Sustainability of a Primary Care-Driven eConsult Service

Successful Electronic Consultation Service Initiative in Quebec, Canada With Primary Care Physicians' and Specialists' Experiences on Acceptance and Use of Technological Innovation: Cross-Sectional Exploratory Study

BACKGROUND

Electronic consultation (eConsult) is an eHealth service that allows primary care providers (PCPs) to electronically consult specialists regarding their patients' medical issues. Many studies have demonstrated that eConsult services improve timely access to specialist care; prevent unnecessary referrals; improve PCPs', specialists', and patients' satisfaction; and therefore have a large impact on costs. However, no studies have evaluated PCPs' and specialists' acceptance of eConsult services in Quebec, Canada, and worldwide.

OBJECTIVE

This exploratory study aims to identify factors affecting eConsult service acceptance by PCPs and specialists in urban and rural primary care clinics across 3 regions in the province of Quebec, Canada, by integrating the Unified Theory of Acceptance and Use of Technology and Task-Technology Fit (TTF) models and user satisfaction. This research was designed to broaden and assist in scaling up this effective eHealth service innovation across the province.

METHODS

A cross-sectional web-based survey was sent to all PCPs (n=263) and specialists (n=62) who used the eConsult Quebec Service between July 2017 and May 2021. We proposed a unified model integrating the Unified Theory of Acceptance and Use of Technology model and TTF model and user satisfaction by endorsing 11 hypotheses. The partial least squares was used to investigate factors influencing the acceptance of the eConsult Quebec Service.

RESULTS

Of the 325 end users, 136 (41.8%) users responded (PCPs: 101/263, 38.4%; specialists: 35/62, 57%). The results of the analysis with partial least squares method indicate that 9 of our 11 hypotheses are supported. The direct relationships uniting the various constructs of the model highlighted the importance of several key constructs and predominant correlations. The results suggest that satisfaction is the key driver behind the use of the eConsult Quebec Service. Performance expectancy (P<.001) and effort expectancy (P=.03) can have a positive impact on behavioral intention (BI), and BI (P<.001) can impact adoption. TTF has an influence on performance expectancy (P<.001), adoption (P=.02), and satisfaction (P<.001). However, the results show that there is no direct effect between social influence (P=.38) and BI or between facilitating conditions (P=.17) and adoption.

CONCLUSIONS

This study provides a better understanding of the factors influencing PCPs' and specialists' intention to adopt the eConsult Quebec Service. Furthermore, this study tests a research model and a technology that have never been explored in Quebec until now. On the basis of the results, the service is a good fit to meet the users' need to improve access to specialized medical advice. Therefore, the results of our study have made a valuable contribution to the implementation of the service by policy makers in order to maximize acceptance, use, adoption, and success across the province of Quebec. Moreover, after 4 successful years, the eConsult Quebec pilot project is now the Conseil Numérique digital consultation service.

Improving Access to Specialty Pediatric Care: Innovative Referral and eConsult Technology in a Specialized Acute Care Hospital

Background: The COVID-19 pandemic has exacerbated wait times for pediatric specialty care. Transformative technologies such as electronic referral (eReferral-automation of patient information) and electronic consultations (eConsult-asynchronous request for specialized advice by primary care providers) have the potential to increase timely access to specialist care. The objective of this study was to present an overview of the current state and characteristics of referrals directed to a pediatric ambulatory medical surgery center, with an emphasis on the innovative use of an eConsult system and to indicate key considerations for system improvement. Methods: This cross-sectional study was conducted at a specialized pediatric acute care hospital in Ottawa, Ontario. Secondary data were obtained over a 2-year period during the COVID-19 pandemic (2019-2022). To gain insights and identify areas of improvement related to the factors pertaining to referrals and eConsults at the process and system levels, quality improvement (QI) methodologies were employed. Descriptive statistics provide a summary of the trends and characteristics of referrals and the utilization of eConsult. Results: Among the 113,790 referrals received, 31,430 were denied. Most common reasons for referral denial were other/null (e.g., unspecified) (29.3%), inappropriate referrals (12.6%), and duplicate referrals (12.4%). Four clinics (e.g., endocrinology, cardiology, neurology, and neurosurgery) reported a total of 277 eConsults, with endocrinology accounting for 95.0% of all eConsults. QI findings revealed the need for standardized workflows among specialties and ensuring that eConsult options are accessible and integrated within the electronic medical record (EMR). Conclusions: Refining the pediatric referral management process and optimizing eConsult through existing clinical systems have the potential to improve the timeliness and quality of specialty care. The results inform future research initiatives targeting improved access to pediatric specialty care and serve as a benchmark for hospitals utilizing EMRs and eConsult.

