Implementation of Inpatient Electronic Consultations During the COVID-19 Crisis and Its Sustainability Beyond the Pandemic: Quality Improvement Study

BACKGROUND

Limiting in-person contact was a key strategy for controlling the spread of the highly infectious novel coronavirus (COVID-19). To protect patients and staff from the risk of infection while providing continued access to necessary health care services, we implemented a new electronic consultation (e-consult) service that allowed referring providers to receive subspecialty consultations for patients who are hospitalized and do not require in-person evaluation by the specialist.

OBJECTIVE

We aimed to assess the impact of implementing e-consults in the inpatient setting to reduce avoidable face-to-face referrals during the COVID-19 pandemic.

METHODS

This quality improvement study evaluated all inpatient e-consults ordered from July 2020 to December 2022 at the University of California Irvine Medical Center. The impact of e-consults was assessed by evaluating use (eg, number of e-consults ordered), e-consult response times, and outcome of the e-consult requests (eg, resolved electronically or converted to the in-person evaluation of patient).

RESULTS

There were 1543 inpatient e-consults ordered across 11 participating specialties. A total of 53.5% (n=826) of requests were addressed electronically, without the need for a formal in-person evaluation of the patient. The median time between ordering an e-consult and a specialist documenting recommendations in an e-consult note was 3.7 (IQR 1.3-8.2) hours across all specialties, contrasted with 7.3 (IQR 3.6-22.0) hours when converted to an in-person consult (P<.001). The monthly volume of e-consult requests increased, coinciding with surges of COVID-19 cases in California. After the peaks of the COVID-19 crisis subsided, the use of inpatient e-consults persisted at a rate well above the precrisis levels.

CONCLUSIONS

An inpatient e-consult service was successfully implemented, resulting in fewer unnecessary face-to-face consultations and significant reductions in the response times for consults requested on patients who are hospitalized and do not require an in-person evaluation. Thus, e-consults provided timely, efficient delivery of inpatient consultation services for appropriate problems while minimizing the risk of direct transmission of the COVID-19 virus between health care providers and patients. The service also demonstrated its value as a tool for effective inpatient care coordination beyond the peaks of the pandemic leading to the sustainability of service and value.

Reduction of Environmental Pollutants and Travel Burden Through an Academic Medical Center-based Electronic Consultation Program

Background: We evaluated the impact of electronic consultation (eConsult) in reducing the environmental pollutants associated with health care delivery. Methods: A retrospective analysis of the eConsult data between July 2018 and December 2022 was extracted from the electronic health record (Epic). Travel time and mileage from the patient home to the academic medical center (AMC) were calculated along with fuel expenditure and greenhouses gas savings. Projected savings through the end of the decade were forecast using a random walk model. Results: A total of 15,499 eConsults were submitted to AMC specialist providers from community primary care providers. Completed eConsults (n = 11,590) eliminated the need for a face-to-face visit with a specialist provider, eliminating mileage, fuel, time, and pollutants associated with face to face visits. In-state travel distance saved was 310,858 miles, travel time saved was 5,491 h, with an associated fuel reduction of 13,575 gallons and $56,893 savings. This reduced greenhouse gas emissions by 128 metric tons of carbon dioxide, 0.022 tons of nitrogen oxide, 0.005 tons of methane, and 0.001 tons of nitrous oxide. Out of state travel distance saved was 188,346 miles with 2,842 h reduced travel time, and associated fuel reduction of 8,225 gallons and of $34,118. Reduced greenhouse gas emissions were equivalent to 77 metric tons of carbon dioxide, 0.0132 tons of nitrogen oxide, 0.0033 tons of methane, and 0.0007 tons of nitrous oxide. Conclusion: This study indicates that medical care provided through telehealth modalities reduces the environmental impact of pollutants associated with face to face visits.

Evaluating an Electronic Consultation Platform to Support Pediatric Primary Care Providers in Caring for Transgender and Nonbinary Adolescents

Background: An electronic consultation (e-consult) platform was implemented to support pediatric primary care providers (PCPs) in providing gender-affirming care to transgender and nonbinary (TNB) adolescents. Following implementation, a study was conducted to (1) explore how access to this e-consult platform impacts PCP confidence and referral patterns, (2) describe the content of questions, and (3) evaluate PCP's perspectives regarding platform usability. Methods: Following each submission, providers completed a 17-item survey. A total of 20 providers submitted 38 e-consults and 26 follow-up surveys between October 2021 and December 2022. Results: All PCPs reported a high overall value and increased confidence caring for TNB adolescents. Nearly one in five (19%) felt it allowed them to avoid submitting a specialty referral. Mean System Usability Scale score was 78.2 indicating good usability. Conclusion: This e-consult platform shows great promise in increasing PCP confidence providing gender-affirming care adolescents. More widespread utilization could help improve access to care and decrease specialty care referrals.

Impact of an Evidence-Based Prioritization System and Electronic Consultation in Early Diagnosis of Colorectal Cancer

(1) Background: Colorectal cancer (CRC) is one of the most common causes of cancer. Timely diagnosis is critical, with even minor delays impacting prognosis. Primary care providers face obstacles in accessing specialist care. This study investigates the impact of implementing an electronic consultation (eConsult) system combined with a specific prioritization system on CRC diagnosis delay and tumor staging. (2) Methods: The study analyzes 245 CRC patients from November 2019 to February 2022, comparing those referred before and after the eConsult system's implementation during the COVID-19 pandemic. Data on referral reasons, pathways, diagnosis delays, and staging were collected. Multivariate analysis aimed to identify independent risk factors for advanced staging at diagnosis. (3) Results: The eConsult system significantly reduced CRC diagnosis delay from 68 to 26 days. The majority of patients referred via eConsult presented with symptoms. Despite expedited diagnoses, no discernible difference in CRC staging emerged between eConsult and traditional referrals. Notably, patients from screening programs or with a positive fecal immunochemical test (FIT) experienced earlier-stage diagnoses. A positive FIT without symptoms and being a never-smoker emerged as protective factors against advanced-stage CRC. (4) Conclusions: This study highlights eConsult's role in reducing CRC diagnosis delay, improving diagnostic efficiency and prioritizing urgent cases, emphasizing FIT effectiveness.

Improving Access to Osteoporosis Specialists Using Electronic Consultations

OBJECTIVE

To identify the types of osteoporosis-related questions being asked by primary care providers (PCPs) and describe the impact of the advice provided by osteoporosis specialists using eConsult.

METHODS

We performed a cross-sectional study of osteoporosis-related eConsults submitted to endocrinologists between January 2018 and December 2020 on the Champlain eConsult BASE™ Service in Ontario, Canada. Each eConsult was coded according to clinical question and answer type through consensus between 2 authors, based on predetermined taxonomies. We analyzed eConsult utilization data, including response times, PCP satisfaction, and referral outcomes (collected via PCP surveys).

RESULTS

Of the 2,528 eConsults sent to endocrinologists during the study period, 408 (16%) were specific to osteoporosis. The most common questions asked by PCPs were regarding whether or not to start treatment (35%), the initial therapy choice (25%), and how often to complete bone mineral density scans (15%). The most common responses from specialists included recommendations for bone mineral density scanning (34%), recommendation to start therapy (24%), and recommendation to treat using a bisphosphonate without the dose specified (23%). The median response interval was 3.1 days. Most cases (84%) were resolved without requiring an in-person referral. Clear advice for a new course of action for PCPs to implement was provided in 54% of cases.

