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.

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.

Using electronic consultation (eConsult) to identify frailty in provider-to-provider communication: a feasibility and validation study.

BACKGROUND: Frailty is a complex age-related clinical condition that increases vulnerability to stressors. Early recognition of frailty is challenging. While primary care providers (PCPs) serve as the first point of contact for most older adults, convenient tools for identifying frailty in primary care are lacking. Electronic consultation (eConsult), a platform connecting PCPs to specialists, is a rich source of provider-to-provider communication data. Text-based patient descriptions on eConsult may provide opportunities for earlier identification of frailty. We sought to explore the feasibility and validity of identifying frailty status using eConsult data. METHODS: eConsult cases closed in 2019 and submitted on behalf of long-term care (LTC) residents or community-dwelling older adults were sampled. A list of frailty-related terms was compiled through a review of the literature and consultation with experts. To identify frailty, eConsult text was parsed to measure the frequency of frailty-related terms. Feasibility of this approach was assessed by examining the availability of frailty-related terms in eConsult communication logs, and by asking clinicians to indicate whether they can assess likelihood of frailty by reviewing the cases. Construct validity was assessed by comparing the number of frailty-related terms in cases about LTC residents with those about community-dwelling older adults. Criterion validity was assessed by comparing clinicians' ratings of frailty to the frequency of frailty-related terms. RESULTS: One hundred thirteen LTC and 112 community cases were included. Frailty-related terms identified per case averaged 4.55 ± 3.95 in LTC and 1.96 ± 2.68 in the community (p < .001). Clinicians consistently rated cases with ≥ 5 frailty-related terms as highly likely of living with frailty. CONCLUSIONS: The availability of frailty-related terms establishes the feasibility of using provider-to-provider communication on eConsult to identify patients with high likelihood of living with this condition. The higher average of frailty-related terms in LTC (versus community) cases, and agreement between clinician-provided frailty ratings and the frequency of frailty-related terms, support the validity of an eConsult-based approach to identifying frailty. There is potential for eConsult to be used as a case-finding tool in primary care for early recognition and proactive initiation of care processes for older patients living with frailty.

Web-Based Asynchronous Tool to Facilitate Communication Between Primary Care Providers and Cancer Specialists: Pragmatic Randomized Controlled Trial.

BACKGROUND: Cancer poses a significant global health burden. With advances in screening and treatment, there are now a growing number of cancer survivors with complex needs, requiring the involvement of multiple health care providers. Previous studies have identified problems related to communication and care coordination between primary care providers (PCPs) and cancer specialists. OBJECTIVE: This study aimed to examine whether a web- and text-based asynchronous system (eOncoNote) could facilitate communication between PCPs and cancer specialists (oncologists and oncology nurses) to improve patient-reported continuity of care among patients receiving treatment or posttreatment survivorship care. METHODS: In this pragmatic randomized controlled trial, a total of 173 patients were randomly assigned to either the intervention group (eOncoNote plus usual methods of communication between PCPs and cancer specialists) or a control group (usual communication only), including 104 (60.1%) patients in the survivorship phase (breast and colorectal cancer) and 69 (39.9%) patients in the treatment phase (breast and prostate cancer). The primary outcome was patient-reported team and cross-boundary continuity (Nijmegen Continuity Questionnaire). Secondary outcome measures included the Generalized Anxiety Disorder Screener (GAD-7), Patient Health Questionnaire on Major Depression, and Picker Patient Experience Questionnaire. Patients completed the questionnaires at baseline and at 2 points following randomization. Patients in the treatment phase completed follow-up questionnaires at 1 month and at either 4 months (patients with prostate cancer) or 6 months following randomization (patients with breast cancer). Patients in the survivorship phase completed follow-up questionnaires at 6 months and at 12 months following randomization. RESULTS: The results did not show an intervention effect on the primary outcome of team and cross-boundary continuity of care or on the secondary outcomes of depression and patient experience with their health care. However, there was an intervention effect on anxiety. In the treatment phase, there was a statistically significant difference in the change score from baseline to the 1-month follow-up for GAD-7 (mean difference -2.3; P=.03). In the survivorship phase, there was a statistically significant difference in the change score for GAD-7 between baseline and the 6-month follow-up (mean difference -1.7; P=.03) and between baseline and the 12-month follow-up (mean difference -2.4; P=.004). CONCLUSIONS: PCPs' and cancer specialists' access to eOncoNote is not significantly associated with patient-reported continuity of care. However, PCPs' and cancer specialists' access to the eOncoNote intervention may be a factor in reducing patient anxiety. TRIAL REGISTRATION: ClinicalTrials.gov NCT03333785; https://clinicaltrials.gov/ct2/show/NCT03333785.

Use of eConsult to enhance genetics service delivery in primary care: A multimethod study.