Increasing primary care capacity and referral efficiency: A case study of a telehealth centre eConsult service in Brazil

INTRODUCTION

eConsults are asynchronous digital communications for primary care professionals to seek timely specialist advice. Potential benefits include increased primary healthcare capacity and referral efficiency. Santa Catarina Telehealth Centre in Brazil has offered eConsults for an increasing number of specialties since 2008. This study described the characteristics of this service, including referral efficiency, sustainability, and satisfaction.

METHODS

Retrospective longitudinal analysis of eConsults activity data from 2015 to 2022 with three domains of the Model for Assessment of Telemedicine Applications used to structure the analysis.

RESULTS

Characteristics of the application: The total number of eConsults performed in 2015 was 4764, reaching 41,178 in 2022. While 30.3% of eConsults were synchronous in 2015, only asynchronous communication remained from 2021. Clinical effectiveness: eConsults requested to refer patients to specialist care resulting in primary care management remaining above 30% of the total for all specialties from 2019 to 2022, with hematology having the highest percentage (>52%). Organizational aspects: Established workflows with local specialists responding to eConsults (cardiology, endocrinology, hematology and orthopaedics) kept a constant or increasing number of eConsults and maintained the proportion of primary care management from 2019 to 2022, once recovered from COVID-19 and funding restrictions-related reductions. Over 90% of primary care professionals are either satisfied or very satisfied with the eConsult service.

CONCLUSION

Over 8 years, 223,734 consultations were conducted, with high satisfaction, demonstrating the substantial potential for increased primary care-sensitive conditions management. Hiring local specialists, fostering integrated care, and enabling sustainable workflows are key to eConsults' success.

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.

Transforming healthcare delivery: a descriptive study of a novel provider-to-provider virtual care platform

Introduction

Addressing challenges in access to specialty care, particularly long wait times and geographic disparities, is a pressing issue in the Canadian healthcare system. This study aimed to evaluate the impact and feasibility of provider-to-provider phone consultations between primary care providers (PCPs) and specialists using a novel virtual care platform in Nova Scotia (Virtual Hallway).

Methods

We conducted a cross-sectional survey over 5 months, involving 211 PCPs and 34 specialists across Nova Scotia. The survey assessed the need for formal in-person referrals as well as clinician satisfaction. Statistical methods included descriptive statistics and the one-sample t-test.

Results

We found that 84% of provider-to-provider phone consultations negated the need for an in-person specialist referral. It was also reported that 90% of patients that did require in-person consultation had enhanced care while they awaited an in-person appointment with a specialist. Very high levels of satisfaction were reported among both PCPs and specialists, and there was a noticeable increase in billing volumes related to these consultations as measured by provincial billing codes.

Conclusion

The findings indicate that provider-to-provider phone consultations are feasible, well-accepted and also effective in reducing the need for in-person specialist visits. This approach offers a promising avenue for alleviating waitlist burdens, enhancing the quality of care, and improving the overall efficiency of healthcare delivery.

A retrospective analysis of the use of electronic consultation in general internal medicine

BACKGROUND

General internists in Canada are subspecialty providers in the inpatient and outpatient settings. Electronic consultations (eConsult) allow primary care providers (PCPs) to virtually consult specialists to address clinical questions. There is a paucity of literature examining the utility and benefits of eConsults by general internists.

AIMS

To determine how an eConsult service is used to access general internists.

METHODS

A retrospective cross-sectional analysis of internal medicine cases was completed between 1 January 2016 and 31 December 2019 via the ChamplainBASE eConsult service. Two authors derived and validated a general internal medicine (GIM)-specific taxonomy using the validated: (i) Taxonomy of Generic Clinical Questions; and (ii) Internal Classification for Primary Care. Two hundred seventy-six cases were coded following taxonomy validation. ChamplainBASE utilisation summary and closeout survey data were also analysed.

RESULTS

eConsults were responded to in a median of 3.1 days and took 15 min to complete. The eConsult's helpfulness and educational value were rated as 4 to 5/5 and often provided advice for a new or additional course of action. In-person referral was avoided in 40% of cases. The majority of eConsults consisted of a single question (88%) related to diagnostic clarification. The median remuneration per eConsult was $50.

