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Bifulco L, Grzejszczak L, Velez I, Angelocci T, Anderson D. A qualitative investigation of uninsured patient and primary care provider perspectives on specialty care eConsults. BMC Health Serv Res 2023; 23:1133. [PMID: 37864170 PMCID: PMC10589958 DOI: 10.1186/s12913-023-10086-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 09/28/2023] [Indexed: 10/22/2023] Open
Abstract
BACKGROUND Uninsured and underinsured patients face specialty care access disparities that prevent them from obtaining the care they need and negatively impact their health and well-being. We aimed to understand how making specialty care electronic consultations (eConsults) available at a multi-site Federally Qualified Health Center (FQHC) in central Texas affected uninsured patients' care-seeking experiences and impacted their ability to receive the needed care. METHODS We used concepts from Ecological Systems Theory to examine individual, interpersonal, organization-level, social, and health policy environment factors that impacted patients' access to specialty care and the use of eConsults. We conducted thematic analysis of semi-structured, qualitative interviews with patients about seeking specialty care while uninsured and with uninsured patients and FQHC PCPs about their experience using eConsults to obtain specialists' recommendations. RESULTS Patients and PCPs identified out-of-pocket cost, stigma, a paucity of local specialists willing to see uninsured patients, time and difficulty associated with travel and transportation to specialty visits, and health policy limitations as barriers to obtaining specialty care. Benefits of using eConsults for uninsured patients included minimizing/avoiding financial stress, expanding access to care, expanding scope of primary care, and expediting access to specialists. Concerns about the model included patients' limited understanding of eConsults, concern about cost, and worry whether eConsults could appropriately meet their specialty needs. CONCLUSIONS Findings suggest that eConsults delivered in a primary care FQHC addressed uninsured patients' specialty care access concerns. They helped to address financial and geographic barriers, provided time and cost savings to patients, expanded FQHC PCPs' knowledge and care provision options, and allowed patients to receive more care in primary care.
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Affiliation(s)
- Lauren Bifulco
- Weitzman Institute, 19 Grand Street, Middletown, CT, USA
| | | | - Idiana Velez
- Weitzman Institute, 19 Grand Street, Middletown, CT, USA
| | - Tracy Angelocci
- Lone Star Circle of Care, 205 East University, Suite 100, Georgetown, TX, USA
| | - Daren Anderson
- Weitzman Institute, 19 Grand Street, Middletown, CT, USA.
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2
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Lai AT, Keely E, McCutcheon T, Liddy C, Afkham A, Frost DW. A retrospective analysis of the use of electronic consultation in general internal medicine. Intern Med J 2023; 53:1642-1647. [PMID: 36308455 DOI: 10.1111/imj.15940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 09/28/2022] [Indexed: 11/05/2022]
Abstract
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.
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Affiliation(s)
- Alison T Lai
- Department of Medicine, University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
- Division of General Internal Medicine, University Health Network, Toronto, Ontario, Canada
| | - Erin Keely
- Department of Medicine, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
- Ontario eConsult Centre of Excellence, Ottawa, Ontario, Canada
| | - Tess McCutcheon
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Clare Liddy
- Ontario eConsult Centre of Excellence, Ottawa, Ontario, Canada
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada
- Department of Family Medicine, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
| | - Amir Afkham
- Ontario Health East, Toronto, Ontario, Canada
| | - David W Frost
- Department of Medicine, University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
- Division of General Internal Medicine, University Health Network, Toronto, Ontario, Canada
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3
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Jungbauer WN, Gudipudi R, Brennan E, Melvin CL, Pecha PP. The Cost Impact of Telehealth Interventions in Pediatric Surgical Specialties: A Systematic Review. J Pediatr Surg 2023; 58:1527-1533. [PMID: 36379748 PMCID: PMC10121966 DOI: 10.1016/j.jpedsurg.2022.10.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 09/21/2022] [Accepted: 10/12/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Telehealth is a rapidly expanding care modality in the United States. Pediatric surgical patients often require complex care which can incur significant expenses, some of which may be alleviated by telehealth. We performed a systematic review comparing telehealth and in-person visits, and telehealth's impacts on the cost of healthcare across pediatric surgical specialties. METHODS A systematic review was performed using the following databases: PubMed (MEDLINE), Scopus (Elsevier), and CINAHL (EBSCOHost), searched from inception to July 10th, 2022. Studies were included per the following criteria: (1) investigated a telehealth intervention for pediatric surgical care and (2) provided some metric of telehealth cost compared to an in-person visit. Non-English or studies conducted outside of the U.S. were excluded. RESULTS Fourteen manuscripts met inclusion criteria and presented data on 7992 visits, including patients with a weighted average age of 7.5 ± 3.5 years. Most (11/14) studies used telehealth in a synchronous, or "real-time" context. Of the studies which calculated dollar cost savings for telehealth visits compared to in-person appointments we found a substantial range of savings per visit, from $48.50 to $344.64. Cost savings were frequently realized in terms of reduced travel expenditures, lower opportunity costs (e.g. lost wages), and decreased hospital labor requirements. CONCLUSIONS This review suggests that telehealth provides cost incentives to pediatric surgical care in many scenarios, including post-operative visits and some routine clinic visits. Future work should focus on standardizing the metrics by which cost impacts are analyzed and detailing which visits are most appropriately facilitated by telehealth. LEVEL OF EVIDENCE V.