CONCLUSION

Osteoporosis eConsults provide timely access to valuable specialist advice while avoiding unnecessary face-to-face clinic visits. We identified commonly recurring osteoporosis questions asked by PCPs, which can be used to inform planning of future continuing professional development events.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Electronic consultation: A vision for primary care management

This article highlights the benefits of electronic-consultations and outlines steps for a primary care-centered approach to implementation. We include descriptions of traditional and electronic-consultation delivery models from the perspective of referring primary care provider. We describe five best practices for consultations regardless of modality, including clearly defined criteria that are best suited for electronic-consultation. Primary care teams must be equipped to explain the electronic-consultation process to the patient, including when and how results will be communicated. A successful electronic-consultation depends on clear questions and communication, flexibility in available data, a set-up that is easy-to-navigate and the ability to nimbly pivot if an alternative modality is needed. Electronic-consultation implementation may begin small with a single consult service and could include broader healthcare systems considerations including financial implications and service agreements. Based on increasing demand and increasing electronic-consultation familiarity and adoption, electronic-consultation will be a future necessity for primary care.

Electronic consultation use by advanced practice nurses in older adult care-A descriptive study of service utilization data

AIMS AND OBJECTIVES

To describe characteristics of service utilization by advanced practice nurses (APNs) employing an electronic consultation (eConsult) service in their care for older adults.

BACKGROUND

Canada's aging population is projected to place unprecedented demands on the healthcare system. APNs, which include clinical nurse specialists (CNSs) and nurse practitioners (NPs), are nurses with advanced knowledge who can independently provide age-appropriate care. eConsult is a secure web-based platform enabling asynchronous, provider-to-provider communication. APNs can send and receive eConsults to address patient-specific concerns.

METHODS

This is a retrospective analysis of eConsult utilization and user survey data for cases completed in 2019, reported in line with the STROBE guidelines. Eligible eConsults included those that had APN involvement (as a referrer or responder) and were concerning an older patient (≥65 years). Descriptive statistics were used to analyse service utilization and survey response data.

RESULTS

Of 430 eligible eConsults, 421 (97.9%) were initiated by NPs and the rest by physicians. 23 (5.3%) were received by a CNS, of which 14 (3.3%) involved an NP-to-CNS exchange. Median specialist response interval was 0.9 days. 53% of eConsults was for dermatology, haematology, cardiology, gastroenterology and endocrinology. 73% of eConsults avoided a face-to-face referral after the consultation. In 90% of eConsults, APNs rated the service as helpful and/or educational.

CONCLUSIONS

Through eConsult, APNs can collaborate with each other and physicians to access and provide a breadth of advice facilitating timely specialist-informed care for older patients, thus helping to alleviate some of the demands placed on the healthcare system.

RELEVANCE TO CLINICAL PRACTICE

There is an opportunity for APNs to further adopt eConsult into their clinical practice, and this can, in turn, support the integration of the APN role in the health workforce.

PATIENT OR PUBLIC CONTRIBUTION

Current APN eConsult users were involved in the study design and interpretation of results.

General Practitioner Use of e-Consultation to Consult Hospital Specialists: Interview Study to Obtain Physician's Perceptions About Digital Interprofessional Communication

BACKGROUND

In recent years, tasks have shifted from specialized hospital care to primary care, leading to both advantages and challenges for general practitioners (GPs). A frequently mentioned tool to face these challenges is e-consultation, a form of asynchronous digital interprofessional communication between GPs and hospital specialists.

OBJECTIVE

The objective of this study was to gain insight into GPs' and hospital specialists' views and experiences of e-consultation.

METHODS

We interviewed 47% (15/32) GPs and 53% (17/32) hospital specialists and performed a thematic analysis.

RESULTS

We found that both GPs and hospital specialists experience a positive effect on the quality of care and collaboration between GPs and hospital specialists. Positive effects were reported on the accessibility of care, efficiency of care, and relationship between the GP and the patient. Furthermore, communication between GP and hospital specialist became more efficient, and e-consultation offered educational value for the GP. Certain improvements are needed to further optimize e-consultation, regarding applicability, communication, and training purposes.

CONCLUSIONS

In the future, clinicians and policy makers can use the insights gained from this study to further optimize and implement e-consultation in clinical practice.

Efficacy and safety of an e-consult program for COVID-19 vaccine allergy concerns

Background: Although severe allergic reactions to coronavirus disease 2019 (COVID-19) vaccines are rare, fear of allergic reactions remains a major source of vaccine hesitancy. For concerned patients and providers alike, allergist consultation is recommended for further guidance on the risk of vaccination. The electronic consultation (e-consult) medium has the potential to make this guidance more widely accessible, thereby supporting vaccination efforts. Objective: To determine the safety and efficacy of an e-consult program for COVID-19 vaccine allergy concerns. Methods: We performed a retrospective analysis of a single-center COVID-19 vaccine allergy e-consult program. Data on demographics, allergy history, and outcomes after recommendations were gathered via review of the electronic medical record (EMR). Patients without EMR data available following the e-consult were called to inquire about vaccination status. Results: Our study included 64 patients, most of whom (51.6% [33/64]) had e-consults placed for second-dose concerns. E-consults were completed within 2 days for all patients. The most common recommendation was that patients receive any COVID-19 vaccination available (62.5%, [40/64]). Forty-one patients (64.1%) were vaccinated after receiving recommendations from an allergist, 11 of whom (26.8%) reported a vaccine reaction. Most of these reactions were nonallergic (9/11 [81.2%]). No anaphylactic events were reported. Conclusion: Results of our study suggest that e-consults were a safe and effective method of providing guidance with regard to COVID-19 vaccine risk in patients with concerns about allergic reactions. The efficiency of this medium, highlighted by the 2-day turnaround time in our study, has the potential to expand access to vaccine risk evaluations by board-certified allergist/immunologists.

Effect of Peer Benchmarking on Specialist Electronic Consult Performance in a Los Angeles Safety-Net: a Cluster Randomized Trial

BACKGROUND

Since the advent of COVID-19, accelerated adoption of systems that reduce face-to-face encounters has outpaced training and best practices. Electronic consultations (eConsults), structured communications between PCPs and specialists regarding a case, have been effective in reducing face-to-face specialist encounters. As the health system rapidly adapts to multiple new practices and communication tools, new mechanisms to measure and improve performance in this context are needed.

OBJECTIVE

To test whether feedback comparing physicians to top performing peers using co-specialists' ratings improves performance.

DESIGN

Cluster-randomized controlled trial PARTICIPANTS: Eighty facility-specialty clusters and 214 clinicians INTERVENTION: Providers in the feedback arms were sent messages that announced their membership in an elite group of "Top Performers" or provided actionable recommendations with feedback for providers that were "Not Top Performers."

MAIN MEASURES

The primary outcomes were changes in peer ratings in the following performance dimensions after feedback was received: (1) elicitation of information from primary care practitioners; (2) adherence to institutional clinical guidelines; (3) agreement with peer's medical decision-making; (4) educational value; (5) relationship building.