CONCLUSIONS

The majority of eConsults to general internists sought diagnostic clarification and confirmed the view of general internists as expert diagnosticians. eConsults cost less than an in-person consultation and were viewed favourably by PCPs. Further research can consider the eConsult provider experience and whether eConsults should become a required part of GIM ambulatory practice.

Implementing a general practitioner-to-general physician eConsult service (eConsultant) in Australia

Background

In response to lengthy wait times for specialist outpatient appointments, electronic consultation (eConsult) services have developed globally, providing asynchronous, secure and timely communication between general practitioner (GP) and specialist. This study aims to track adoption of a Queensland eConsultant service in two Australian Primary Health Networks (Western Queensland and Brisbane South) to understand key barriers and enablers to adoption and inform modification of the implementation strategy. 

Methods

Our theory-informed mixed-methods evaluation assessed implementation between July 2020 and March 2022. Adoption and implementation activities were prospectively recorded in bespoke tracking spreadsheets with implementation activities coded against the Expert Recommendations for Implementing Change (ERIC) strategies. Semi-structured interviews with GPs and stakeholders informed by the Consolidated Framework for Implementation Research (CFIR) were conducted to understand determinants of implementation. 

Results

Of the 40 practices invited to take part in the eConsultant service, 20 (50%) enrolled. Of the 97 GPs who consented, 38 sent at least one Request for Advice (RFA) to the eConsultant with a total of 112 RFA sent. Implementation was predominantly guided by eight strategies. Qualitative interviews were conducted with 11 GPs and 4 stakeholders (12 from rural/remote regions, 11 females and two sole practitioners). Interviewees felt the eConsultant service supported outpatient appointment avoidance and provided efficient, timely access to specialist support for GPs and their patients. Barriers identified to using eConsultant related to digital infrastructure, competing priorities, and keeping the service ‘front of mind’. Key enablers identified were the relative advantage of eConsultant over other options, patient benefits and COVD-19 facilitating the use of digital technology.

Conclusions

This evaluation highlighted service enablers as well as user priorities for broader implementation. A focus on a well-integrated digital system and availability of a variety of eConsultant specialties are seen as key strategies to embedding the eConsultant option in GP advice processes in Australia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08663-2.

Characterising Australian memory clinics: current practice and service needs informing national service guidelines

Background

Memory clinics (MCs) play a key role in accurate and timely diagnoses and treatment of dementia and mild cognitive impairment. However, within Australia, there are little data available on current practices in MCs, which hinder international comparisons for best practice, harmonisation efforts and national coordination. Here, we aimed to characterise current service profiles of Australian MCs.

Methods

The ‘Australian Dementia Network Survey of Expert Opinion on Best Practice and the Current Clinical Landscape’ was conducted between August-September 2020 as part of a larger-scale Delphi process deployed to develop national MC guidelines. In this study, we report on the subset of questions pertaining to current practice including wait-times and post-diagnostic care.

Results

Responses were received from 100 health professionals representing 60 separate clinics (45 public, 11 private, and 4 university/research clinics). The majority of participants were from clinics in metropolitan areas (79%) and in general were from high socioeconomic areas. While wait-times varied, only 28.3% of clinics were able to offer an appointment within 1-2 weeks for urgent referrals, with significantly more private clinics (58.3%) compared to public clinics (19.5%) being able to do so. Wait-times were less than 8 weeks for 34.5% of non-urgent referrals. Only 20.0 and 30.9% of clinics provided cognitive interventions or post-diagnostic support respectively, with 7.3% offering home-based reablement programs, and only 12.7% offering access to group-based education. Metropolitan clinics utilised neuropsychological assessments for a broader range of cases and were more likely to offer clinical trials and access to research opportunities.

Conclusions

In comparison to similar countries with comprehensive government-funded public healthcare systems (i.e., United Kingdom, Ireland and Canada), wait-times for Australian MCs are long, and post-diagnostic support or evidence-based strategies targeting cognition are not common practice. The timely and important results of this study highlight a need for Australian MCs to adopt a more holistic service of multidisciplinary assessment and post-diagnostic support, as well as the need for the number of Australian MCs to be increased to match the rising number of dementia cases.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03253-7.

eConsults' Impact on Care Access and Wait Times in Rheumatology

BACKGROUND/OBJECTIVE

A growing number of health systems have implemented eConsults to improve access to specialty advice, but few studies have described their use in rheumatology or impact on visit wait times. We evaluated the uptake of an eConsult program and its impact on wait times for in-person rheumatology visits.