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Affiliation(s)
- W Nicholas Jungbauer
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, 135 Rutledge Ave, MSC 550, Charleston, SC 29425, United States
| | - Rachana Gudipudi
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, 135 Rutledge Ave, MSC 550, Charleston, SC 29425, United States
| | - Emily Brennan
- Department of Research and Education Services, Medical University of South Carolina, Charleston, SC, United States
| | - Cathy L Melvin
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, United States
| | - Phayvanh P Pecha
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, 135 Rutledge Ave, MSC 550, Charleston, SC 29425, United States.
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4
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Hellingman T, van Beneden MLH, den Bakker CM, Zonderhuis BM, Kazemier G. Perspectives of patients with colorectal cancer liver metastases on e-consultation in transmural care: a qualitative study : Is privacy really an issue? BMC Health Serv Res 2023; 23:541. [PMID: 37231462 DOI: 10.1186/s12913-023-09408-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 04/15/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Comprehensive cancer networks have been established to deliver high-quality care for patients with cancer. Logistic challenges are faced, when patients need to be referred for specialized treatments. Despite strengthened privacy legislations, digital platforms are increasingly used to consult specialists from dedicated liver centers or refer patients with colorectal cancer liver metastases (CRLM) for local treatment strategies. This qualitative study aimed to explore the perspectives of patients with CRLM regarding e-consultation of transmural specialists. METHODS A focus group study was conducted. Patients referred from regional hospitals to an academic liver center for treatment of CRLM were asked to participate. Focus group discussions were audio-recorded and transcribed verbatim. A thematic content analysis of data was conducted, comprising open, axial, and selective coding of the transcripts. The consolidated criteria for reporting qualitative research (COREQ) were used. RESULTS Two focus groups were held, involving 11 patients and 8 relatives. Three major themes were identified with regard to e-consultation in transmural care: 'data management', 'expertise', and 'information and coordination'. Confidence in the expertise of physicians appeared most important during the course of treatment, as patients experienced uncertainty after diagnosis of cancer. Despite the privacy risks, use of digital communication platforms to contact experts in the field were strongly endorsed to improve eligibility for potentially curative treatment. Moreover, e-consultation of specialists may reduce waiting times, due to effective coordination of care. CONCLUSION Initiatives to improve medical data transfer between care providers were encouraged to achieve effective coordination of oncological care. The potential hazard of privacy violation associated with digital data exchange is accepted by patients and their relatives, provided that use of digital data improves patient's own health care, research or education.