KEY RESULTS

Specialists showed significant improvements on 3 of the 5 consultation performance dimensions: medical decision-making (odds ratio 1.52, 95% confidence interval 1.08-2.14, p<.05), educational value (1.86, 1.17-2.96) and relationship building (1.63, 1.13-2.35) (both p<.01).

CONCLUSIONS

The pandemic has shed light on clinicians' commitment to professionalism and service as we rapidly adapt to changing paradigms. Interventions that appeal to professional norms can help improve the efficacy of new systems of practice. We show that specialists' performance can be measured and improved with feedback using aspirational norms.

TRIAL REGISTRATION

clinicaltrials.gov NCT03784950.

Evaluation of an Electronic Consultation Service for COVID-19 Care

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

HbA1c-Triggered Endocrinology Electronic Consultation for Type 2 Diabetes Management

BACKGROUND

Electronic consultation (eConsultation) offers a potential mechanism to increase access to specialty care, address knowledge gaps, and overcome therapeutic inertia in patients with type 2 diabetes (T2DM) being managed by primary care physicians (PCPs).

OBJECTIVE

To develop and implement a system to provide unsolicited endocrinology eConsult for T2DM patients with HbA1c 8.5-10.5% managed by PCPs.

DESIGN

Cluster-randomized matched cohort study with implementation evaluation.

PARTICIPANTS

PCPs affiliated with Massachusetts General Hospital (MGH).

INTERVENTIONS

Unsolicited endocrinology eConsultation.

MAIN MEASURES

The primary clinical outcome was mean change in HbA1c at 6 months. Secondary process outcomes included referral completion rate, prescription rates of glucose-lowering medications, differences in rate of other management recommendations, change in all glucose-lowering medications, and number of face-to-face endocrinology visits.

KEY RESULTS

161 PCPs were randomly assigned to intervention (n=81) and control (n=80) arms. eConsultations were triggered on 130 patients from intervention arm PCPs. Intervention arm patients had a 0.89 (SD 1.45) decrease in HbA1c compared to 0.69 (SD 1.32) decrease in the control arm (p=0.28). There were significant differences in prescribing of glucose-lowering medications between arms. There was a 19.3% increase in patients prescribed GLP-1 RA or SGLT2i in the intervention arm compared to a 6.9% increase in control (p=0.003). There were also significant increases in prescription rates of metformin (3.1% vs -3.1%, p=0.03) and sulfonylureas (1.5% vs -6.9%, p=0.03). At 6-month follow-up, the intervention arm had 13 in-person endocrinology visits compared to 29 (p=0.012) in the control arm. PCPs were more likely to accept recommendations regarding adherence to or dose adjustment of current medications than initiation of new medications.

CONCLUSIONS

The implementation of an unsolicited endocrinology eConsult system for patients with poorly controlled T2DM is feasible. Unsolicited eConsultation was associated with increased prescribing of glucose-lowering medications without significant difference in HbA1c.

TRIAL REGISTRATION

Clinicaltrials.gov registration: NCT03542084.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Improving primary care access to respirologists using eConsult

BACKGROUND

Patients and primary care providers (PCPs) can experience frustration about poor access to specialist care. The Champlain Building Access to Specialists through eConsultation (BASETM) is a secure online platform that allows PCPs to ask a clinical question to 142 different specialty groups. The specialist is expected to respond within 7 days.

METHODS

This is a retrospective review of the Champlain BASETM respirology eConsults from January 2017 to December 2018. The eConsults were categorized by types of questions asked by the referring provider and by the clinical content of the referral. Specialists' response time and time spent answering the clinical question were analyzed. Referring providers' close-out surveys were reviewed to assess the impact of the respirology eConsult service on traditional referral rates and clinical course of action.

RESULTS

Of the 26 679 cases submitted to the Champlain BASE TM eConsult service, 268 were respirology cases (1%). 91% were sent by family physicians and 9% by nurse practitioners. The median time to respond by specialists was 0.8 days, and the median time billed by specialists was 20 min. The most common topics were pulmonary nodules and masses (16.4%), cough (10.4%), infective problems (8.6%), chronic obstructive pulmonary disease (8.6%) and dyspnea Not Yet Diagnosed (NYD) (7.8%). The most common types of questions asked by PCP were related to investigations warranted (43.1% of cases), general management (17.5%), monitoring (12.6%), need for a respirology referral (12.3%) and drug of choice (6.3%). In 23% of cases, the PCP indicated they were planning to refer the patient for an in-person consultation but no longer needed to after receiving the eConsult advice (avoided referrals). On the other hand, in 13% of cases, the PCP was not going to refer but did after the eConsult (prompted referrals). The eConsult led to a new or additional clinical course of action by the PCP in 49% of cases. In 51% of cases, the PCP suggested the clinical topic would be well suited to a CME event.

CONCLUSIONS

Participation in eConsult services can improve timely access to respirologists while potentially avoiding clinic visits and significantly impacting referring PCPs clinical course of action. Using the most common clinical topics and types of questions for CME planning should be considered. Future research may include a cost analysis and provider perspectives on the role of eConsult in respirology care.

A Community-Health System Intervention to Improve the Primary Healthcare of Adults With Down Syndrome Through Electronic Consultations

Health systems often fail to tap the expertise of the developmental disabilities community support and service system. In this 9-month pilot health system-level quality improvement project, a multi-disciplinary team of physician, pharmacist, and disabilities advocate reviewed electronic records of patients with Down syndrome in advance of pre-scheduled appointments with their primary care physician (PCP) and generated 100 electronic consultations. Post-consultation chart review documented meaningful uptake of clinical recommendations, including screening for thyroid disease, celiac disease, and heart disease, pneumococcal vaccination, and screening physical examination for myelopathy. In addition to clinical recommendations regarding screening, diagnosis, and treatment, each consultation provided an average of eight tailored suggestions for potential community-based resources related to mental and behavioral health, recreation, socialization, and other relevant services and supports. "Push" multi-disciplinary electronic consultations in advance of primary care appointments enriched with input from disabilities community experts have the potential to improve the quality of health care provided to persons with developmental disabilities.

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

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

Perspectives of Health Care Providers in an Integrated Health Care Delivery Network on Inpatient Electronic Consultation (e-Consult) Use During the COVID-19 Pandemic

A large academic hospital system (Allegheny Health Network) introduced inpatient electronic consultations (e-Consults) during the COVID-19 crisis. Providers were invited to complete an anonymous survey on their perceptions of e-Consults. Descriptive statistics were used to analyze Likert-scale data. Cronbach’s alpha was used to assess internal consistency. Ninety-five providers completed the survey. Requesting and consulting providers agreed that e-Consults were easy to use (100% and 96.2%, respectively). Both groups also concurred that e-Consults either decreased or did not significantly impact their workload (81% and 74%, respectively) and that training was appropriate (77.8% and 86.8%, respectively). The advantage and barrier selected most frequently by specialists was “timelier completion of the consult versus in-person” and “inadequate information to complete the consult,” respectively. The disadvantage selected most frequently by requesting physicians was “lack of communication between providers.” Open-ended comments were categorized into themes. Concerns were raised regarding whether provider–provider communication via this platform offered enough information to make recommendations compared to traditional encounters. The perceived benefits and barriers of e-Consults should be further explored with the goal of improving patient care delivery and provider satisfaction.

