural academic medical center.

METHODS

This is a retrospective review of 343 eConsults placed between May 2016 and February 2019 by primary care providers at a single academic medical center. The content of eConsult requests, including patient diagnosis, consult question type, specialist recommendations, patient demographics, the distance of patient and primary care providers from the consulting provider, rate of implementation of the recommendation, and response time, were analyzed.

RESULTS

The most common diagnoses associated with eConsults were depression (162/450, 36%) and anxiety (118/450, 26%). The most commonly asked eConsult question was regarding medication management, including medication choice, side effects, interactions, and medication taper (288/343, 84%). More than one recommendation was included in 76% (259/343) of eConsults, and at least one recommendation was implemented by the primary care provider in 94% (282/300) of eConsults. The average time to respond to an eConsult was 26 hours.

CONCLUSIONS

This study demonstrates that psychiatry eConsults can be conducted in a timely manner and that primary care providers implement the recommendations at a high rate.

Evaluation of an electronic consultation service for transgender care

BACKGROUND

Access to transgender care in Canada is poor. Although primary care providers are ideally positioned to initiate care, many feel uncomfortable providing transgender care. This study aimed to explore the impact of an electronic consultation (eConsult) service between primary care providers and transgender care specialists on access to care and to explore the content of clinical questions that were asked.

METHODS

This was a retrospective mixed methods analysis of 62 eConsults submitted between January 2017 and December 2018 by primary care providers to specialists in transgender care in a health region in eastern Ontario, Canada. A descriptive analysis was conducted to assess the average response time and the total time spent by the specialist for the eConsults. An inductive and deductive content analysis was carried out to identify common themes of clinical questions being asked to transgender specialists. A post-eConsult survey completed by primary care providers was assessed to gain insight into avoided face-to-face referrals and overall provider satisfaction.

RESULTS

The median specialist response time was 1.2 days (range: 1 h to 5 days) and the average time spent by specialists per eConsult was 18 min (range: 10 to 40 min). The qualitative analysis identified six major themes: 1) interpretation/management of abnormal bloodwork, 2) change in management due to lack of desired effect/hormone levels not a target, 3) initiation of hormone therapy/initial work up, 4) management of adverse effects of hormone therapy, 5) transition related surgery counseling and post-op complications, and 6) management of patients with comorbidities. Approximately one-third of eConsults resulted in an avoided face-to-face referral and 95% of primary care providers rated the value of their eConsult as a 5 (excellent value) or 4.

CONCLUSIONS

This study demonstrated that a transgender eConsult service has potential to significantly improve access to care for transgender patients. Given the importance that timely access has on improving mental health and reducing suicide attempts, eConsult has the potential to make a substantial clinical impact on this population. Identified themes of eConsult questions provides insight into potential gaps in knowledge amongst primary care providers that could help inform future continuing education events.

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Online Consultations Between General Practitioners and Psychiatrists in the Netherlands: A Qualitative Study

Objective: To examine the nature and scope of questions about psychiatric patient cases submitted by general practitioners (GPs) to an established online consultation platform and to determine if they could have been answered by consulting existing clinical guidelines. Methods: All anonymized psychiatric cases submitted by GPs to the online electronic Prisma platform between September 2018 and November 2019 were examined in a mixed-methods study. Descriptive statistics and qualitative thematic analysis were used, followed by axial coding to arrive at overarching themes to characterize cases. Results: Of the 136 included cases, 44.1% concerned female patients and about half concerned patients aged 31-60 years. Common psychiatric disorders were depression, attention deficit hyperactivity disorder, sleeping problems, sexual disorders, and eating disorders. The first response was usually given within 2 h (interquartile range, 0-14.3 h), with 86% answered within 24 h and 95% within 48 h. Qualitative analysis revealed four themes, namely "type of question," "cases in relation to current clinical guidelines," "case complexity" and "the doctor being pressured." Type of question comprised diagnostic, therapeutic, and referral questions. Notably, for 44.1% of questions no current clinical guidelines was present and 46.3% of cases were deemed complex in nature. GPs were willing to share their experiences of coping with being pressured by patients. Conclusion: The findings of this study support the potential for an online electronic consultation platform to facilitate feasible and useful interprofessional consultation between GPs and psychiatrists for a broad range mental illnesses and questions of varying complexity.