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Affiliation(s)
- T Hellingman
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, de Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
| | - M L H van Beneden
- Department of Strategy and Innovation, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, de Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - C M den Bakker
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, de Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
- Department of Surgery, Spaarne Gasthuis, Boerhaavelaan 22, 2035 RC, Haarlem, The Netherlands
| | - B M Zonderhuis
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, de Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - G Kazemier
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, de Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
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5
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Singer A, Ireland L, Sepehri Z, Brown K, Turner K, Liddy C, Keely E, Oppenheimer L. Evaluation of BASE eConsult Manitoba: patient perspectives on the use of electronic consultation to improve access to specialty advice in Manitoba. BMC Health Serv Res 2023; 23:131. [PMID: 36755243 PMCID: PMC9909129 DOI: 10.1186/s12913-022-08913-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 11/30/2022] [Indexed: 02/10/2023] Open
Abstract
BACKGROUND The burden of waiting to access specialist expertise may contribute to poorer health outcomes and causes distress for patients and providers. One solution to improve access to specialist care is to use innovative tools such as remote asynchronous electronic consultation (eConsult). Modeled after the Champlain BASE™ (Building Access to Specialist Advice) eConsult service, BASE™ eConsult Manitoba was launched in 2017 to help address long waits for patients to access specialist advice. OBJECTIVE We aimed to evaluate patients' experiences after obtaining a BASE™ eConsult Manitoba service in their primary care setting. METHODS Patients whose Primary Care Providers (PCPs) used BASE™ eConsult as part of their care were asked to participate and complete a telephone-based or online 29-question survey between January 2021 and October 2021. The survey questions were created in consultation with patient partners and based on questions asked in studies done in other jurisdictions. RESULTS Of the 36 patients who chose to participate, 29 completed the entire survey (80%). Two-thirds (n = 22) agreed that eConsult has been helpful in their situation, and over 80% (n = 24) of participants agreed that eConsult was an acceptable way to access specialist care. During the visit when their PCP sent the eConsult, 7 patients were expecting to be referred to a specialist for a face-to-face consultation. Over half of all respondents (n = 15) reported that before the eConsult occurred, their PCP asked them what questions they wanted to be answered by the specialist. Almost all of these respondents' questions were fully answered by the eConsult. All of the respondents were satisfied with the experience of receiving an eConsult. CONCLUSION Using eConsult is an acceptable way to improve access to specialist advice from patients' perspectives. Consideration should be given to expanding the use of eConsult services to improve access to specialist expertise for PCPs and their patients.
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Affiliation(s)
- Alexander Singer
- Department of Family Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, D009-780 Bannatyne Ave., MB, Winnipeg, R3E 0W2, Canada.
| | - Laurie Ireland
- grid.21613.370000 0004 1936 9609Department of Family Medicine, University of Manitoba, D009-780 Bannatyne Ave., MB Winnipeg, R3E 0W2 Canada ,grid.422680.aNine Circles Community Health Centre, 705 Broadway Ave. , Winnipeg, MB R3G 0X2 Canada
| | - Zahra Sepehri
- grid.444944.d0000 0004 0384 898XDepartment of Internal Medicine, Zabol University of Medical Sciences, Zabol, Iran ,grid.21613.370000 0004 1936 9609Department of Family Medicine, Max Rady College of Medicine, University of Manitoba, P219 – 780 Bannatyne Ave, MB Winnipeg, R3E 0W2 Canada
| | | | - Kevin Turner
- grid.21613.370000 0004 1936 9609eConsult Centre of Excellence, University of Manitoba Alumni, Winnipeg, MB R33 0W2 Canada
| | - Clare Liddy
- grid.418792.10000 0000 9064 33337 C.T. Lamont Primary Health Care Research Centre, Bruyere Research Institute, Ottawa, ON Canada ,grid.28046.380000 0001 2182 2255Department of Family Medicine, University of Ottawa, Ottawa, ON Canada ,grid.412687.e0000 0000 9606 5108eConsult Centre of Excellence, The Ottawa Hospital, Ottawa, ON Canada
| | - Erin Keely
- grid.412687.e0000 0000 9606 5108eConsult Centre of Excellence, The Ottawa Hospital, Ottawa, ON Canada ,grid.28046.380000 0001 2182 2255Department of Medicine, University of Ottawa, Ottawa, ON Canada ,grid.412687.e0000 0000 9606 5108Division of Endocrinology and Metabolism, The Ottawa Hospital, Ottawa, ON Canada
| | - Luis Oppenheimer
- grid.21613.370000 0004 1936 9609Department of Surgery, University of Manitoba and Winnipeg Regional Health Authority, Winnipeg, MB Canada
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Abu Libdeh A, Flanigan J, Heinan K. Experience with Pediatric Neurology e-Consults from a Specialist Perspective at an Academic Center. J Child Neurol 2022; 37:373-379. [PMID: 35300549 DOI: 10.1177/08830738221077760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION E-consults improve access to specialty expertise and increase satisfaction for patients and Primary Care Providers (PCPs). Pediatric neurology may be perceived as less amenable to e-consults compared to other specialties. METHODS We performed a retrospective analysis of e-consults performed by pediatric neurologists at the University of Virginia. We reviewed the electronic medical records and analyzed the content of e-consults, recommendations from specialists, and subsequent actions by PCPs. RESULTS Between April 2019 and April 2021, 58 e-consults were performed by pediatric neurologists. Most common indications included spells, headache, and tremor. In 56.9% of cases, the answer was provided without recommending a face-to-face (FTF) visit. For patients seen in clinic, e-consults reduced wait time and facilitated the clinic visit. DISCUSSION E-consults are a suitable option for pediatric neurology, and they help with the workflow. Further education is needed to improve utility of e-consults in pediatric neurology.