Impact of Electronic Consultation on Timeliness and Guideline Concordance of Workups Leading to Thyroid Nodule Fine-Needle Aspiration Biopsy

OBJECTIVE

Electronic consultations (e-consults) are commonly used to obtain endocrinology input on clinical questions without a face-to-face visit, but sparse data exist on the resultant quality of care for specific conditions. We examined workups resulting in a thyroid nodule fine-needle aspiration (FNA) biopsy to investigate whether endocrinology e-consults were more timely and similarly guideline-concordant compared with endocrinology face-to-face visits and whether endocrinology e-consults were more guideline-concordant compared with workups without endocrinology input.

METHODS

We retrospectively reviewed charts of 302 thyroid FNA biopsies conducted in the Veterans Affairs health system between May 1, 2017, and February 4, 2020 (e-consult, n = 99; face-to-face visit, n = 100; no endocrinology input, n = 103). We used t tests to compare timeliness, χ² tests to compare the proportion of guideline-concordant workups, and multivariable linear and logistic models to control for demographic factors.

RESULTS

FNAs preceded by an endocrinology e-consult had more timely workups compared with those preceded by endocrinology face-to-face visits in terms of days elapsed between referral and FNA biopsy (geometric mean 44.7 days vs 61.7 days, P = .01). The difference in the summary measure of guideline concordance across groups was not statistically significant (P =.38).

CONCLUSION

E-consults were faster than face-to-face consults and similarly guideline-concordant compared with both face-to-face consults and no endocrinology input for workups resulting in FNA. Decisions about the appropriate use of e-consults for thyroid nodules should take into account these data while also considering the potential benefits of direct patient-endocrinologist interaction for complex situations.

Modernizing the Otolaryngology Referral Workflow: The Impact of Electronic Consultation

OBJECTIVES/HYPOTHESIS

To determine the impact of electronic consultation on the otolaryngology clinic workflow at our high-volume public hospital.

STUDY DESIGN

Retrospective Observational Study.

METHODS

This is a retrospective observational analysis study. Operational data regarding clinic volume, referral patterns, and scheduling efficiency were assessed over a 9-month period in 2018 prior to implementation of electronic consultation. The same data were collected for the 9-month period immediately following implementation of electronic consultation in 2019.

RESULTS

During the pre-implementation (pre-EC) period, 3,243 otolaryngology referrals were made as compared to 4,249 post-implementation (post-EC). 86% of referrals were scheduled for a clinic appointment pre-EC, compared to 61% post-EC (P < .00001) 24.5% of patients were evaluated within 30 days pre-EC compared to 53.6% post-EC (P < .00001). The average time to be seen by an otolaryngology provider declined from 60.8 days pre-EC to 42.8 days post-EC (P = .0029). There was a 50% decline in the percentage of appointments canceled by patients in the post-EC period as compared to pre-EC.

CONCLUSIONS

In our experience, implementation of electronic consultation significantly reduced both wait times for a clinic appointment and the percentage of no-show or canceled appointments. Electronic consultation may be a valuable tool in improving the efficiency and yield of the modern otolaryngology clinic.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E1792-E1796, 2021.

Primary Care Providers' Perspectives on the Ontario eConsult Program

Background: Electronic consultation (eConsult) allows asynchronous virtual communication between primary care providers (PCPs) and specialists regarding patient care. Introduction: The Ontario eConsult Program enables timely and equitable access to specialist advice for Ontarians. This study examines clinicians' perspectives and experiences with the program. Materials and Methods: We conducted an anonymous survey of PCPs registered for the Ontario eConsult Program. The survey ran from June to August 2019 and included questions on PCPs' experiences with the service, opinions on remuneration, and recommendations for enhancement. Results: One thousand two hundred fifty-six PCPs completed the survey (response rate of 16%). Seventy-eight percent had submitted an eConsult, of whom 67% were active users (i.e., had submitted ≥3 eConsults in the past 6 months). The majority of PCPs stated that their user experience was very good (57%) or good (31%), 74% agreed that eConsult improved their referral decision making, and 73% agreed that eConsult increased their ability to manage a broader array of diagnoses. Thirty-seven percent felt adequately compensated for using eConsult, 30% wanted higher rates of remuneration, and 31% were not compensated or were unaware of the fee code. Discussion: The majority of PCPs who use eConsult had positive experiences with the service. Nevertheless, improvements to further streamline the service's use, particularly through electronic medical record integration, were broadly cited as a desirable improvement. Conclusions: PCPs expressed an overall positive experience with the Ontario eConsult Program, citing prompt response times and improved care delivery as chief benefits.

Investigating the Acceptance of Video Consultation by Patients in Rural Primary Care: Empirical Comparison of Preusers and Actual Users

BACKGROUND

The ongoing digitalization in health care is enabling patients to receive treatment via telemedical technologies, such as video consultation (VC), which are increasingly being used by general practitioners. Rural areas in particular exhibit a rapidly aging population, with an increase in associated health issues, whereas the level of attraction for working in those regions is decreasing for young physicians. Integrating telemedical approaches in treating patients can help lessen the professional workload and counteract the trend toward the spatial undersupply in many countries. As a result, an increasing number of patients are being confronted with digital treatment and new forms of care delivery. These novel ways of care engender interactions with patients and their private lives in unprecedented ways, calling for studies that incorporate patient needs, expectations, and behavior into the design and application of telemedical technology within the field of primary care.

OBJECTIVE

This study aims to unveil and compare the acceptance-promoting factors of patients without (preusers) and with experiences (actual users) in using VC in a primary care setting and to provide implications for the design, theory, and use of VC.

METHODS

In total, 20 semistructured interviews were conducted with patients in 2 rural primary care practices to identify and analyze patient needs, perceptions, and experiences that facilitate the acceptance of VC technology and adoption behavior. Both preusers and actual users of VC were engaged, allowing for an empirical comparison. For data analysis, a procedure was followed based on open, axial, and selective coding.

RESULTS

The study delivers factors and respective subdimensions that foster the perceptions of patients toward VC in rural primary care. Factors cover attitudes and expectations toward the use of VC, the patient-physician relationship and its impact on technology assessment and use, patients' rights and obligations that emerge with the introduction of VC in primary care, and the influence of social norms on the use of VC and vice versa. With regard to these factors, the results indicate differences between preusers and actual users of VC, which imply ways of designing and implementing VC concerning the respective user group. Actual users attach higher importance to the perceived benefits of VC and their responsibility to use it appropriately, which might be rooted in the technological intervention they experienced. On the contrary, preusers valued the opinions and expectations of their peers.