METHODS

In this quality improvement project, we analyzed electronic health record data from 4 intervention clinics and 4 comparison clinics, 12 months before and after implementation of an eConsult program. We compared median wait time for rheumatology appointments using a pre-post difference-in-differences analysis and quantile regression, adjusting for patient age, race, sex, clinic pair, and primary insurance payer. We also interviewed 11 primary care providers from the intervention clinics and conducted a rheumatology provider focus group (n = 4) to elucidate experiences with the program.

RESULTS

Rheumatologists recommended management in primary care or referral to another specialty for 41% of eConsults, reducing initial demand for in-person visits. The median wait times dropped in the intervention and the comparison clinics (42 and 25 days, respectively). Intervention clinic median wait time dropped 17 days more than comparison clinics, and this was nonstatistically significant (p = 0.089). eConsults fit provider care tasks best for triage or initial workup for diagnosis, and less well when tests required interpretation, or when back and forth communication was needed to manage the patient's condition.

CONCLUSIONS

Implementation of eConsults for rheumatology was associated with reduced wait times for rheumatology appointments and supported primary care providers in the triage and workup for a substantial portion of patients.

The Utilization of an Electronic Consultation Service During the Coronavirus Disease 2019 Pandemic

Objective: The coronavirus disease 2019 (COVID-19) pandemic forced many clinicians to rapidly adopt changes in their practice. In this study, we compared patterns of utilization of Ontario eConsult before and after the onset of the COVID-19 pandemic, to assess COVID 19's impact on how eConsult is used. Materials and Methods: We conducted a longitudinal analysis of registration and utilization data for Ontario eConsult. All primary care providers (PCPs) and specialists who joined the service between March 2019 and November 2020, and all eConsult cases closed during the same period were included. The data were divided into two timeframes for comparison: prepandemic (March 2019-February 2020) and pandemic (March 2020-November 2020). Results: In total, 5,925 PCPs joined during the study period, more than doubling total enrollment to 11,397. The average monthly number of eConsults increased from 2,405 (standard deviation [SD] = 260) prepandemic to 3,906 (SD = 420) pandemic. Case volume jumped to 24.3% in the first month of the pandemic, and increased by 71% during the COVID-19 pandemic timeframe. The median response time was similar in both timeframes (prepandemic: 1.0 days; pandemic: 0.9 days). The proportion of cases resulting in new/additional information (prepandemic: 55%, pandemic: 57%) or avoidance of a contemplated referral (prepandemic: 52%, pandemic: 51%) remained consistent between timeframes. Conclusions: Registration to and usage of eConsult increased during the pandemic. Metrics of the service's impact, including response time, percentage of cases resulting in new or additional information, and avoidance of originally contemplated referrals were all consistent between the prepandemic and COVID-19 pandemic timeframes, suggesting scalability.

Impact of the Connected Medicine collaborative in improving access to specialist care: a cross-sectional analysis

BACKGROUND

In 2017, the Canadian Foundation for Healthcare Improvement launched the Connected Medicine collaborative to support the implementation, spread and adaptation of 2 innovative remote consult solutions - the Champlain Building Access to Specialists through eConsultation (BASE) eConsult service and the Rapid Access to Consultative Expertise (RACE) service - across Canada. We evaluated the impact of the programs implemented through the collaborative.

METHODS

We conducted a cross-sectional analysis of data from provincial teams that participated in the Connected Medicine collaborative, which took place between June 2017 and December 2018 in 7 provinces across Canada (British Columbia, Alberta, Saskatchewan, Manitoba, Quebec, New Brunswick, Newfoundland and Labrador). Data included utilization data collected automatically by the BASE and RACE services and, where available, responses to surveys completed by primary care providers at the end of each case. We assessed programs on the following outcomes: usage (i.e., number of cases completed, average specialist response time), number of specialties available, impact on primary care provider's decision to refer and impact on emergency department visits. We performed descriptive analyses.

RESULTS

Ten provincial teams participated in the collaborative and implemented or adapted either the RACE service (4 teams), the BASE service (5 teams) or a combination of the 2 services (1 team). Average monthly case volume per team ranged from 14.7 to 424.5. All programs offered multispecialty access, with specialists from 5 to 37 specialty groups available. Specialists responded to eConsults within 7 days in 80% (n = 294/368) to 93% (n = 164/176) of cases. Six programs provided survey data on avoidance of referrals, which occurred in 48% (n = 667/1389) to 76% (n = 302/398) of cases. Two programs reported on the avoidance of potential emergency department visits, noting that originally considered referrals were avoided in 28% (n = 138/492) and 74% (n = 127/171) of cases, respectively.

