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

BACKGROUND

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

METHODS

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

RESULTS

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

INTERPRETATION

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

How long are Canadians waiting to access specialty care? Retrospective study from a primary care perspective

OBJECTIVE

To calculate patient wait times for specialist care using data from primary care clinics across Canada.

DESIGN

Retrospective chart audit.

SETTING

Primary care clinics.

PARTICIPANTS

A total of 22 primary care clinics across 7 provinces and 1 territory.

MAIN OUTCOME MEASURES

Wait time 1, defined as the period between a patient's referral by a family physician to a specialist and the visit with said specialist.

RESULTS

Overall, 2060 referrals initiated between January 2014 and December 2016 were included in the analysis. The median national wait time 1 was 78 days (interquartile range [IQR] of 34 to 175 days). The shortest waits were observed in Saskatchewan (51 days; IQR = 23 to 101 days) and British Columbia (59 days; IQR = 29 to 131 days), whereas the longest were in New Brunswick (105 days; IQR = 43 to 242 days) and Quebec (104 days; IQR = 36 to 239 days). Median wait time 1 varied substantially among different specialty groups, with the longest wait time for plastic surgery (159 days; IQR = 59 to 365 days) and the shortest for infectious diseases (14 days; IQR = 6 to 271 days).

CONCLUSION

This is the first national examination of wait time 1 from the primary care perspective. It provides a picture of patient access to specialists across provinces and specialty groups. This research provides decision makers with important context for developing programs and policies aimed at addressing the largely ignored stage of the wait time continuum from the time of referral to eventual appointment time with the specialist.

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

OBJECTIVE

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

DESIGN

Cross-sectional study.

SETTING

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

PARTICIPANTS

All eConsult cases submitted in four participating provinces were included.

INTERVENTION

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Electronic Consultation Services Worldwide: Environmental Scan

BACKGROUND

Excessive wait times for specialist care pose a serious concern for many patients, leading to duplication of tests, patient anxiety, and poorer health outcomes. In response to this issue, many health care systems have begun implementing technological innovations designed to improve the referral-consultation process. Among these services is electronic consultation (eConsult), which connects primary care providers and specialists through a secure platform to facilitate discussion of patients' care.

OBJECTIVE

This study aims to examine different eConsult services available worldwide and compare the strategies, barriers, and successes of their implementation in different health care contexts.

METHODS

We conducted an environmental scan comprising 3 stages as follows: literature review; gray literature search; and targeted, semistructured key informant interviews. We searched MEDLINE and EMBASE (literature review) and Google (gray literature search). Upon completing the search, we generated a list of potential interview candidates from among the stakeholders identified. Potential participants included researchers, physicians, and decision makers. The maximum variation sampling was used to ensure sufficient breadth of participant experience. In addition, we conducted semistructured interviews by telephone using an interview guide based on the RE-AIM framework. Analyses of transcripts were conducted using a thematic synthesis approach.

RESULTS

A total of 53 services emerged from the published and gray literature. Respondents from 10 services participated in telephonic interviews. The following 4 major themes emerged from the analysis: service structure; benefits of eConsult; implementation challenges; and implementation enablers.

CONCLUSIONS

eConsult services have emerged in a variety of countries and health system contexts worldwide. Despite differences in structure, platform, and delivery of their services, respondents described similar barriers and enablers to the implementation and growth and reported improved access and high levels of satisfaction.

Physician Remuneration for Remote Consults: An Overview of Approaches across Canada

While lengthy waits for medical specialists remains a persistent problem across Canada, remote consult presents a strategy to address this issue. Connecting primary healthcare providers to specialists via electronic (eConsult) or telephone consult enables care providers to deliver appropriate, speciality-informed care for their patients in the primary care setting, reducing the time spent waiting for specialists and potentially preventing unnecessary referrals to specialty care. These remote consult models are the focus of a new pan-Canadian quality improvement collaborative delivered by the Canadian Foundation for Healthcare Improvement in partnership with Canada Health Infoway, the College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada. Successful implementation of remote consult services requires alignment of remuneration for physicians. This article presents an overview of compensation arrangements across Canada for remote (telephone or electronic) and select in-person consults. It also shares key messages for payers and providers to inform future direction in this area.