CONCLUSIONS

The way the limitations and potential of VC are perceived varies across patients. When practicing VC in primary care, different aspects should be considered when dealing with preusers, such as maintaining a physical interaction with the physician or incorporating social cues. Once the digital intervention takes place, patients tend to value benefits such as flexibility and effectiveness over potential concerns.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Enabling patient-centred policy for electronic consultations: A qualitative analysis of discussions from a stakeholder meeting

INTRODUCTION

To support the expansion of a successful regional electronic consultation (eConsult) service, we hosted a full-day national eConsult Policy Think Tank, connecting health-services researchers, clinicians, patients and policymakers to discuss policy considerations related to eConsult. In this paper, we assess the discussion arising from the Think Tank to identify and understand the policy enablers and barriers to the national spread and scale of eConsult services across Canada.

METHODS

We conducted a constant comparative thematic analysis of stakeholder discussions captured during the Think Tank held in Ottawa, Canada, on 5 December 2016. Forty-seven participants attended and debated the following topic areas: (a) delivery of services and standards; (b) payment considerations; and (c) equitable access. The meeting was recorded, and verbatim transcripts were analysed using qualitative approaches.

RESULTS

We identified four themes affecting spread and scale of eConsult innovation from a policy perspective: (a) patient-centredness; (b) value; (c) regulation; and (d) considerations for spread and scale. Patient-centredness was viewed as a foundational principle upon which policy shifts should be guided. Active participation of patient partners transitioned the discussions and resulting recommendations from provider-centred to patient-centred thinking around the relevant policy issues, explicitly demonstrating the importance of patient involvement in healthcare policy decision making.

DISCUSSION

eConsult was viewed as a high-value, disruptive innovation with great potential to transform access to specialists in Canada. A patient-centred approach to policy change (and not just healthcare delivery) was identified as a novel yet critical enabler to the scale and spread of eConsult across Canada.

Barriers and Facilitators That Influence Telemedicine-Based, Real-Time, Online Consultation at Patients' Homes: Systematic Literature Review

Background

Health care providers are adopting information and communication technologies (ICTs) to enhance their services. Telemedicine is one of the services that rely heavily on ICTs to enable remote patients to communicate with health care professionals; in this case, the patient communicates with the health care professional for a follow-up or for a consultation about his or her health condition. This communication process is referred to as an e-consultation. In this paper, telemedicine services refer to health care services that use ICTs, which enable patients to share, transfer, and communicate data or information in real time (ie, synchronous) from their home with a care provider—normally a physician—at a clinical site. However, the use of e-consultation services can be positively or negatively influenced by external or internal factors. External factors refer to the environment surrounding the system as well as the system itself, while internal factors refer to user behavior and motivation.

Objective

This review aims to investigate the barriers and the facilitators that influence the use of home consultation systems in the health care context. This review also aims to identify the effectiveness of Home Online Health Consultation (HOHC) systems in improving patients’ health as well as their satisfaction with the systems.

Methods

We conducted a systematic literature review to search for articles—empirical studies—about online health consultation in four digital libraries: Scopus, Association for Computing Machinery, PubMed, and Web of Science. The database search yielded 2518 articles; after applying the inclusion and exclusion criteria, the number of included articles for the final review was 45. A qualitative content analysis was performed to identify barriers and facilitators to HOHC systems, their effectiveness, and patients’ satisfaction with them.

Results

The systematic literature review identified several external and internal facilitators and barriers to HOHC systems that were used in the creation of a HOHC framework. The framework consists of four requirements; the framework also consists of 17 facilitators and eight barriers, which were further categorized as internal and external influencers on HOHC.

Conclusions

Patients from different age groups and with different health conditions benefited from remote health services. HOHC via video conferencing was effective in delivering online treatment and was well-accepted by patients, as it simulated in-person, face-to-face consultation. Acceptance by patients increased as a result of online consultation facilitators that promoted effective and convenient remote treatment. However, some patients preferred face-to-face consultation and showed resistance to online consultation. Resistance to online consultation was influenced by some of the identified barriers. Overall, the framework identified the facilitators and barriers that positively and negatively influenced the uptake of HOHC systems, respectively.

Improved patient access and outcomes with the integration of an eConsult program (teledermatology) within a large academic medical center

BACKGROUND

Insurance, racial, and socioeconomic health disparities continue to pose significant challenges for access to dermatologic care. Studies applying teledermatology to increase access to underinsured individuals and ethnic minorities are limited.

OBJECTIVE

To determine how the implementation of a teledermatology program affects access to health care and patient outcomes.

METHODS

A cross-sectional evaluation was performed of all ambulatory dermatology referrals and electronic dermatology consultations (eConsults) at Ohio State University within a 25-month period.

RESULTS

Compared with ambulatory referrals, eConsults served more nonwhite patients (612 of 1698 [36.0%] vs 4040 of 16,073 [25.1%]; P < .001) and more Medicaid enrollees (459 of 1698 patients [27.0%] vs 3266 of 16,073 [20.3%]; P < .001). In addition, ambulatory referral patients were significantly less likely to attend their scheduled appointment compared with eConsult patients, as either "no-shows" (246 of 2526 [9.7%] vs 3 of 62 [4.8%]) or cancellations (742 of 2526 [29.4%] vs 8 of 62 [12.9%]; P = .003). There were fewer median days to extirpation for eConsult patients compared with ambulatory referral patients (interquartile range; 80.7 ± 79.8 vs 116.9 ± 86.6 days; P = .004).

CONCLUSION

Integrating dermatologic care through a telemedicine system can result in improved access for underserved patients through improved efficiency outcomes.

Scaling up eConsult for access to specialists in primary healthcare across four Canadian provinces: study protocol of a multiple case study

BACKGROUND

Canada has been referred to as the land of 'perpetual pilot projects'. Effective innovations often remain small in scale, with limited impact on health systems. Several innovations have been developed in Canada to tackle important challenges such as poor access to services and excessive wait times - one of the most promising innovations that has been piloted is eConsult, which is a model of asynchronous communication that allows primary care providers to electronically consult with specialists regarding their patients' medical issues. eConsult pilot projects have been shown to reduce wait times for specialist care, prevent unnecessary referrals and reduce health system costs. eConsult has been spread throughout Ontario as well as to certain regions in Manitoba, Quebec, and Newfoundland and Labrador. Our aim is to understand and support the scale-up process of eConsult in Ontario, Quebec, Manitoba, and Newfoundland and Labrador. Our specific objectives are to (1) describe the main components of eConsult relevant to the scale-up process in each province; (2) understand the eConsult scale-up process in each province and compare across provinces; (3) identify policy issues and strategies to scaling up eConsult in each province; and (4) foster cross-level and cross-jurisdictional learning on scaling up eConsult.

METHODS

We will conduct a qualitative multiple case study to investigate the scaling up of eConsult in four Canadian provinces using a grey literature review, key stakeholder interviews (10 interviews/province), non-participant observations, focus groups and deliberative dialogues. We will identify the main components of eConsult to be scaled up using logic models (obj. 1). Scaling up processes will be analysed using strategies adapted from process research (obj. 2). Policy issues and strategies to scale-up eConsult will be analysed thematically (obj. 3). Finally, a symposium will foster pan-Canadian learning on the process of scaling up eConsult (obj. 4).

DISCUSSION

This study will likely increase learning and support evidence-based policy-making across participating provinces and may improve the capacity for a pan-Canadian scale-up of eConsult, including in provinces where eConsult has not yet been implemented. This work is essential to inform how similar innovations can reshape our health systems in the evolving information age.

