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Hanevold CD, Brady TM. Screening and Management of Pediatric High Blood Pressure-Challenges to Implementing the Clinical Practice Guideline. Curr Hypertens Rep 2024; 26:259-271. [PMID: 38460067 DOI: 10.1007/s11906-024-01298-0] [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] [Accepted: 02/23/2024] [Indexed: 03/11/2024]
Abstract
PURPOSE OF REVIEW Elevated blood pressure (BP) and hypertension in childhood convey risk for hypertension and cardiovascular events in adulthood. Early recognition of abnormal BPs is key to preventing or lessening this risk. However, the process for making the diagnosis of hypertension is complex, and overall adherence to the 2017 American Academy of Pediatrics Clinical Practice Guidelines (CPG) is poor. We will review obstacles to adherence to the CPG and approaches designed to improve the diagnosis and management of hypertension in children. RECENT FINDINGS Baseline data from the multi-center quality improvement intervention, "Boosting Primary Care Awareness and Treatment of Hypertension" (BP-CATCH), demonstrate that childhood hypertension remains underdiagnosed. Other studies confirm a lack of compliance with the process outlined in the CPG. The provision of electronic prompts, coaching, and education results in modest improvements. The combination of embedded medical record tools and education seems to offer the most hope for improvement.
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Affiliation(s)
- Coral D Hanevold
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA.
| | - Tammy M Brady
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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2
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Campaz-Landazábal D, Vargas I, Vázquez ML. Impact of coordination mechanisms based on information and communication technologies on cross-level clinical coordination: A scoping review. Digit Health 2024; 10:20552076241271854. [PMID: 39130524 PMCID: PMC11311193 DOI: 10.1177/20552076241271854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 07/04/2024] [Indexed: 08/13/2024] Open
Abstract
Background Coordination mechanisms based on information and communication technologies (ICTs) are gaining attention, especially since the pandemic, due to their potential to improve communication between health professionals. However, their impact on cross-level clinical coordination remains unclear. The aim is to synthesize the evidence on the impact of ICT-based coordination mechanisms on clinical coordination between primary care and secondary care (SC) doctors and to identify knowledge gaps. Methods A scoping review was conducted by searching for original articles in six electronic databases and a manual search, with no restrictions regarding time, area, or methodology. Titles and abstracts were screened. Full texts of the selected articles were reviewed and analysed to assess the impact of each mechanism, according to the cross-level clinical coordination conceptual framework. Results Of the 6555 articles identified, 30 met the inclusion criteria. All had been conducted in high-income countries, most (n = 26) evaluated the impact of a single mechanism - asynchronous electronic consultations via electronic health records (EHR) - and were limited in terms of design and types and dimensions of cross-level clinical coordination analysed. The evaluation of electronic consultations showed positive impacts on the appropriateness of referrals and accessibility to SC, yet the qualitative studies also highlighted potential risks. Studies on other mechanisms were scarce (shared EHR, email consultations) or non-existent (videoconferencing, mobile applications). Conclusions Evidence of the impact of ICT-based mechanisms on clinical coordination between levels is limited. Rigorous evaluations are needed to inform policies and strategies for improving coordination between healthcare levels, thus contributing to high-quality, efficient healthcare.
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Affiliation(s)
- Daniela Campaz-Landazábal
- Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Barcelona, Spain
| | - Ingrid Vargas
- Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Barcelona, Spain
| | - María-Luisa Vázquez
- Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Barcelona, Spain
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3
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Downes MH, Morgenstern R, Naasan G, Patterson S, Pace A, Agarwal P, Shin S, Abrams R, Mueller B, Young J, Tamler R, Vickrey BG, Kummer BR. Healthcare utilization impacts of an eConsult program for headache at an academic medical center. J Telemed Telecare 2023:1357633X231207908. [PMID: 37901905 DOI: 10.1177/1357633x231207908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
INTRODUCTION Interprofessional consultations ("eConsults") can reduce healthcare utilization. However, the impact of eConsults on healthcare utilization remains poorly characterized among patients with headache. METHODS We performed a retrospective, 1:1 matched cohort study comparing patients evaluated for headache via eConsult request or in-person referral at the Mount Sinai Health System in New York. Groups were matched on clinical and demographic characteristics. Our primary outcome was one or more outpatient headache-related encounters in 6 months following referral date. Secondary outcomes included one or more all-cause outpatient neurology and headache-related emergency department (ED) encounters during the same period. We used univariable and multivariable logistic regression to model associations between independent variables and outcomes. RESULTS We identified 74 patients with headache eConsults who were matched to 74 patients with in-person referrals. Patients in the eConsult group were less likely to achieve the primary outcome (29.7% vs 62.2%, P < 0.0001) or have an all-cause outpatient neurology encounter (33.8% vs 79.7%, P < 0.0001) than patients in the comparison group. Both groups did not significantly differ by headache-related ED encounters. In multivariable analyses, patients in the eConsult group had significantly lower odds of having one or more headache-related or all-cause neurology encounters than patients in the comparison group (odds ratio (OR) 0.3, 95% confidence interval (CI) 0.1-0.6; OR 0.1, 95% CI 0.1-0.3, respectively). DISCUSSION In comparison to in-person referrals, eConsult requests for headache were associated with reduced likelihood of outpatient neurology encounters in the short-term but not with differential use of headache-related ED encounters. Larger-scale, prospective studies should validate our findings and assess patient outcomes.