INTERPRETATION

The 2 innovative virtual care solutions implemented through the Connected Medicine collaborative received widespread usage and affected primary care providers' decisions to refer patients to specialists. The impact of these models of care in multiple settings shows that they are an effective means to move beyond the pilot stage and achieve spread and scale.

‘Evaluation of the First Year(s) of Physicians’ Collaboration on an Interdisciplinary Electronic Consultation Platform in the Netherlands: a mixed-methods observational study. (Preprint)

Background

Complexity of health problems and aging of the population create an ongoing burden on the health care system with the general practitioner (GP) being the gatekeeper in primary care. In GPs daily practice, collaboration with specialists and exchange of knowledge from the secondary care play a crucial role in this system. Communication between primary and secondary care has shortcomings for health care workers that want to practice sustainable patient-centered health care. Therefore, a new digital interactive platform was developed: Prisma.

Objective

This study aims to describe the development of a digital consultation platform (Prisma) to connect GPs with hospital specialists via the Siilo application and to evaluate the first year of use, including consultations, topic diversity, and number of participating physicians.

Methods

We conducted a mixed methods observational study, analyzing qualitative and quantitative data for cases posted on the platform between June 2018 and May 2020. Any GP can post questions to an interdisciplinary group of secondary care specialists, with the platform designed to facilitate discussion and knowledge exchange for all users.

Results

In total, 3674 cases were posted by 424 GPs across 16 specialisms. Most questions and answers concerned diagnosis, nonmedical treatment, and medication. Mean response time was 76 minutes (range 44-252). An average of 3 users engaged with each case (up to 7 specialists). Almost half of the internal medicine cases received responses from at least two specialisms in secondary care, contrasting with about one-fifth for dermatology. Of note, the growth in consultations was steepest for dermatology.

Conclusions

Digital consultations offer the possibility for GPs to receive quick responses when seeking advice. The interdisciplinary approach of Prisma creates opportunities for digital patient-centered networking.

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.

Electronic consultations (eConsults): a proof of concept trial in Australia

BACKGROUND

Electronic consultations (eConsults) allows general practitioners (GPs) to seek the advice of a specialist via secure asynchronous digital communication.

AIMS

To report the outcomes of a proof of concept (POC) trial of eConsults for patients with diabetes and endocrine disorders.

METHODS

A prospective observational study conducted from Nov 2020 to May 2021. eConsults were provided by endocrinologists from the Princess Alexandra Hospital, Brisbane. The requests for advice were from GPs in Brisbane South. An online questionnaire was completed by the GP and endocrinologist after each eConsult.

RESULTS

Forty eConsults were performed over 7 months. The majority were in relation to type 2 diabetes (30%) or thyroid conditions (30%). All eConsult responses were performed within the target of 72 hours with 92.5% responses provided within 24 hrs. The average time taken for the endocrinologist to perform the eConsult was 14.2 ± 4.4 minutes. The GPs rated the value of eConsults as excellent 97% of the time. The eConsult resulted in a new or additional course of action 68% (19/28) of the time and confirmed a course of action 32% (9/28) of the time. The eConsult avoided the need for referral of the patient for a face-to-face specialist review in 55% of the eConsults.

CONCLUSION

An eConsult service was able to be delivered by endocrinologists from a tertiary hospital to GPs in Brisbane South. With an appropriate funding model, the broader implementation and adoption of eConsults has the potential to address specialist waiting lists and facilitate models of integrated care. This article is protected by copyright. All rights reserved.

Comparing the content of traditional faxed consultations to eConsults within an academic endocrinology clinic

Objective

To compare the content of traditional faxed referrals and electronic consultations (eConsults) and determine how many questions sent by traditional referral could be successfully addressed using eConsult.

Methods

We conducted a cross-sectional, qualitative study of eConsults and faxed referrals sent to a tertiary diabetes and endocrinology clinic in Ottawa, Ontario. A convenience sample of 300 faxed referrals sent between March and July 2017 and 300 eConsults submitted between January and December 2017 were selected and coded using an established taxonomy to determine question type. Two endocrinologists reviewed the faxed referrals to assess whether they could have been addressed using eConsult. Responses to a mandatory closeout survey were reviewed for all eConsults, assessing the case’s outcome, impact on decision to refer, and educational value.