Implementation of psychiatric e-consultation in family medicine community health centers

Psychiatric E-consult is an innovative model of psychiatric consultation via the electronic health record. The project was completed as a quality improvement effort within a residency program in order to increase timely access to psychiatric consultation. Over 100 electronic consultations were requested in the initial 20 months of this project. Questions ranged from assistance with medication management, diagnostic clarification, to referral to outside resources. Findings from this quality improvement project include that the e-consultation model enhanced primary care physicians’ and associated primary care health professionals’ management of behavioral issues, increased behavioral health knowledge, and subjectively improved patient care.

Evolving Toward Shared HIV Care Using the Champlain BASE eConsult Service

Background. Electronic consultation (eConsultation) is a potential strategy to improve access to specialist expertise and facilitate collaborative care models. The Champlain BASE eConsult service allows for asynchronous communication between primary care providers (PCP) and specialists on a secure, web-based system. HIV experts accessible include HIV physician specialists, HIV pharmacists, and social workers with expertise in HIV. Objective. This study aims to describe the use, value, and utility of this eConsultation service in the care of people living with HIV and to characterize the common question types and clinical topics asked by PCPs. Methods. We analyzed the data from eConsults sent to the HIV specialty group in Ontario’s Champlain Local Health Integration Network between February 2015 and December 2017. Usage data and close-out survey responses were analyzed using descriptive statistics, eConsults were classified using a predefined list of validated taxonomy, and a thematic analysis was performed on the consultation logs to identify common clinical themes. Results. Among the 46 eConsults, the most common question type related to drug treatment (58.7%, n = 27) and management (19.6%, n = 9). The main clinical themes involved the care of significant complexities in people living with HIV, such as comorbidities and drug interactions, and suggestions of coordinated patient care. As well, eConsult was used for advice regarding pre-exposure prophylaxis for HIV-negative patients at risk of HIV infection. PCPs highly valued the eConsult service (average rating 4.8/5). Conclusion. Overall, this study demonstrates that eConsult provides an efficient and valuable service to PCPs caring for patients living with or at risk for HIV by improving access to HIV specialists and facilitating the delivery of team-based comprehensive care.

Pathology perspective on gynaecologic malignancy screening questions in electronic consultation

INTRODUCTION

The electronic consultation service, eConsult, is an asynchronous web-based platform for provider-to-provider consultation with specialists. This study described the utilization of eConsult by primary care providers to obtain specialist opinion in gynaecologic malignancy screening, with a specific focus on pathology-related inquiries.

METHODS

This is a cross-sectional retrospective review of eConsults submitted to obstetrics/gynaecology between September 2011 and December 2016. All questions pertaining to gynaecologic cancer screening and their pathologies were included. Each question was classified based on a pre-determined taxonomy. The mandatory primary care providers' exit surveys were analysed to determine eConsult's influence on patient care, primary care providers' referral patterns, primary care providers' satisfaction and educational value.

RESULTS

In total, 1,357 electronic consultations were submitted to the obstetrics and gynaecology service during the study period, of which 329 met inclusion criteria. Indications for a screening test based on patient risk factors made up 36% of consults pertaining to gynaecologic malignancy screening and 17% were inquiries about test intervals based on previous results. Primary care providers pointed out gaps in current screening guidelines. In total, 38% of primary care providers reported the eConsult service helped avoid a specialist referral, whereas 47% of primary care providers received new or additional courses of action. Pathology report interpretation accounted for 5% of eConsults and 6% of primary care providers wished for clarification of incidental pathology findings.

CONCLUSION

This study uncovered areas of uncertainty among primary care providers regarding gynaecologic cancer screening and gaps in current clinical guidelines. Furthermore, the role of pathology consultants in an eConsult platform is explored and may be extrapolated into practice.

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.

Shared Care: Using an Electronic Consult Form to Facilitate Primary Care Provider-Specialty Care Coordination

OBJECTIVE

The quality of children's health is compromised by poor care coordination between primary care providers (PCPs) and specialists. Our objective was to determine how an electronic consultation and referral system impacts referral patterns and PCP-specialist communication.

METHODS

The primary care clinic at Boston Children's Hospital piloted an electronic referral and consultation system with the neurology and gastroenterology departments from April 1, 2014, to October 31, 2016. PCPs completed an electronic consult form, and if needed, specialists replied with advice or facilitated expedited appointments. Specialist response times, referral rates, wait times, and completion rates for specialty visits were tracked. PCPs and specialists also completed a survey to evaluate feasibility and satisfaction.

RESULTS

A total of 82 PCPs placed 510 consults during the pilot period. Specialists responded to 88% of requests within 3 business days. Eighteen percent of specialty visits were deferred and 21% were expedited. Wait times for specialty appointments to both departments significantly decreased, from 48 to 34 days (P < .001), and completion rates improved from 58% to 70% (P < .01), but referral volumes remained stable (25 per month to 23 per month; P = .29). Most PCPs said the Shared Care system facilitated better communication with specialists (89%) and enabled them to provide superior patient care (92%). Specialists reported that the system required a minimal amount of time and enabled them to educate PCPs and triage referrals.

CONCLUSIONS

Implementation of an electronic referral and consultation system was feasible and provided timely access to specialty care, but did not affect referral volume. This system could serve as a model for other health care organizations and specialties.

Improving access to specialists in remote communities: a cross-sectional study and cost analysis of the use of eConsult in Nunavut

Background: Residents of remote communities face inequities in access to specialists, excessive wait times, and poorly coordinated care. The Champlain BASE^TM (Building Access to Specialists through eConsultation) service facilitates asynchronous communication between primary care providers (PCP) and specialists. The service was extended to several PCPs in Nunavut in 2014.

Objective: To (1) describe the use of eConsult services in Nunavut, and (2) conduct a costing evaluation.

Design: A cross-sectional study and cost analysis of all eConsult cases submitted between August 2014 and April 2016.

Results: PCPs from Nunavut submitted 165 eConsult cases. The most popular specialties were dermatology (16%), cardiology (8%), endocrinology (7%), otolaryngology (7%), and obstetrics/gynaecology (7%). Specialists provided a response in a median of 0.9 days (IQR=0.3–3.0, range=0.01–15.02). In 35% of cases, PCPs were able to avoid the face-to-face specialist visits they had originally planned for their patients. Total savings associated with eConsult in Nunavut are estimated at $180,552.73 or $1,100.93 per eConsult.

Conclusions: The eConsult service provided patients in Nunavut’s remote communities with prompt access to specialist advice. The service’s chief advantage in Canada’s northern communities is its ability to offer electronic access to a breadth of specialties far greater than could be supported locally. Our findings suggest that a territory-wide adoption of eConsult would generate enormous savings.

Sustainability of a Primary Care-Driven eConsult Service

PURPOSE

Excessive wait times for specialist appointments pose a serious barrier to patient care. To improve access to specialist care and reduce wait times, we launched the Champlain BASE (Building Access to Specialists through eConsultation) eConsult service in April 2011. The objective of this study is to report on the impact of our multiple specialty eConsult service during the first 5 years of use after implementation, with a focus on growth and sustainability.