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Affiliation(s)
| | - Rachelle Morgenstern
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Georges Naasan
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Shanna Patterson
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Anna Pace
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Parul Agarwal
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Susan Shin
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rory Abrams
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bridget Mueller
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - James Young
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ronald Tamler
- Division of Endocrinology, Diabetes, and Bone Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Clinical Informatics, Mount Sinai Health System, New York, NY, USA
| | - Barbara G Vickrey
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Benjamin R Kummer
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Clinical Informatics, Mount Sinai Health System, New York, NY, USA
- Windreich Department of Artificial Intelligence and Human Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Karslioglu French E, Kanter J, Winger ME, Williams K, Grumski T, Schuster J, Beckjord E. A Payer-Provider Partnership for Endocrine Targeted Automatic eConsults: Implementation and Early Impact on Diabetes and Cost Outcomes. Popul Health Manag 2023. [PMID: 37093168 DOI: 10.1089/pop.2023.0008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2023] Open
Abstract
In the United States, many individuals with diabetes mellitus (DM) do not achieve treatment goals despite the availability of effective interventions. Provider clinical inertia is one cause of these unfavorable outcomes. Targeted automatic eConsults (TACos) are an emerging technology-based intervention with potential to address clinical inertia in primary care (PC). TACos prospectively identify at-risk patients and use unsolicited specialist recommendations to prompt treatment intensification. Through a payer-provider collaboration, a TACos intervention was piloted for adults with uncontrolled DM (HbA1c >8%) to understand impact on DM clinical inertia and outcomes. Clinical inertia was assessed by measuring whether a PC provider implemented recommended therapeutic changes. Six-month changes in HbA1c and health care costs per member per month were evaluated using an observational matched design and intention-to-treat (ITT) analysis. The analysis included 196 individuals who received a TACos between February 2021 and August 2021 (ITT group) matched to 392 controls based on clinical and demographic criteria. TACos recommendations were implemented 65% of the time. Median percent change in HbA1c was significantly greater for the ITT group versus controls (-10.9% vs. -10.2%; P = 0.0359). Median total costs were 7.9% lower in the ITT group (P = 0.0900). A per protocol analysis was done to examine effects between ITT group individuals with an implemented TACos recommendation (n = 126) and controls. Median percent change in HbA1c was significantly greater (-19.5% vs. -10.2%; P < 0.0001), but there was no difference in total costs (-7.9%; P = 0.1753). TACos may feasibly address clinical inertia in PC and improve HbA1c for uncontrolled DM.
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Affiliation(s)
| | - Justin Kanter
- UPMC Center for High-Value Health Care, Pittsburgh, Pennsylvania, USA
| | - Mary E Winger
- UPMC Insurance Services Division, Department of Health Economics, Pittsburgh, Pennsylvania, USA
| | - Kelly Williams
- UPMC Center for High-Value Health Care, Pittsburgh, Pennsylvania, USA
| | - Tammi Grumski
- UPMC Insurance Services Division, Pittsburgh, Pennsylvania, USA
| | - James Schuster
- UPMC Insurance Services Division, Pittsburgh, Pennsylvania, USA
| | - Ellen Beckjord
- UPMC Insurance Services Division, Pittsburgh, Pennsylvania, USA
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Clinard V, Stebbins M, Lynch S. The Evolution of Drug Information Services to Asynchronous Delivery of Pharmacist eConsults. J Pharm Technol 2021; 37:316-319. [PMID: 34790970 DOI: 10.1177/87551225211049470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Drug information (DI) services provided an avenue to expand the role of pharmacists as the medication experts. The focus of DI has shifted from general questions submitted to DI centers to patient-specific questions that optimize care. One method to increase access to pharmacist expertise is through pharmacy eConsults. Pharmacy eConsults provide specialist care for medically complex patients using a patient-centered, asynchronous approach. The purpose of this article is to describe the evolution of consults from formal drug information services and describe one academic medical center's implementation of a pharmacy eConsult service to provide patient-specific DI.