Results

Most faxed consultations were requests for shared care in diabetes mellitus, whereas most eConsults requested help in diagnostic test interpretation. 25–27% of faxed consults were felt to be potentially amenable to eConsult. Referring provider behaviour was changed in 45.3% of eConsult cases through avoidance of face-to-face consultation.

Conclusion

eConsult is a promising tool for PCPs to improve access to specialist opinion without necessitating a face-to-face visit.

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

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

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.

Perspectives of VA Primary Care Clinicians Toward Electronic Consultation-Related Workload Burden: A Qualitative Analysis

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.

Key factors for national spread and scale-up of an eConsult innovation

BACKGROUND

Expanding healthcare innovations from the local to national level is a complex pursuit requiring careful assessment of all relevant factors. In this study (a component of a larger eConsult programme of research), we aimed to identify the key factors involved in the spread and scale-up of a successful regional eConsult model across Canada.

METHODS

We conducted a constant comparative thematic analysis of stakeholder discussions captured during a full-day National eConsult Forum meeting held in Ottawa, Canada, on 11 December 2017. Sixty-four participants attended, representing provincial and territorial governments, national organisations, healthcare providers, researchers and patients. Proceedings were recorded, transcribed and underwent qualitative analysis using the Framework for Applied Policy Research.

RESULTS

This study identified four main themes that were critical to support the intentional efforts to spread and scale-up eConsult across Canada, namely (1) identifying population care needs and access problems, (2) engaging stakeholders who were willing to roll up their sleeves and take action, (3) building on current strategies and policies, and (4) measuring and communicating outcomes.

CONCLUSIONS

Efforts to promote innovation in healthcare are more likely to succeed if they are based on an understanding of the forces that drive the spread and scale-up of innovation. Further research is needed to develop and strengthen the conceptual and applied foundations of the spread and scale-up of healthcare innovations, especially in the context of emergent learning health systems across Canada and beyond.

Early experiences with cardiology electronic consults: A systematic review

Many health systems have begun implementing electronic consultation programs. The clinical and financial impact of these programs in cardiology and the potential for more widespread adoption remains unknown.

OBJECTIVES

To systematically review the current literature related to electronic consultation in cardiology.

METHODS

Following the PRISMA guidelines, we conducted a systematic review in August 2018 of English literature. We searched PubMed, the Cochrane Library, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases for studies related to electronic consultation in cardiology.

RESULTS

A total of 21 studies were included. Two of the studies were randomized controlled trials, 16 were quantitative studies with defined endpoints, and 3 were qualitative descriptions. Most studies were conducted in the United States and Canada. The available literature suggests cardiology e-consult programs can be implemented in different practice settings, have good patient and provider satisfaction, deliver greater and timelier access to outpatient cardiac care, and do so in a cost saving fashion. While studies suggest cardiology e-consultation is safe, there are no studies evaluating hard clinical outcomes.

CONCLUSIONS

Cardiology e-consults appear to be a promising tool for increasing access to outpatient cardiac care. Further investigation is required to evaluate the effects of cardiology electronic consultation on the quality of care.

CONDENSED ABSTRACT

Here we present the first systematic review of electronic consultation in cardiology. The available literature suggests cardiology e-consult programs can be implemented in different practice settings, have good patient and provider satisfaction, deliver greater and timelier access to outpatient cardiac care, and do so in a cost saving fashion. While studies suggest cardiology e-consultation is safe, there are no studies evaluating hard clinical outcomes. Overall, cardiology e-consults appear to be a promising tool for increasing access to outpatient cardiac care. Further investigation is required to evaluate the effects of cardiology electronic consultation on the quality of care.