METHODS

We conducted a cross-sectional study of all eConsult cases submitted between April 1, 2011 and April 30, 2016, and measured impact with system utilization data and mandatory close-out surveys completed at the end of each eConsult. Impact indicators included time interval to obtain specialist advice, effect of specialist advice on the primary care clinician's course of action, and rate of avoidance of face-to-face visits.

RESULTS

A total of 14,105 eConsult cases were directed to 56 different medical specialty groups, completed with a median response time of 21 hours, and 65% of all eConsults were resolved without a specialist visit. We observed rapid growth in the use of eConsult during the study period: 5 years after implementation the system was in use by 1,020 primary care clinicians, with more than 700 consultations taking place per month.

CONCLUSIONS

This study presents the first in-depth look at the growth and sustainability of the multispecialty eConsult service. The results show the positive impact of an eConsult service and can inform other regions interested in implementing similar systems.

Monoclonal gammopathies: Electronic subspecialty consultation

IMPORTANCE

Electronic consultation (e-consult) is an important component of care for patients in the Veterans Health Administration who require subspecialty consultation but not urgent face-to-face evaluation. Monoclonal gammopathy of undetermined significance (MGUS) is a common reason for e-consult. While often benign, MGUS requires careful evaluation and persistent surveillance over time.

OBJECTIVE

To identify areas to improve MGUS care delivery by e-consult.

METHODS

We performed a retrospective review of our e-consult database and identified a cohort of 152 MGUS patients triaged for e-consult over a 5-year period (2010-2014).

RESULTS

The median time to completion of an e-consult was 2 days. Ninety-six percent of MGUS e-consults had a hemoglobin >10 g/dL, and 90% had a creatinine <2 mg/dL. While the majority of e-consults were low risk, paraprotein surveillance varied over time and tracked with consult utilization. With a median follow-up of 44 months, there were 6 documented progression events, representing a mean rate of progression of 1% per year.

CONCLUSIONS

E-consult is a helpful mechanism for the evaluation of MGUS, reducing the need for outpatient appointments. However, timely risk stratification and persistent surveillance over time are critical for e-consult to work well.

Adopting innovation in gynaecology: The introduction of e-consult

OBJECTIVE

To describe the development of an e-consultation service as part of the triaging and grading process of referrals and to report on the efficacy and safety of such a service.

METHODS

All gynaecology e-consults in the study period June 2015 to March 2016 were retrospectively reviewed. The outcomes of interest were the initial reduction in first face-to-face hospital visits, and the rate of re-referrals. Acute admission for the same reason, a subsequent diagnosis of underlying (pre)-malignancy, or patient death from the condition related to the index referral were selected as measures for patient safety.

RESULTS

Seven thousand and forty-two (7042) referrals were made to the gynaecology service in the 10 month study period. After exclusion of referrals to colposcopy and the early pregnancy clinic, 4738 e-referrals remained. Of these, 1013 referrals (21.4%) were triaged for an e-consult. One hundred and forty-seven patients (14.5%) with an initial e-consult were re-referred within 6 months for the same condition. The reduction in face-to-face contacts was 18.2% (866/4738). No death and/or acute admission for the same reason as stated in the initial referral occurred among the patients with e-consultation and none were later diagnosed with an underlying (pre)-malignancy.

CONCLUSION

E-consultation was effective at reducing the number of first outpatient face-to-face contacts without notable compromise of the quality of care or patient safety. E-consultation allows specialists to provide expert clinical guidance, management and support to the referring provider when appropriate. Topics for further study include patient benefits and satisfaction, and further assessment of the social, economic and financial impacts on all parties involved.

Who Uses eConsult? Investigating Physician Characteristics Associated with Usage (and Nonusage)

BACKGROUND

The Champlain BASE™ eConsult Service was developed in a Local Health Integration Network (LHIN) in Ontario, Canada in 2010 to reduce wait times and improve access to specialist care. The service allows primary care providers to receive advice from specialists via a secure electronic platform without necessarily requiring a face-to-face consultation.

INTRODUCTION

As of 2015, over half of the LHIN's family physicians were registered and trained to use the service. However, 24% of registrants never went on to submit a case. The purpose of this study is to examine the demographic characteristics associated with usage.

MATERIALS AND METHODS

Usage data for the pool of physicians registered between January 1, 2011 and September 30, 2015 were linked to physician characteristics retrieved from the College of Physicians and Surgeons of Ontario database. Probit regressions were estimated to determine characteristics associated with usage.

RESULTS

Neither sex, being an international medical school graduate-documented predictors of electronic medical records adoption-nor proximity to specialists were found to explain usage. Only length of time in practice was found to be predictive. Being out of medical school an additional 10 years was estimated to decrease the probability of ever using eConsult by five percentage points (p < 0.01).

CONCLUSION

Lower use by veteran physicians may reflect their lower need for services like eConsult given their well-established specialist networks, or their greater confidence in practicing medicine. Future work should explore the reasons and barriers for not registering, or not using eConsult, with an aim toward increasing the appropriate use of this cost-effective and innovative service.

Electronic consultation system demonstrates educational benefit for primary care providers

Background Electronic consultation systems allow primary care providers to receive timely speciality expertise via iterative electronic communication. The use of such systems is expanding across the USA with well-documented high levels of user satisfaction. We characterise the educational impact for primary care providers of a long-standing integrated electronic consultation and referral system. Methods Primary care providers' perceptions of the educational value inherent to electronic consultation system communication and the impact on their ability to manage common speciality clinical conditions and questions were examined by electronic survey using five-point Likert scales. Differences in primary care providers' perceptions were examined overall and by primary care providers' speciality, provider type and years of experience. Results Among 221 primary care provider participants (35% response rate), 83.9% agreed or strongly agreed that the integrated electronic consultation and referral system provided educational value. There were no significant differences in educational value reported by provider type (attending physician, mid-level provider, or trainee physician), primary care providers' speciality, or years of experience. Perceived benefit of the electronic consultation and referral system in clinical management appeared stronger for laboratory-based conditions (i.e. subclinical hypothyroidism) than more diffuse conditions (i.e. abdominal pain). Nurse practitioners/physician assistants and trainee physicians were more likely to report improved abilities to manage specific clinical conditions when using the electronic consultation and/or referral system than were attending physicians, as were primary care providers with ≤10 years experience, versus those with >20 years of experience. Conclusions Primary care providers report overwhelmingly positive perceptions of the educational value of an integrated electronic consultation and referral system. Nurse practitioners, physician assistants, trainee physicians and less-experienced primary care providers report the greatest clinical educational benefit, particularly for conditions involving lab-based diagnosis and management.

Improving access to otolaryngology-head and neck surgery expert advice through eConsultations

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.

Patient and provider perspectives on the design and implementation of an electronic consultation system for kidney care delivery in Canada: a focus group study

OBJECTIVES

We assessed stakeholder perceptions on the use of an electronic consultation system (e-Consult) to improve the delivery of kidney care in Alberta. We aim to identify acceptability, barriers and facilitators to the use of an e-Consult system for ambulatory kidney care delivery.

METHODS

This was a qualitative focus group study using a thematic analysis design. Eight focus groups were held in four locations in the province of Alberta, Canada. In total, there were 72 participants in two broad stakeholder categories: patients (including patients' relatives) and providers (including primary care physicians, nephrologists, other care providers and policymakers).