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Russell AW, Adkins P, Hayes L, Prior E, McCormack C, DiGregorio J. Electronic consultations (eConsults): a proof of concept trial in Australia. Intern Med J 2021; 52:2150-2156. [PMID: 34432347 DOI: 10.1111/imj.15495] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 08/14/2021] [Accepted: 08/15/2021] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Anthony W Russell
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Woolloongabba, Qld, Australia.,Centre for Health Services Research, University of Queensland, Brisbane, Qld, Australia
| | - Peter Adkins
- Brisbane South Primary Healthcare Network, Eight Mile Plains, Qld, Australia
| | - Lisa Hayes
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Woolloongabba, Qld, Australia
| | - Erin Prior
- Clinical Informatics, Metro South Health, Princess Alexandra Hospital, Woolloongabba, Qld, Australia
| | - Christine McCormack
- Strategic Partnerships, Metro South Health, Eight Mile Plains, Qld, Australia
| | - John DiGregorio
- Clinical Informatics, Metro South Health, Princess Alexandra Hospital, Woolloongabba, Qld, Australia
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Jarjou'i A, Mendlovic J, Dadon Z, Sneineh MA, Tabi M, Kalak G, Jarallah YR, Yinnon AM, Munter G. Availability, timeliness, documentation and quality of consultations among hospital departments: a prospective, comparative study. Isr J Health Policy Res 2021; 10:19. [PMID: 33866967 PMCID: PMC8053423 DOI: 10.1186/s13584-021-00446-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 02/10/2021] [Indexed: 01/03/2023] Open
Abstract
Background Many in-patients require care from practitioners in various disciplines. Consultations most probably have significant implications for hospitalization outcomes. Purpose To determine key aspects of consultations provided by various departments to formulate an optimal policy. Methods This study comprised two methods: first, a questionnaire was completed in 2019 by 127 physicians interns, residents and senior doctors) from the medical and surgical departments (64 from the surgical wards, 43 from the medical wards and 22 from the emergency room and General ICU) regarding the availability, timeliness and documentation rate of the consultations they received from different disciplines. The investigators rounded through the various departments that were included in the study and they accosted a sample of interns, residents and attending physicians, who were then asked to fill the questionnaire. Overall compliance of filling the questionnaire was 95%. Residents accounted for 72% of the filled questionnaires, seniors and interns accounted for 15 and 13% respectively. Second, a convenience sample of 300 electronic records of hospitalized patients (135 from the surgical wards, 129 from the Medical wards and 36 from the emergency room and General ICU) of actually carried out consultations was reviewed for validated indicators of quality for both the consultation request and response. We used a 5-point Likert scale, ranging from poor (1) to superb (5), to grade the measured parameters. Results The availability, timeliness and documentation rate for medical consultations were 4 ± 0.9, 4.1 ± 0.9 and 4.3 ± 0.9 respectively, as compared with surgical consultations 3.2 ± 1.1, 3.4 ± 1.2 and 3.6 ± 1.2 respectively (P < 0.001). The mean time (in hours) from the consultation request till documentation (of the requested consultation) by consultants in the medical and surgical departments was 3.9 ± 5.9 and 10.0 ± 15.6, respectively (P < 0.001). The quality of requests of consultations from the medical and surgical departments was 3.4 ± 1.1 and 2.8 ± 1.2, respectively (P < 0.001). Two different models of consultations are employed: while each medical department adopts several departments for medical consultations, each day’s on-call surgeon provides all the hospital’s surgical consultations. Conclusion We detected significant differences in key aspects of consultations provided by the departments. The medical model of consultations, in which each medical department adopts several other wards to which it provides consulting services upon request, should probably be adopted as a major policy decision by hospitals directors to enhance inter-departmental consultations. Supplementary Information The online version contains supplementary material available at 10.1186/s13584-021-00446-0.
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Affiliation(s)
- Amir Jarjou'i
- Internal Medicine, Shaare Zedek Medical Center, Affiliated with the Hadassah-Hebrew University School of Medicine, Jerusalem, Israel. .,Division of Internal Medicine, Shaare Zedek Medical Center, Affiliated with the Hadassah-Hebrew University School of Medicine, P.O. Box 3235, 91031, Jerusalem, Israel.
| | - Joseph Mendlovic
- Deputy CEO, Shaare Zedek Medical Center, Affiliated with the Hadassah-Hebrew University School of Medicine, Jerusalem, Israel
| | - Ziv Dadon
- Division of Internal Medicine, Shaare Zedek Medical Center, Affiliated with the Hadassah-Hebrew University School of Medicine, P.O. Box 3235, 91031, Jerusalem, Israel.,Department of Cardiology, Shaare Zedek Medical Center, Affiliated with the Hadassah-Hebrew University School of Medicine, Jerusalem, Israel
| | - Marwan Abu Sneineh
- Division of Internal Medicine, Shaare Zedek Medical Center, Affiliated with the Hadassah-Hebrew University School of Medicine, P.O. Box 3235, 91031, Jerusalem, Israel
| | - Meir Tabi
- Division of Internal Medicine, Shaare Zedek Medical Center, Affiliated with the Hadassah-Hebrew University School of Medicine, P.O. Box 3235, 91031, Jerusalem, Israel.,Department of Cardiology, Shaare Zedek Medical Center, Affiliated with the Hadassah-Hebrew University School of Medicine, Jerusalem, Israel
| | - George Kalak
- Division of Internal Medicine, Shaare Zedek Medical Center, Affiliated with the Hadassah-Hebrew University School of Medicine, P.O. Box 3235, 91031, Jerusalem, Israel
| | - Yousef R Jarallah
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Affiliated with the Hadassah-Hebrew University School of Medicine, Jerusalem, Israel
| | - Amos M Yinnon
- Division of Internal Medicine, Shaare Zedek Medical Center, Affiliated with the Hadassah-Hebrew University School of Medicine, P.O. Box 3235, 91031, Jerusalem, Israel.