Effective Integration of an eConsult Service into an Existing Referral Workflow Within a Primary Care Clinic

Background: When implementing e-health solutions, effective integration into a clinic's existing processes is essential to facilitate adoption and sustained usage. Introduction: This article examines the effectiveness of adoption/utilization of an electronic consultation (eConsult) service by primary care providers (PCPs) using a "delegate model," through which referral clerks manage requests on behalf of PCPs, thereby reducing PCPs' administrative burden. Materials and Methods: We conducted a retrospective cross-sectional study of all eConsults submitted between May 1, 2013, and December 31, 2017, by the Bruyère Academic Family Health Team (FHT), after the clinic implemented the service using a delegate model. We assessed system utilization, including monthly volume of submitted eConsults, requested specialties, and impact on PCP referral behavior based on the mandatory closeout surveys. We also conducted a subanalysis to compare the volumes of eConsults per provider between the FHT and all other providers. Results: The Bruyère Academic FHT submitted 3,233 eConsult cases. Volume increased 3.5 fold, from 285 in the first year to 1,016 in the last year. Active Bruyère Academic FHT providers (those who submitted ≥3 cases in 6 months) submitted a median of 25 eConsults (interquartile range [IQR]: 14.75-35.25) versus 14 (IQR 8-24) for all other active users. In 36% of cases, a referral was originally contemplated but avoided based on specialist advice. In 5% of cases, the referral was not originally contemplated but deemed appropriate by the PCP based on specialist advice. Discussion: Our findings show high levels of eConsult use in the clinic utilizing a delegate model, which persisted throughout the study period and was reported to significantly reduce the backlog of traditional referrals at the clinic. Conclusions: The integration of eConsult capability into existing clinic operations was successful in that it allowed the PCPs to request eConsult using a familiar process, avoiding the challenges associated with adopting a new and unfamiliar technology.

Supporting the spread and scale-up of electronic consultation across Canada: cross-sectional analysis

OBJECTIVE

To examine the process of implementing an electronic consultation (eConsult) service and evaluate its impact along key metrics outlined by the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework.

DESIGN

Cross-sectional study.

SETTING

Clinics using eConsult in four provinces across Canada: Alberta, Manitoba, Quebec and Newfoundland and Labrador.

PARTICIPANTS

All eConsult cases submitted in four participating provinces were included.

INTERVENTION

The eConsult service is a secure online application that allows primary care providers and specialists to communicate regarding a patient's care. We measured the impact using system utilisation data and mandatory close-out surveys completed at the end of each eConsult.

MAIN OUTCOME MEASURES

Implementation progress and impact were examined using the five categories outlined by the RE-AIM framework: reach, effectiveness, adoption, implementation and maintenance.

RESULTS

Four provinces provided data from different periods, ranging from 4 years (Alberta) to 10 months (Manitoba). Total cases completed ranged from 96 (Manitoba) to 6885 (Alberta). Newfoundland had the largest menu of available specialties (n=35), while Alberta and Quebec had the smallest (n=22). The most frequently requested groups varied across provinces, with only endocrinology appearing in the top five for all provinces. The average specialist response time ranged from 3 days (Manitoba) to 16.7 days (Alberta). Between 54% (Newfoundland) and 66% (Manitoba) of cases resulted in new or additional information. Primary care providers avoided completing referrals they had originally considered in 36% (Newfoundland) to 53% of cases (Manitoba), while only between 27 % (Quebec) and 29% (Newfoundland) of cases resulted in a referral. In every province, services demonstrated higher rates of usage in their last quarter of data than their first.

CONCLUSIONS

eConsult was successfully implemented in four new provinces across Canada. Implementation strategies and scope varied, but services demonstrated substantial consistency on several key metrics, most notably on whether new information was learnt and impact on decision to refer.

DETELPROG Study. Effectiveness of a New Model of Scheduled Telephone Referral from Primary Care to Internal Medicine. A Randomised Controlled Study

In Spain, the average waiting time for a specialist consultation is 58 days. A determinant factor that contributes to this situation is the poor communication between primary care and specialised care, which is mainly due to the waiting days for a consultation, number of avoided/avoidable face-to-face referrals, and waiting days for the resolution of the process. DETELPROG is a referral system in which the family physician requests a scheduled outpatient internal medicine consultation, integrated into the usual consultations agenda of both physicians, the family, and the outpatient clinic physician, in order to have a telephone consultation. A randomized controlled clinical trial has been carried out to assess the effectiveness of DELTELPROG. In a sample of 255 patients, the experimental group was referred via a scheduled telephone call, and those in the control group, by face-to-face hospital consultation area. The results showed statistically significant differences between both groups of 27 days (95% confidence interval (CI): 20–33) regarding specialised consultation, 47 days (95% CI: 17–74) as for the resolution of the process, and 91.7% for avoided face-to-face consultations. The DETELPROG resulted as a low coverage system (53%), which makes it a complementary referral model. It is necessary to make an in-depth analysis of the causes that have led to this technologically low coverage.