FINDINGS

The e-Consult system was generally acceptable across all stakeholder groups. The key barriers identified were length of time required for referring physicians to complete the e-Consult due to lack of integration with current electronic medical records, and concerns that increased numbers of requests might overwhelm nephrologists and lead to a delayed response or an unsustainable system. The key facilitators identified were potential improvement of care coordination, dissemination of best practice through an educational platform, comprehensive data to make decisions without the need for face-to-face consultation, timely feedback to primary care providers, timeliness/reduced delays for patients' rapid triage and identification of cases needing urgent care and improved access to information to facilitate decision-making in patient care.

CONCLUSIONS

Stakeholder perceptions regarding the e-Consult system were favourable, and the key barriers and facilitators identified will be considered in design and implementation of an acceptable and sustainable electronic consultation system for kidney care delivery.

Electronic consultation systems: worldwide prevalence and their impact on patient care-a systematic review

BACKGROUND

Many health organizations are exploring the potential of electronic consultation (eConsult) services to address excessive wait times for specialist care.

OBJECTIVE

To understand the effectiveness, population impact and costs associated with implementation of eConsult services.

METHODS

We conducted a systematic review using a narrative synthesis approach. We searched Medline and Embase from inception to August 2014 (English/French). Included studies focused on communication between primary care providers and specialist physicians through an asynchronous, directed communication over a secure electronic medium. We assessed study quality with a modified version of the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies. We synthesized the results using the Triple Aim framework.

RESULTS

A total of 36 studies were included. Most were set in the USA and focused on single-specialty services (most commonly dermatology). Population health outcomes included patient populations, adoption/utilization and provider attitudes. Providers cited timely advice from specialists, good medical care, confirmation of diagnoses and educational benefits. No clinical outcomes were reported. Patient experience of care was generally positive, with quick specialist response times (4.6 hours to 3.9 days), avoided referrals (12-84%) and satisfaction ranging from 78% to 93%. System costs were reported in only seven studies using different outcome measures and settings, limiting comparability.

CONCLUSION

Though eConsult systems are highly acceptable for patients and providers and deliver improved access to specialist advice, gaps remain regarding eConsult's impact on population health and system costs. To achieve optimized health system performance, eConsult services must include specialty services as determined by community needs and further explore cost-effectiveness.

Disruptive Innovation: Implementation of Electronic Consultations in a Veterans Affairs Health Care System

BACKGROUND

Electronic consultations (e-consults) offer rapid access to specialist input without the need for a patient visit. E-consult implementation began in 2011 at VA Boston Healthcare System (VABHS). By early 2013, e-consults were available for all clinical services. In this implementation, the requesting clinician selects the desired consultation within the electronic health record (EHR) ordering menu, which creates an electronic form that is pre-populated with patient demographic information and allows free-text entry of the reason for consult. This triggers a message to the requesting clinician and requested specialty, thereby enabling bidirectional clinician-clinician communication.

OBJECTIVE

The aim of this study is to examine the utilization of e-consults in a large Veterans Affairs (VA) health care system.

METHODS

Data from the electronic health record was used to measure frequency of e-consult use by provider type (physician or nurse practitioner (NP) and/or physician assistant), and by the requesting and responding specialty from January 2012 to December 2013. We conducted chart reviews for a purposive sample of e-consults and semi-structured interviews with a purposive sample of clinicians and hospital leaders to better characterize the process, challenges, and usability of e-consults.

RESULTS

A total of 7097 e-consults were identified, 1998 from 2012 and 5099 from 2013. More than one quarter (27.56%, 1956/7097) of the e-consult requests originated from VA facilities in New England other than VABHS and were excluded from subsequent analysis. Within the VABHS e-consults (72.44%, 5141/7097), variability in frequency and use of e-consults across provider types and specialties was found. A total of 64 NPs requested 2407 e-consults (median 12.5, range 1-415). In contrast, 448 physicians (including residents and fellows) requested 2349 e-consults (median 2, range 1-116). More than one third (37.35%, 1920/5141) of e-consults were sent from primary care to specialists. While most e-consults reflected a request for specialist input to a generalist's question in diagnosis or management in the ambulatory setting, we identified creative uses of e-consults, including requests for face-to-face appointments and documentation of pre-operative chart reviews; moreover, 7.00% (360/5141) of the e-consults originated from our sub-acute and chronic care inpatient units. In interviews, requesting providers reported high utility and usability. Specialists recognized the value of e-consults but expressed concerns about additional workload.

CONCLUSIONS

The e-consult mechanism is frequently utilized for its initial intended purpose. It has also been adopted for unexpected clinical and administrative uses, developing into a "disruptive innovation" and highlighting existing gaps in mechanisms for provider communication. Further investigation is needed to characterize optimal utilization of e-consults within specialty and the medical center, and what features of the e-consult program, other than volume, represent valid measures of access and quality care.

Improving Access to Specialist Care for an Aging Population

Objective: The objective of the study is to examine the Champlain. BASETM (Building Access to Specialists through eConsultation) eConsult service's impact on access to care for older persons. Methods: We conducted a cross-sectional analysis of all eConsult cases submitted between April 15, 2011, and July 31, 2015, in which the patient was above the age of 65 years. Study data consisted of utilization data collected automatically by the service and responses to surveys completed by primary care providers at the conclusion of all eConsult cases. Results: A total of 1,796 cases were submitted for older persons between April 15, 2011, and July 31, 2015, accounting for 21.3% of all cases submitted during the study period. Specialists responded to cases in a median of 0.8 days. In 94% of cases, providers rated eConsult as having great or excellent value for themselves and their patients. Sixty-eight percent of eConsults did not require a face-to-face visit; only 28% of all cases resulted in a referral. Discussion: As they suffer from higher than average rates of comorbid disease and mobility issues, older persons stand to benefit from shorter wait times and better access to care, which the eConsult service can provide.

A comparison of referral patterns to a multispecialty eConsultation service between nurse practitioners and family physicians: The case for eConsult

PURPOSE

To explore referral patterns of nurse practitioners (NPs) and family physicians (FPs) using an electronic consultation (eConsult) service, and assess their perspectives on the service's value to their patients and themselves.

DATA SOURCES

A mixed methods study including a cross-sectional analysis of utilization data drawn from all eConsults completed from April 15, 2011 to September 30, 2014, and a content analysis of NP survey responses completed from January 1 to September 30, 2014.

CONCLUSIONS

A total of 4260 eConsults were included in the cross-sectional analysis (3686 from FPs and 574 from NPs). In our sample, NPs directed more cases to dermatology and fewer cases to cardiology and neurology (p < .0001) than did FPs, and were more likely to report that an eConsult led to new advice for a new or additional course of action (62.8% vs. 57.5%) and less likely to report it resulted in an avoided referral (35.5% vs. 41.8%, p = .005). NPs reported slightly higher levels of perceived value of eConsults for their patients and themselves.

IMPLICATIONS FOR PRACTICE

Differences in use and impact of eConsult exist between NPs and FPs. NPs value the service highly for their patients and themselves. The service reduces potential inequities related to outdated payment and scope of practice policies.