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Affiliation(s)
- Amal Abu Libdeh
- Department of Neurology, 2358University of Virginia, Charlottesville, VA, US
| | - Joseph Flanigan
- Department of Neurology, 2358University of Virginia, Charlottesville, VA, US
| | - Kristen Heinan
- Department of Neurology, 2358University of Virginia, Charlottesville, VA, US
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Malcolm EJ, Brandon Z, Wilson LE, Shoup JP, King HA, Lewinski A, Greiner MA, Malone S, Miller J, Keenan RT, Tarrant TK, Phinney D, Cho A, Bosworth HB, Shah K. eConsults' Impact on Care Access and Wait Times in Rheumatology. J Clin Rheumatol 2022; 28:147-154. [PMID: 35067514 DOI: 10.1097/rhu.0000000000001825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND/OBJECTIVE A growing number of health systems have implemented eConsults to improve access to specialty advice, but few studies have described their use in rheumatology or impact on visit wait times. We evaluated the uptake of an eConsult program and its impact on wait times for in-person rheumatology visits. METHODS In this quality improvement project, we analyzed electronic health record data from 4 intervention clinics and 4 comparison clinics, 12 months before and after implementation of an eConsult program. We compared median wait time for rheumatology appointments using a pre-post difference-in-differences analysis and quantile regression, adjusting for patient age, race, sex, clinic pair, and primary insurance payer. We also interviewed 11 primary care providers from the intervention clinics and conducted a rheumatology provider focus group (n = 4) to elucidate experiences with the program. RESULTS Rheumatologists recommended management in primary care or referral to another specialty for 41% of eConsults, reducing initial demand for in-person visits. The median wait times dropped in the intervention and the comparison clinics (42 and 25 days, respectively). Intervention clinic median wait time dropped 17 days more than comparison clinics, and this was nonstatistically significant (p = 0.089). eConsults fit provider care tasks best for triage or initial workup for diagnosis, and less well when tests required interpretation, or when back and forth communication was needed to manage the patient's condition. CONCLUSIONS Implementation of eConsults for rheumatology was associated with reduced wait times for rheumatology appointments and supported primary care providers in the triage and workup for a substantial portion of patients.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Julie Miller
- From the Duke University School of Medicine, Durham
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8
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Rea CJ, Toomey SL, Rosen M, Le T, Shah S. Understanding Caregiver Perspectives on an Electronic Consultation and Referral System. Clin Pediatr (Phila) 2022; 61:270-279. [PMID: 35090366 DOI: 10.1177/00099228221074856] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study examined caregiver impressions of an electronic consultation and referral (ECR) system. Participants included 56 caregivers of primary care patients referred through the ECR system. Semistructured interviews and surveys were conducted between August 2018 and April 2019. Transcripts were coded and themes developed using thematic content analysis. A total of 51% of caregivers stated that they would prefer to see their child's primary care provider (PCP) for a specialty issue if they could receive the same quality of care. All caregivers who received an electronic consult (n = 28) said that they would utilize that process again. Three themes emerged: (1) caregivers expect immediate action prior to or instead of a specialty referral; (2) caregiver preferences for PCP versus specialist are mediated by both child and provider characteristics; (3) caregiver attitudes toward the ECR system are influenced by external considerations and experiences with the system. Results suggest caregivers value enhanced communication and immediate access to specialty input facilitated by the ECR system.