| | - Gabriel Munter
- Internal Medicine, Shaare Zedek Medical Center, Affiliated with the Hadassah-Hebrew University School of Medicine, Jerusalem, Israel.,Division of Internal Medicine, Shaare Zedek Medical Center, Affiliated with the Hadassah-Hebrew University School of Medicine, P.O. Box 3235, 91031, Jerusalem, Israel
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8
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Vimalananda VG, Orlander JD, Afable MK, Fincke BG, Solch AK, Rinne ST, Kim EJ, Cutrona SL, Thomas DD, Strymish JL, Simon SR. Electronic consultations (E-consults) and their outcomes: a systematic review. J Am Med Inform Assoc 2021; 27:471-479. [PMID: 31621847 DOI: 10.1093/jamia/ocz185] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 08/06/2019] [Accepted: 09/30/2019] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- Varsha G Vimalananda
- Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, Massachusetts, USA.,Section of Endocrinology, Diabetes, and Metabolism, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Jay D Orlander
- Department of General Medicine, VA Boston Healthcare System, Boston, Massachusetts, USA.,Evans Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Melissa K Afable
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, Massachusetts, USA.,Department of Quality, Safety and Value, Partners Healthcare System, Boston, Massachusetts, USA
| | - B Graeme Fincke
- Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, Massachusetts, USA.,Section of Health Law, Policy & Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Amanda K Solch
- Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, Massachusetts, USA
| | - Seppo T Rinne
- Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, Massachusetts, USA.,Section of Pulmonary, Allergy, Sleep, and Critical Care Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Eun Ji Kim
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, Massachusetts, USA.,Division of General Internal Medicine, Zucker School of Medicine, Hofstra Northwell, Manhasset, New York, USA
| | - Sarah L Cutrona
- Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, Massachusetts, USA.,Division of Health Informatics and Implementation Science, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Dylan D Thomas
- Center for Healthcare Organization and Implementation Research, Bedford VA Medical Center, Bedford, Massachusetts, USA.,Section of Endocrinology, Diabetes, and Metabolism, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Judith L Strymish
- Department of Medicine, Harvard Medical School, Cambridge, Massachusetts, USA.,Department of Medicine and Infectious Diseases, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Steven R Simon
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, Massachusetts, USA.,Department of Medicine, Harvard Medical School, Cambridge, Massachusetts, USA.,Geriatrics and Extended Care Service, VA Boston Healthcare System, Boston, Massachusetts, USA
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Osman MA, Schick-Makaroff K, Thompson S, Bialy L, Featherstone R, Kurzawa J, Zaidi D, Okpechi I, Habib S, Shojai S, Jindal K, Braam B, Keely E, Liddy C, Manns B, Tonelli M, Hemmelgarn B, Klarenbach S, Bello AK. Barriers and facilitators for implementation of electronic consultations (eConsult) to enhance access to specialist care: a scoping review. BMJ Glob Health 2019; 4:e001629. [PMID: 31565409 PMCID: PMC6747903 DOI: 10.1136/bmjgh-2019-001629] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 08/04/2019] [Accepted: 08/10/2019] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION Electronic consultation (eConsult)-provider-to-provider electronic asynchronous exchanges of patient health information at a distance-is emerging as a potential tool to improve the interface between primary care providers and specialists. Despite growing evidence that eConsult has clinical benefits, it is not widely adopted. We investigated factors influencing the adoption and implementation of eConsult services. METHODS We applied established methods to guide the review, and the recently published Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews to report our findings. We searched five electronic databases and the grey literature for relevant studies. Two reviewers independently screened titles and full texts to identify studies that reported barriers to and/or facilitators of eConsult (asynchronous (store-and-forward) use of telemedicine to exchange patient health information between two providers (primary and secondary) at a distance using secure infrastructure). We extracted data on study characteristics and key barriers and facilitators were analysed thematically and classified using the Quadruple Aim framework taxonomy. No date or language restrictions were applied. RESULTS Among the 2579 publications retrieved, 130 studies met eligibility for the review. We identified and summarised key barriers to and facilitators of eConsult adoption and implementation across four domains: provider, patient, healthcare system and cost. Key barriers were increased workload for providers, privacy concerns and insufficient reimbursement for providers. Main facilitators were remote residence location, timely responses from specialists, utilisation of referral coordinators, addressing medicolegal concerns and incentives for providers to use eConsult. CONCLUSION There are multiple barriers to and facilitators of eConsult adoption across the domains of Quadruple Aim framework. Our findings will inform the development of practice tools to support the wider adoption and scalability of eConsult implementation.
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Affiliation(s)
- Mohamed A Osman
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Stephanie Thompson
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Liza Bialy
- Alberta Research Centre for Health Evidence, University of Alberta, Edmonton, Alberta, Canada
- Alberta SPOR SUPPORT Unit, Knowledge Translation platform, Edmonton, Alberta, Canada
| | - Robin Featherstone
- Alberta Research Centre for Health Evidence, University of Alberta, Edmonton, Alberta, Canada
- Alberta SPOR SUPPORT Unit, Knowledge Translation platform, Edmonton, Alberta, Canada
| | - Julia Kurzawa
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Deenaz Zaidi
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Ikechi Okpechi
- Division of Nephrology and Hypertension, University of Cape Town, Cape Town, South Africa
| | - Syed Habib
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Soroush Shojai
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Kailash Jindal
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Branko Braam
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Erin Keely
- Departments of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Division of Endocrinology/Metabolism, The Ottawa Hospital, Ottawa, Ontario, Canada
- Ottawa Research Institute, Ottawa, Ontario, Canada
| | - Clare Liddy
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
- CT Lamont Primary Healthcare Research Centre, Bruyere Research Institute, Ottawa, Ontario, Canada
| | - Braden Manns
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Marcello Tonelli
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Brenda Hemmelgarn
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Scott Klarenbach
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Aminu K Bello
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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10
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de Man G, Moroz I, Mercer J, Keely E, Liddy C. Primary Care Clinician Adherence to Specialist Advice in Electronic Consultation. Ann Fam Med 2019; 17:150-157. [PMID: 30858258 PMCID: PMC6411398 DOI: 10.1370/afm.2355] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 12/14/2018] [Accepted: 12/31/2018] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Electronic consultation (eConsult) services can improve access to specialist advice. Little is known, however, about whether and how often primary care clinicians adhere to the advice they receive. We evaluated how primary care clinicians use recommendations conveyed by specialists via the Champlain BASE (Building Access to Specialists through eConsultation) eConsult service and how eConsult affects clinical management of patients in primary care. METHODS This is a descriptive analysis based on a retrospective chart audit of 291 eConsults done between January 20, 2017 and August 31, 2017 at the Bruyère Family Health Team, located in Ottawa, Canada. Patients' charts were reviewed until 6 months after specialist response for the following main outcomes: implementation of specialist advice by primary care clinicians, communication of the results to the patients, method, and time frame of communication. RESULTS Primary care clinicians adhered to specialist advice in 82% of cases. Adherence ranged from 62% to 93% across recommendation categories. Questions asked by primary care clinicians related to diagnosis (63%), management (27%), drug treatment (10%), and procedures (1%). Recommendations of the eConsult were communicated to patients in 79% of cases, most often by face-to-face visit (38%), telephone call (32%), or use of the patient portal (9%). Communication occurred in a median of 5 days. CONCLUSIONS We found little evidence of barriers to implementing specialist advice with use of eConsult, which suggests recommendations given through service were actionable. With a high primary care clinician adherence to specialist recommendations and primary care clinician-to-patient communication, we conclude that eConsult delivers good-quality care and improves patient management.