Using Continuous Quality Improvement to Design and Implement a Telepsychiatry Program in Rural Illinois

Although telepsychiatry has emerged as an innovative tool for increasing access to behavioral health services, few studies have examined the complexities associated with designing and implementing telepsychiatry programs. This column examines a multisite, multimodal telepsychiatry program that has been providing direct care, synchronous consultation, and asynchronous consultation services in rural Illinois since 2016. The program used quality improvement metrics and implementation science strategies to improve its long-term impact and sustainability. Program impact was assessed through satisfaction surveys of patients and primary care physicians, chart reviews, wait times, and volume of patients served. Results indicate that the design and implementation of this telepsychiatry program improved access to behavioral health services and effectively supported primary care providers, with high degrees of patient and provider satisfaction.

A Literature Review Comparing Clinicians' Approaches and Skills to In-Person, Synchronous, and Asynchronous Care: Moving Toward Competencies to Ensure Quality Care

Introduction: Research is increasing on asynchronous technologies used by specialist clinicians and primary care, including e-mail, text, e-consultation, and store-and-forward (asynchronous) options. Studies typically describe interventions and care outcomes rather than development of clinical skills for using technology. Methods: This article attempts to compare clinicians' approaches to, and skills for, asynchronous technologies versus in-person and synchronous (i.e., video) care. Literature from technology, health care, pedagogy, and business were searched from 2000 to 2019 for title words, including synchronous (e.g., video, telemental or behavioral health, telepsychiatry), asynchronous (e.g., app, e-consultation, e-mail, text, sensor in a wearable device), education, clinical, and consultation. Results: From a total of 4,812 potential references, two authors (D.M.H., J.T.) found 4,622 eligible for full text review and found 381 articles directly relevant to the concept areas in combination for full text review. However, exclusion criteria subtracted 305, leaving a total of 76 articles. While in-person and synchronous care are similar in many ways, the clinical approach to asynchronous care has many differences. As asynchronous technologies and models of care are feasible and effective, often for consultation, an outline of patient, primary care provider, and specialist clinician goals and skills are presented. Few studies specifically discuss skills or competencies for asynchronous care, but components from published clinical informatics, video, social media, and mobile health competencies were organized into Accreditation Council of Graduate Medical Education domains. Conclusions: Further implementation of science research is needed for asynchronous technology interventions, as well as clinician competencies using asynchronous technologies, to ensure optimal outcomes for patients in health care.

The Digital Revolution in Behavioral Health

BACKGROUND: Technology is disrupting every modern industry, from supermarkets to car manufacturing, and is now entering the health care space. Technological innovations in psychiatry include the opportunity for conducting therapy via two-way video conferencing, providing electronic consultations, and telementoring and education of community health care providers. Use of mobile health applications is also an expanding area of interest and promise. OBJECTIVE: The purpose of this article is to review the evolution and pros and cons of technology-enabled health care since the digital movement in psychiatry began more than 50 years ago as well as describe the University of Rochester's innovative digital behavioral health care model. METHODS: A review of the literature and recent reports on innovations in digital behavioral health care was conducted, along with a review of the University of Rochester's model to describe the current state of digital behavioral health care. RESULTS: Given the lack of access to care and mental health professional shortages in many parts of the United States, particularly rural areas, digital behavioral health care will be an increasingly important strategy for managing mental health care needs. However, there are numerous hurdles to be overcome in adopting digital health care, including provider resistance and knowledge gaps, lack of reimbursement parity, restrictive credentialing and privileging, and overregulation at both the state and federal levels. CONCLUSIONS: Digital health innovations are transforming the delivery of mental health care services and psychiatric mental health nurses can be on the forefront of this important digital revolution.