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Affiliation(s)
- Corinna J Rea
- Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Sara L Toomey
- Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | | | - Tiffany Le
- Boston Children's Hospital, Boston, MA, USA
| | - Snehal Shah
- Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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Rankine J, Yeramosu D, Matheo L, Sequeira GM, Miller E, Ray KN. Optimizing e-Consultations to Adolescent Medicine Specialists: Qualitative Synthesis of Feedback From User-Centered Design. JMIR Hum Factors 2021; 8:e25568. [PMID: 34383665 PMCID: PMC8380586 DOI: 10.2196/25568] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 01/21/2021] [Accepted: 05/24/2021] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND e-Consultations between primary care physicians and specialists are a valuable means of improving access to specialty care. Adolescents and young adults (AYAs) face unique challenges in accessing limited adolescent medicine specialty care resources, which contributes to delayed or forgone care. e-Consultations between general pediatricians and adolescent medicine specialists may alleviate these barriers to care. However, the optimal application of this model in adolescent medicine requires careful attention to the nuances of AYA care. OBJECTIVE This study aims to qualitatively analyze feedback obtained during the iterative development of an e-consultation system for communication between general pediatricians and adolescent medicine specialists tailored to the specific health care needs of AYAs. METHODS We conducted an iterative user-centered design and evaluation process in two phases. In the first phase, we created a static e-consultation prototype and storyboards and evaluated them with target users (general pediatricians and adolescent medicine specialists). In the second phase, we incorporated feedback to develop a functional prototype within the electronic health record and again evaluated this with general pediatricians and adolescent medicine specialists. In each phase, general pediatricians and adolescent medicine specialists provided think-aloud feedback during the use of the prototypes and semistructured exit interviews, which was qualitatively analyzed to identify perspectives related to the usefulness and usability of the e-consultation system. RESULTS Both general pediatricians (n=12) and adolescent medicine specialists (n=12) perceived the usefulness of e-consultations for AYA patients, with more varied perceptions of potential usefulness for generalist and adolescent medicine clinicians. General pediatricians and adolescent medicine specialists discussed ways to maximize the usability of e-consultations for AYAs, primarily by improving efficiency (eg, reducing documentation, emphasizing critical information, using autopopulated data fields, and balancing specificity and efficiency through text prompts) and reducing the potential for errors (eg, prompting a review of autopopulated data fields, requiring physician contact information, and prompting explicit discussion of patient communication and confidentiality expectations). Through iterative design, patient history documentation was streamlined, whereas documentation of communication and confidentiality expectations were enhanced. CONCLUSIONS Through an iterative user-centered design process, we identified user perspectives to guide the refinement of an e-consultation system based on general pediatrician and adolescent medicine specialist feedback on usefulness and usability related to the care of AYAs. Qualitative analysis of this feedback revealed both opportunities and risks related to confidentiality, communication, and the use of tailored documentation prompts that should be considered in the development and use of e-consultations with AYAs.