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Affiliation(s)
- Gwen de Man
- CT Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Radboud University, Nijmegen, The Netherlands
| | - Isabella Moroz
- CT Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Jay Mercer
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Bruyère Academic Family Health Team, Bruyère Continuing Care, Ottawa, Ontario, Canada
| | - Erin Keely
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Division of Endocrinology/Metabolism, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Clare Liddy
- CT Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada .,Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
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11
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Liddy C, Moroz I, Mihan A, Nawar N, Keely E. A Systematic Review of Asynchronous, Provider-to-Provider, Electronic Consultation Services to Improve Access to Specialty Care Available Worldwide. Telemed J E Health 2019; 25:184-198. [DOI: 10.1089/tmj.2018.0005] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Affiliation(s)
- Clare Liddy
- C.T. Lamont Primary Health Care Research Center, Bruyère Research Institute, Ottawa, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Canada
| | - Isabella Moroz
- C.T. Lamont Primary Health Care Research Center, Bruyère Research Institute, Ottawa, Canada
| | - Ariana Mihan
- C.T. Lamont Primary Health Care Research Center, Bruyère Research Institute, Ottawa, Canada
| | - Nikhat Nawar
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Erin Keely
- Department of Medicine, University of Ottawa, Ottawa, Canada
- Division of Endocrinology/Metabolism, The Ottawa Hospital, Ottawa, Canada
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12
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Tuot DS, Liddy C, Vimalananda VG, Pecina J, Murphy EJ, Keely E, Simon SR, North F, Orlander JD, Chen AH. Evaluating diverse electronic consultation programs with a common framework. BMC Health Serv Res 2018; 18:814. [PMID: 30355346 PMCID: PMC6201558 DOI: 10.1186/s12913-018-3626-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 10/15/2018] [Indexed: 11/17/2022] Open
Abstract
Background Electronic consultation is an emerging mode of specialty care delivery that allows primary care providers and their patients to obtain specialist expertise without an in-person visit. While studies of individual programs have demonstrated benefits related to timely access to specialty care, electronic consultation programs have not achieved widespread use in the United States. The lack of common evaluation metrics across health systems and concerns related to the generalizability of existing evaluation efforts may be hampering further growth. We sought to identify gaps in knowledge related to the implementation of electronic consultation programs and develop a set of shared evaluation measures to promote further diffusion. Methods Using a case study approach, we apply the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) and the Quadruple Aim frameworks of evaluation to examine electronic consultation implementation across diverse delivery systems. Data are from 4 early adopter healthcare delivery systems (San Francisco Health Network, Mayo Clinic, Veterans Administration, Champlain Local Health Integration Network) that represent varied organizational structures, care for different patient populations, and have well-established multi-specialty electronic consultation programs. Data sources include published and unpublished quantitative data from each electronic consultation database and qualitative data from systems’ end-users. Results Organizational drivers of electronic consultation implementation were similar across the systems (challenges with timely and/or efficient access to specialty care), though unique system-level facilitators and barriers influenced reach, adoption and design. Effectiveness of implementation was consistent, with improved patient access to timely, perceived high-quality specialty expertise with few negative consequences, garnering high satisfaction among end-users. Data about patient-specific clinical outcomes are lacking, as are policies that provide guidance on the legal implications of electronic consultation and ideal remuneration strategies. Conclusion A core set of effectiveness and implementation metrics rooted in the Quadruple Aim may promote data-driven improvements and further diffusion of successful electronic consultation programs. Electronic supplementary material The online version of this article (10.1186/s12913-018-3626-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Delphine S Tuot
- Center for Innovation in Access and Quality at Priscilla Chan and Mark Zuckerberg San Francisco General Hospital and Trauma Center, University of California San Francisco, San Francisco, CA, 94110, USA. .,Deparment of Medicine, University of California, San Francisco, San Francisco, CA, USA.