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Affiliation(s)
- Jacquelin Rankine
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Deepika Yeramosu
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Loreta Matheo
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Gina M Sequeira
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States.,Division of Adolescent Medicine, Seattle Children's Hospital, Seattle, WA, United States
| | - Elizabeth Miller
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Kristin N Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
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10
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Fantasia KL, Stockman MC, Ju Z, Ortega P, Crable EL, Drainoni ML, Walkey AJ, Bergstrom M, O'Brien K, Steenkamp D. Professional continuous glucose monitoring and endocrinology eConsult for adults with type 2 diabetes in primary care: Results of a clinical pilot program. JOURNAL OF CLINICAL AND TRANSLATIONAL ENDOCRINOLOGY 2021; 24:100254. [PMID: 33898271 PMCID: PMC8054187 DOI: 10.1016/j.jcte.2021.100254] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 03/03/2021] [Accepted: 03/25/2021] [Indexed: 11/30/2022]
Abstract
Background Limitations in access to specialty diabetes care exist. Endocrinology eConsult that integrates professional continuous glucose monitoring (CGM-enhanced eConsult) may improve healthcare delivery, but has yet to be evaluated. We implemented a pilot program for patients with type 2 diabetes (T2DM) managed by primary care clinical pharmacists using CGM-enhanced eConsult and evaluated the acceptability and clinical outcomes in comparison to routine in-person endocrinology consultation. Methods Seventy-four adult patients with established T2DM (age 18-65) were included. Twenty-nine were seen in-person by endocrinology and 45 were seen by pharmacists in primary care. Thirteen patients were referred for CGM-enhanced eConsult. Acceptability was assessed with pre/post clinician acceptability questionnaires and patient assessment of perceived burden. Clinical outcomes included time to first specialty appointment, baseline and 3-month follow-up HbA1c, and antihyperglycemic medication use. Results There were no differences in patient acceptability of the CGM-enhanced eConsult as compared to endocrinology referral or pharmacy care. At baseline, all patients referred for eConsult were prescribed insulin. Three-month glycemic outcomes were comparable, with HbA1c reduction 1% + 2% in endocrinology, 1.5% + 1.1% with CGM-enhanced eConsult, and 1.6% + 1.8% in clinical pharmacy (p = 0.19). Time to an initial diabetes visit with a pharmacist was significantly shorter than with endocrinology, 20 days (IQR 26) for pharmacy vs. 45 days (IQR 54) for endocrinology, (p = 0.0001). Conclusions CGM-enhanced eConsult resulted in more timely access to endocrinology expertise, was acceptable to patients, and resulted in similar short-term glycemic outcomes compared to in-person consultation. Effectiveness of CGM-enhanced eConsults should be further explored.
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Key Words
- BMC, Boston Medical Center
- BMI, Body mass index
- CGM, Continuous glucose monitoring
- Certified diabetes educators
- DPP-4, Dipeptidyl peptidase-4
- Diabetes mellitus, type 2
- ED, Emergency department
- EMR, Electronic medical record
- GLP-1 RA, glucagon-like peptide-1 receptor agonist
- HbA1c, Hemoglobin A1c
- IQR, Interquartile range
- Pharmacists
- Professional continuous glucose monitoring
- Referral and consultation
- eConsult, Electronic consultation
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Affiliation(s)
- Kathryn L Fantasia
- Boston University School of Medicine, Department of Medicine, Section of Endocrinology, Diabetes, Nutrition and Weight Management, United States
| | - Mary-Catherine Stockman
- Boston University School of Medicine, Department of Medicine, Section of Endocrinology, Diabetes, Nutrition and Weight Management, United States
| | - Zhihui Ju
- Boston University School of Medicine, Department of Medicine, Section of Endocrinology, Diabetes, Nutrition and Weight Management, United States
| | - Paola Ortega
- Boston University School of Medicine, Department of Medicine, Section of Endocrinology, Diabetes, Nutrition and Weight Management, United States
| | - Erika L Crable
- Boston University School of Medicine, Department of Medicine, Evans Center for Implementation and Improvement Sciences, United States.,Boston University School of Public Health, Department of Health Law, Policy & Management, United States
| | - Mari-Lynn Drainoni
- Boston University School of Medicine, Department of Medicine, Evans Center for Implementation and Improvement Sciences, United States.,Boston University School of Medicine, Department of Medicine, Section of Infectious Diseases, United States.,Boston University School of Public Health, Department of Health Law, Policy & Management, United States
| | - Allan J Walkey