| | - Clare Liddy
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Varsha G Vimalananda
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Medical Center, Bedford, MA, USA.,Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Jennifer Pecina
- Department of Family Medicine, Mayo Clinic, Rochester, MN, USA
| | - Elizabeth J Murphy
- Center for Innovation in Access and Quality at Priscilla Chan and Mark Zuckerberg San Francisco General Hospital and Trauma Center, University of California San Francisco, San Francisco, CA, 94110, USA.,Deparment of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Erin Keely
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,The Ottawa Hospital, Ottawa, ON, Canada
| | - Steven R Simon
- Harvard Medical School, Boston, USA.,VA Boston Healthcare System, Boston, USA
| | - Frederick North
- Department of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jay D Orlander
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA.,VA Boston Healthcare System, Boston, USA
| | - Alice Hm Chen
- Center for Innovation in Access and Quality at Priscilla Chan and Mark Zuckerberg San Francisco General Hospital and Trauma Center, University of California San Francisco, San Francisco, CA, 94110, USA.,Deparment of Medicine, University of California, San Francisco, San Francisco, CA, USA
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13
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Archibald D, Liddy C, Lochnan HA, Hendry PJ, Keely EJ. Using Clinical Questions Asked by Primary Care Providers Through eConsults to Inform Continuing Professional Development. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2018; 38:41-48. [PMID: 29351133 DOI: 10.1097/ceh.0000000000000187] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
INTRODUCTION Continuing professional development (CPD) offerings should address the educational needs of health care providers. Innovative programs, such as electronic consultations (eConsults), provide unique educational opportunities for practice-based needs assessment. The purpose of this study is to assess whether CPD offerings match the needs of physicians by coding and comparing session content to clinical questions asked through eConsults. METHODS This study analyzes questions asked by primary care providers between July 2011 and January 2015 using a service that allows specialists to provide consultation over a secure web-based server. The content of these questions was compared with the CPD courses offered in the area in which these primary care providers are practicing over a similar period (2012-2014). The clinical questions were categorized by the content area. The percentage of questions asked about each content area was calculated for each of the 12 specialties consulted. CPD course offerings were categorized using the same list of content areas. Percentage of minutes dedicated to each content area was calculated for each specialty. The percentage of questions asked and the percentage of CPD course minutes for each content area were compared. RESULTS There were numerous congruencies and discrepancies between the proportion of questions asked about a given content area and the CPD minutes dedicated to it. DISCUSSION Traditional needs assessment may underestimate the need to address topics that are frequently the subject of eConsults. Planners should recognize eConsult questions as a valuable source of practice-associated challenges that can identify professional development needs of physicians.
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Affiliation(s)
- Douglas Archibald
- Dr. Archibald: Assistant Professor, CT Lamont Primary Health Care Research Centre, Department of Family Medicine, University of Ottawa; Bruyère Research Institute, Ottawa, Ontario, Canada. Dr. Liddy: Associate Professor, CT Lamont Primary Health Care Research Centre, Department of Family Medicine, University of Ottawa; Bruyère Research Institute, Ottawa, Ontario, Canada. Dr. Lochnan: Associate Professor, Department of Medicine, University of Ottawa; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada. Dr. Hendry: Professor, Department of Surgery, University of Ottawa; University of Ottawa Heart Institute, Ottawa, Ontario, Canada. Dr. Keely: Professor, Department of Medicine, University of Ottawa; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Rushakoff RJ, Rushakoff JA, Kornberg Z, MacMaster HW, Shah AD. Remote Monitoring and Consultation of Inpatient Populations with Diabetes. Curr Diab Rep 2017; 17:70. [PMID: 28726156 DOI: 10.1007/s11892-017-0896-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW Inpatient hyperglycemia is common and is linked to increased morbidity and mortality. We review current and innovative ways diabetes specialists consult in the management of inpatient diabetes. RECENT FINDINGS With electronic medical records (EMRs), remote monitoring and intervention may improve the management of inpatient hyperglycemia. Automated reports allow monitoring of glucose levels and allow diabetes teams to intervene through formal or remote consultation. Following a 2-year transition of our complex paper-based insulin order sets to be EMR based, we leveraged this change by developing new daily glycemic reports and a virtual glucose management service (vGMS). Based on a daily report identifying patients with two or more glucoses over 225 mg/dl and/or a glucose <70 mg/dl in the past 24 h, a vGMS note with management recommendations was placed in the chart. Following the introduction of the vGMS, the proportion of hyperglycemic patients decreased 39% from a baseline of 6.5 per 100 patient-days to 4.0 per 100 patient-days The hypoglycemia proportion decreased by 36%. Ninety-nine percent of surveyed medical and surgical residents said the vGMS was both important and helpful.
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Affiliation(s)
- Robert J Rushakoff
- Division of Endocrinology and Metabolism, University of California, San Francisco, 2200 Post St., Suite C-430, San Francisco, CA, 94115, USA.
| | - Joshua A Rushakoff
- School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Zachary Kornberg
- School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | | | - Arti D Shah
- Division of Endocrinology and Metabolism, University of California, San Francisco, San Francisco, CA, USA
- Division of Endocrinology and Metabolism, University of California, Los Angeles, Los Angeles, CA, USA
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15
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Lowenstein M, Bamgbose O, Gleason N, Feldman MD. Psychiatric Consultation at Your Fingertips: Descriptive Analysis of Electronic Consultation From Primary Care to Psychiatry. J Med Internet Res 2017; 19:e279. [PMID: 28778852 PMCID: PMC5562932 DOI: 10.2196/jmir.7921] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 07/12/2017] [Accepted: 07/13/2017] [Indexed: 11/13/2022] Open
Abstract
Background Mental health problems are commonly encountered in primary care, with primary care providers (PCPs) experiencing challenges referring patients to specialty mental health care. Electronic consultation (eConsult) is one model that has been shown to improve timely access to subspecialty care in a number of medical subspecialties. eConsults generally involve a PCP-initiated referral for specialty consultation for a clinical question that is outside their expertise but may not require an in-person evaluation. Objective Our aim was to describe the implementation of eConsults for psychiatry in a large academic health system. Methods We performed a content analysis of the first 50 eConsults to psychiatry after program implementation. For each question and response, we coded consults as pertaining to diagnosis and/or management as well as categories of medication choice, drug side effects or interactions, and queries about referrals and navigating the health care system. We also performed a chart review to evaluate the timeliness of psychiatrist responses and PCP implementation of recommendations. Results Depression was the most common consult template selected by PCPs (20/50, 40%), followed by the generic template (12/50, 24%) and anxiety (8/50, 16%). Most questions (49/50, 98%) pertained primarily to management, particularly for medications. Psychiatrists commented on both diagnosis (28/50, 56%) and management (50/50, 100%), responded in an average of 1.4 days, and recommended in-person consultation for 26% (13/50) of patients. PCPs implemented psychiatrist recommendations 76% (38/50) of the time. Conclusions For the majority of patients, psychiatrists provided strategies for ongoing management in primary care without an in-person evaluation, and PCPs implemented most psychiatrist recommendations. eConsults show promise as one means of supporting PCPs to deliver mental health care to patients with common psychiatric disorders.
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Affiliation(s)
- Margaret Lowenstein
- University of Pennsylvania Perelman School of Medicine, National Clinician Scholars Program, Philadelphia, PA, United States
| | - Olusinmi Bamgbose
- Marin General Hospital, Department of Psychiatry, Greenbrae, CA, United States
| | - Nathaniel Gleason
- University of California, San Francisco, Division of General Internal Medicine, San Francisco, CA, United States
| | - Mitchell D Feldman
- University of California, San Francisco, Division of General Internal Medicine, San Francisco, CA, United States
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16
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A cohort study of a general surgery electronic consultation system: safety implications and impact on surgical yield. BMC Health Serv Res 2017. [PMID: 28645288 PMCID: PMC5481906 DOI: 10.1186/s12913-017-2375-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Electronic consultation (eConsult) systems have enhanced access to specialty expertise and enhanced care coordination among primary care and specialty care providers, while maintaining high primary care provider (PCP), specialist and patient satisfaction. Little is known about their impact on the efficiency of specialty care delivery, in particular surgical yield (percent of ambulatory visits resulting in a scheduled surgical case). METHODS Retrospective cohort of a random selection of 150 electronic consults from PCPs to a safety-net general surgery clinic for the three most common general surgery procedures (herniorrhaphy, cholecystectomy, anorectal procedures) in 2014. Electronic consultation requests were reviewed for the presence/absence of consult domains: symptom acuity/severity, diagnostic evaluation, concurrent medical conditions, and attempted diagnosis. Logic regression was used to examine the association between completeness of consult requests and scheduling an ambulatory clinic visit. Surgical yield was also calculated, as was the percentage of patients requiring unanticipated healthcare visits. RESULTS In 2014, 1743 electronic consultations were submitted to general surgery. Among the 150 abstracted, the presence of consult domains ranged from 49% to 99%. Consult completeness was not associated with greater likelihood of scheduling an ambulatory visit. Seventy-six percent of consult requests (114/150) were scheduled for a clinic appointment and surgical yield was 46%; without an eConsult system, surgical yield would have been 35% (p=0.07). Among patients not scheduled for a clinic visit (n=36), 4 had related unanticipated emergency department visits. CONCLUSION Econsult systems can be used to safely optimize the surgical yield of a safety-net general surgery service.
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17
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Kohlert S, Murphy P, Tse D, Liddy C, Afkham A, Keely E. Improving access to otolaryngology-head and neck surgery expert advice through eConsultations. Laryngoscope 2017; 128:350-355. [PMID: 28573644 DOI: 10.1002/lary.26677] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 04/14/2017] [Accepted: 04/20/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVES/HYPOTHESIS Prolonged wait times have become common. Electronic consultations (eConsults) have been shown in previous studies to reduce unnecessary face-to-face consultations to specialists, but no prior study has investigated the feasibility or efficacy of eConsults in an otolaryngology-head and neck surgery (OTO-HNS) practice. STUDY DESIGN Prospective observational study. METHODS The Champlain BASE eConsult system is a secure web portal allowing primary care physicians (PCPs) to communicate asynchronously with specialists about a patient, without requiring a formal face-to-face consult. The data from all eConsults sent through this portal to OTO-HNS practices between July 2011 and January 2015 were collected and analyzed. RESULTS Response time was rapid; over 40% of eConsults received a response within 24 hours, and nearly all eConsults were answered within 7 calendar days. The median response time was nearly 29 times faster than traditional face-to-face consultation. Unnecessary face-to-face referrals were avoided in 33.4% of all eConsults, and in nearly 50% of cases where the PCP initially planned a formal referral. PCPs reported adopting a new or additional course of action over 50% of the time following an eConsult. Eighty-eight percent of PCPs reported the service to be valuable for their patients, and 92% found it valuable for themselves. eConsults require only a limited time commitment from specialists, with over 75% taking less than 10 minutes to complete. CONCLUSIONS eConsultation is a cost-effective system that can lead to decreased wait times, improved communication between PCPs and otolaryngologists, and help guide the development of targeted continuing professional development modules for PCPs. LEVEL OF EVIDENCE 4. Laryngoscope, 128:350-355, 2018.