- Boston University School of Medicine, Department of Medicine, Evans Center for Implementation and Improvement Sciences, United States.,Boston University School of Public Health, Department of Health Law, Policy & Management, United States.,Boston University School of Medicine, Department of Medicine, The Pulmonary Center, United States
| | - Megan Bergstrom
- Boston Medical Center, Department of Pharmacy, Section of General Internal Medicine, United States
| | - Katelyn O'Brien
- Boston Medical Center, Department of Pharmacy, Section of General Internal Medicine, United States
| | - Devin Steenkamp
- Boston University School of Medicine, Department of Medicine, Section of Endocrinology, Diabetes, Nutrition and Weight Management, United States
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Sigurdsson EL, Blondal AB, Jonsson JS, Tomasdottir MO, Hrafnkelsson H, Linnet K, Sigurdsson JA. How primary healthcare in Iceland swiftly changed its strategy in response to the COVID-19 pandemic. BMJ Open 2020; 10:e043151. [PMID: 33293329 PMCID: PMC7722808 DOI: 10.1136/bmjopen-2020-043151] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To describe how the primary healthcare (PHC) in Iceland changed its strategy to handle the COVID-19 pandemic. DESIGN Descriptive observational study. SETTING Reykjavik, the capital of Iceland. POPULATION The Reykjavik area has a total of 233 000 inhabitants. MAIN OUTCOME MEASURES The number and the mode of consultations carried out. Drug prescriptions and changes in the 10 most common diagnoses made in PHC. Laboratory tests including COVID-19 tests. Average numbers in March and April 2020 compared with the same months in 2018 and 2019. RESULTS Pragmatic strategies and new tasks were rapidly applied to the clinical work to meet the foreseen healthcare needs caused by the pandemic. The number of daytime consultations increased by 35% or from 780 to 1051/1000 inhabitants (p<0.001) during the study period. Telephone and web-based consultations increased by 127% (p<0.001). The same tendency was observed in out-of-hours services. The number of consultations in maternity and well-child care decreased only by 4% (p=0.003). Changes were seen in the 10 most common diagnoses. Most noteworthy, apart from a high number of COVID-19 suspected disease, was that immunisation, depression, hypothyroidism and lumbago were not among the top 10 diagnoses during the epidemic period. The number of drug prescriptions increased by 10.3% (from 494 to 545 per 1000 inhabitants, p<0.001). The number of prescriptions from telephone and web-based consultations rose by 55.6%. No changes were observed in antibiotics prescriptions. CONCLUSIONS As the first point of contact in the COVID-19 pandemic, the PHC in Iceland managed to change its strategy swiftly while preserving traditional maternity and well-child care, indicating a very solid PHC with substantial flexibility in its organisation.
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Affiliation(s)
- Emil Larus Sigurdsson
- Department of Family Medicine, Faculty of Medicine, University of Iceland School of Health Sciences, Reykjavik, Iceland
- Development Centre for Primary Healthcare in Iceland, Primary Health Care of the Capital Area, Reykjavik, Iceland
| | - Anna Bryndis Blondal
- Development Centre for Primary Healthcare in Iceland, Primary Health Care of the Capital Area, Reykjavik, Iceland
- Faculty of Pharmaceutical Sciences, University of Iceland, Reykjavik, Iceland
| | - Jon Steinar Jonsson
- Department of Family Medicine, Faculty of Medicine, University of Iceland School of Health Sciences, Reykjavik, Iceland
- Development Centre for Primary Healthcare in Iceland, Primary Health Care of the Capital Area, Reykjavik, Iceland
| | - Margret Olafia Tomasdottir
- Department of Family Medicine, Faculty of Medicine, University of Iceland School of Health Sciences, Reykjavik, Iceland
- Development Centre for Primary Healthcare in Iceland, Primary Health Care of the Capital Area, Reykjavik, Iceland
| | - Hannes Hrafnkelsson
- Department of Family Medicine, Faculty of Medicine, University of Iceland School of Health Sciences, Reykjavik, Iceland
| | - Kristjan Linnet
- Development Centre for Primary Healthcare in Iceland, Primary Health Care of the Capital Area, Reykjavik, Iceland
| | - Johann Agust Sigurdsson
- Faculty of Medicine, Department of Public Health and Nursing/General Practice Research Unit, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
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Rea CJ, Samuels RC, Shah S, Rosen M, Toomey SL. Electronic Consultation: Latest Evidence Regarding the Impact on Referral Patterns, Patient Experience, Cost, and Quality. Acad Pediatr 2020; 20:891-892. [PMID: 32534872 DOI: 10.1016/j.acap.2020.06.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/13/2020] [Accepted: 06/07/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Corinna J Rea
- Division of General Pediatrics, Boston Children's Hospital (CJ Rea, RC Samuels, S Shah, M Rosen, and SL Toomey), Boston, Mass; Harvard Medical School (CJ Rea, RC Samuels, S Shah, and SL Toomey), Boston, Mass.