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Affiliation(s)
- Scott Kohlert
- Department of Otolaryngology-Head and Neck Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada.,Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Patrick Murphy
- Department of Otolaryngology-Head and Neck Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada.,Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Darren Tse
- Department of Otolaryngology-Head and Neck Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada.,Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Clare Liddy
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Amir Afkham
- Champlain Local Health Integration Network, Ottawa, Ontario, Canada
| | - Erin Keely
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Division of Endocrinology/Metabolism, The Ottawa Hospital, Ottawa, Ontario, Canada
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18
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Hendrickson CD, Saini S, Pothuloori A, Mecchella JN. ASSESSING REFERRALS AND IMPROVING INFORMATION AVAILABILITY FOR CONSULTATIONS IN AN ACADEMIC ENDOCRINOLOGY CLINIC. Endocr Pract 2016; 23:190-198. [PMID: 27849384 DOI: 10.4158/ep161514.or] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Outpatient specialty consultations rely on the timeliness and completeness of referral information to facilitate a valuable patient-specialist interaction. This project aimed to increase essential diagnostic information availability at the initial consultation for patients referred for common endocrine conditions frequently lacking such data-diabetes mellitus, thyroid nodule, thyrotoxicosis, and hypercalcemia. METHODS At an endocrinology clinic at an academic medical center in rural New England, providers see several thousand new patients annually, the majority of whom are referred by providers external to the clinic's healthcare system. Through consensus, endocrinology clinic providers agreed on the two or three data elements essential for a meaningful initial consultation for each. A quality improvement team employed a planned series of interventions based on previously published methods and an innovative approach: dissemination of a referral guideline, an assessment of referral adequacy in the endocrinology clinic workflow, coupled with focused requests for missing items, and a pre-visit lab appointment. RESULTS Between April 2015 and March 2016, 762 referrals were reviewed. At baseline for the four conditions, referrals contained all essential elements only 27.5% (22 of 80) of the time. Over a 7-month period, the team implemented the interventions, with subsequent referrals containing all essential elements increasing to 75.5% (P<.0001), largely attributable to the pre-visit lab appointment. CONCLUSION Incoming referrals that lack essential information are a significant problem in specialty care and may adversely affect patient experience, provider satisfaction, and clinic efficiency. Improvement may require innovative approaches, such as the potentially transferable and generalizable ones employed here. ABBREVIATIONS DHMC = Dartmouth-Hitchcock Medical Center EHR = electronic health record PDSA = Plan-Do-Study-Act.
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Lau A, Ewing C, Gnanapragasam J, Majaesic C, MacLean J, Mandhane PJ. Changes to a pediatric sleep disordered breathing clinic improve wait-times and clinic efficiency. Pediatr Pulmonol 2016; 51:1234-1241. [PMID: 27133382 DOI: 10.1002/ppul.23440] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 02/08/2016] [Accepted: 02/11/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND Recognition of the impact of sleep disordered breathing (SDB) on health has increased referrals in pediatric respiratory medicine with a concomitant increase in wait-times. METHODS To reduce wait-time (primary outcome), we developed a rapid SDB clinic (RSC) to identify, diagnose, and treat patients with few to no comorbidities (uncomplicated) and presumed SDB based on the referral letter. The RSC uses 1) parent-report questionnaires to capture the patients' medical history and 2) sleep testing (e.g., overnight oximetry) completed prior to the initial consultation. RESULTS The combination of pre-clinic electronic-questionnaires and testing increased patient consult capacity by 100%. Of the 256 patients referred to the RSC over 28 months, 130 patients were seen through the RSC, 17 patients were re-triaged to a standard sleep clinic (SSC) after questionnaire review, 51 patients were completing the RSC process, and 75 patients had their referral cancelled. An electronic-questionnaire RSC (n = 45) reduced wait-times by 34% to 142.8 (SD 57) days compared to a paper-questionnaire RSC (P < 0.001). The electronic RSC was also associated with 77.4 (SD 74.1) days reduction in wait-time (P = 0.04) for SSC patients seen during the same timeframe. RSC patients were 75% less likely to require a follow-up visit (P < 0.001) compared to SSC patients seen during the same timeframe. CONCLUSION A targeted, streamlined clinic using electronic-questionnaires for uncomplicated patients can improve wait-times for children being referred to pediatric respiratory medicine for evaluation of sleep disordered breathing. Pediatr Pulmonol. 2016;51:1234-1241. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Amanda Lau
- University of Alberta, Edmonton, Alberta, Canada
| | - Chris Ewing
- University of Alberta, Edmonton, Alberta, Canada.,Stollery Children's Hospital, Edmonton, Alberta, Canada
| | | | - Carina Majaesic
- University of Alberta, Edmonton, Alberta, Canada.,Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Joanna MacLean
- University of Alberta, Edmonton, Alberta, Canada.,Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Piush J Mandhane
- University of Alberta, Edmonton, Alberta, Canada. .,Stollery Children's Hospital, Edmonton, Alberta, Canada.
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Rushakoff RJ, Rushakoff JA. Evolution of the curbside consult commentary on transforming the endocrine consult: asynchronous provider consultations. Endocr Pract 2015; 21:554-6. [PMID: 25716641 DOI: 10.4158/ep15625.co] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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