| | - Ronald C Samuels
- Division of General Pediatrics, Boston Children's Hospital (CJ Rea, RC Samuels, S Shah, M Rosen, and SL Toomey), Boston, Mass; Harvard Medical School (CJ Rea, RC Samuels, S Shah, and SL Toomey), Boston, Mass
| | - Snehal Shah
- Division of General Pediatrics, Boston Children's Hospital (CJ Rea, RC Samuels, S Shah, M Rosen, and SL Toomey), Boston, Mass; Harvard Medical School (CJ Rea, RC Samuels, S Shah, and SL Toomey), Boston, Mass
| | - Melissa Rosen
- Division of General Pediatrics, Boston Children's Hospital (CJ Rea, RC Samuels, S Shah, M Rosen, and SL Toomey), Boston, Mass
| | - Sara L Toomey
- Division of General Pediatrics, Boston Children's Hospital (CJ Rea, RC Samuels, S Shah, M Rosen, and SL Toomey), Boston, Mass; Harvard Medical School (CJ Rea, RC Samuels, S Shah, and SL Toomey), Boston, Mass
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13
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Houchens N, Gupta A. Quality and safety in the literature: September 2020. BMJ Qual Saf 2020; 29:780-784. [DOI: 10.1136/bmjqs-2020-011887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 06/27/2020] [Indexed: 11/04/2022]
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Ackerman SL, Gleason N, Shipman SA. Comparing Patients' Experiences with Electronic and Traditional Consultation: Results from a Multisite Survey. J Gen Intern Med 2020; 35:1135-1142. [PMID: 32076987 PMCID: PMC7174441 DOI: 10.1007/s11606-020-05703-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 10/18/2019] [Accepted: 01/30/2020] [Indexed: 01/18/2023]
Abstract
BACKGROUND There have been no large-scale studies to date of patients' experiences with electronic consultation (eConsult) between primary and specialty care. OBJECTIVE Compare experiences with eConsult and referral for in-person specialist consultation. DESIGN Online survey 2-6 weeks following eConsult or referral at 9 US academic medical centers. PARTICIPANTS Adult patients with no more than one eConsult or referral order from a primary care provider (PCP) in the prior month. Over 9 months, 29,291 email invitations were sent (88% referral; 12% eConsult). MAIN MEASURES Trust in and satisfaction with PCP; consult type awareness; agreement with decision to seek specialist input; timeliness of care; mode of PCP-patient eConsult communication; satisfaction with specialist's recommendations; future preference for eConsult or referral. KEY RESULTS A 27.6% response rate yielded 8087 respondents (88.4% referral; 11.6% eConsult). Many did not know that their PCP had placed a referral (32.8% unaware) or eConsult (52.9%), and eConsult awareness was significantly higher among patients reporting better health (OR 1.62, 95% CI 1.18-2.23). Most (81.4% eConsult; 82.0% referral) were satisfied with the specialist's recommendations. Those who had a good primary care experience were more likely to be satisfied (eConsult: OR 10.63, 95% CI 2.95-38.32; referral: OR 2.87, 95% CI 1.86-4.44). For a similar problem in the future, 78% of eConsult and 32% percent of referral patients preferred eConsult. CONCLUSIONS This multisite study demonstrates that many patients find virtual consultation to be an acceptable strategy for the management of their medical condition and that trust and confidence in one's PCP are crucial ingredients for a satisfying eConsult experience. The lack of awareness of eConsult among many patients who were beneficiaries of the service warrants an increased effort to include patients in eConsult decision-making and communication. Further research is needed to assess eConsult acceptability and satisfaction in more diverse patient populations.
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Affiliation(s)
- Sara L Ackerman
- Department of Social and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, USA.
| | - Nathaniel Gleason
- Division of General Internal Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Scott A Shipman
- Association of American Medical Colleges, Washington, DC, USA
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