PURPOSE: Electronic consultation (eConsult) is a freely-available secure online platform connecting primary care providers (PCPs) to geneticists. Our purpose was to determine whether eConsult is effective in improving genetics service delivery in primary care. METHODS: PCP questionnaires regarding eConsult's utility, geneticists' tracking form assessments of eConsult type and appropriateness, and geneticists' interviews on implementing eConsult were carried out. RESULTS: In 2 regions of Ontario, Canada, from January 2019 to June 2020, there were 305 genetics eConsults. For 169 (55%), PCPs indicated receiving good advice for a new course of action; for 110 (36%), referral was now avoided; and for 261 (86%), eConsult was perceived valuable for patient management. Of the 131 geneticist-completed tracking forms, cancer questions were most common (68, 52%). For 63 (48%), geneticists disagreed/strongly disagreed PCPs should know the answer to the referral question. From the interview data, it was observed that geneticists described eConsult positively and suggested how it might improve access and efficiencies if integrated into genetic service delivery. Dealing with eConsults virtually could reduce waitlists, and suggesting appropriate investigations for PCPs could improve efficiencies. CONCLUSION: eConsult offers a potential solution for receiving timely genetics advice and avoiding unnecessary patient referrals, however, greater effect on access and wait times will need systematic integration into PCP and geneticist practice.

Cancer specialist perspectives on implementing an online communication system with primary care providers.

Context: The Canadian Team to Improve Community-Based Cancer Care along the Continuum (CanIMPACT) is a group of researchers, primary care providers (PCPs), cancer specialists, patients and caregivers working to improve cancer care coordination between PCPs and cancer specialists. Previous research by CanIMPACT and others has identified problems related to communication, coordination, and continuity of care. Objective: Describe findings from qualitative interviews with cancer specialists on implementation of an online communication system with PCPs. Study Design: Hybrid type I effectiveness-implementation study that included a qualitative research component and a pragmatic RCT. Setting: Ottawa Hospital Cancer Program and primary care practices in the Champlain region. Population Studied: Cancer specialists (nurses, medical and radiation oncologists, program administrators). Interviews conducted with 12 cancer specialists. Intervention: Cancer-specific adaptation of Champlain BASE™ eConsult, an online communication system for PCPs and cancer specialists called "eOncoNote". For patients receiving treatment for prostate or breast cancer, cancer specialists had an opportunity to participate in eOncoNote discussion with PCP for 4-6 months; for breast and colorectal cancer survivors, the eOncoNote discussion lasted for 1 year post discharge to the patient's PCP. Results: Cancer specialists described limited PCP involvement in cancer care while patients received active treatment, with one-way communication and notes being "sent into a vacuum". There was more communication with PCPs regarding patients with metastatic disease, comorbid conditions, after patients have completed treatment, or during palliative care. Patients and caregivers play a critical role in coordinating cancer care, helping to facilitate coordination. Lack of access to the same electronic medical record (EMR) among healthcare providers poses a barrier to cancer care coordination. eOncoNote had the potential to be useful tool but it was not used extensively. Conclusions: Accessing eOncoNote as a separate system was challenging to incorporate into the workflow, and cancer specialists highlighted the need for integration with their EMR. eOncoNote did not affect information sharing with PCPs, as there was limited uptake within primary care.

Teledermatology Utilization and Integration in Residency Training Over the COVID-19 Pandemic.

BACKGROUND: During the 2019 Coronavirus (COVID-19) pandemic, the Division of Dermatology, University of Ottawa, adapted pre-existing local healthcare infrastructures to provide increased provider-to-provider teledermatology services as well as integrated teledermatology into the dermatology residency training program. OBJECTIVES: (1) To assess the differences in utilization of provider-to-provider teledermatology services before and during the COVID-19 pandemic; and (2) to assess dermatology resident and faculty experiences with the integration of teledermatology into dermatology residency training at the University of Ottawa. METHODS: We conducted a cross-sectional analysis comparing provider-to-provider teledermatology consults submitted to dermatologists from April 2019 to October 2019 pre-pandemic with the same period during the pandemic in 2020. Two different questionnaires were also disseminated to the dermatology residents and faculty at our institution inquiring about their perspectives on teledermatology, education, and practice. RESULTS: The number of dermatologists completing consults, the number of providers submitting a case to Dermatology, and the number of consults initiated all increased during the pandemic period. Ninety-one percent of residents agreed that eConsults and teledermatology enhanced their residency education, enabled continuation of training during the pandemic, and that eConsult-based training should be incorporated into the curriculum. Ninety-six percent of staff incorporated a virtual dermatology practice model, and one-third used teledermatology with residents during the pandemic. Most staff felt there was value in providing virtual visits in some capacity during the pandemic. CONCLUSIONS: Our study confirms that the use of teledermatology services continues to increase accessibility during the pandemic. Teledermatology enhances the education and training of residents and will be incorporated into dermatology residency programs.

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.

Electronic Consultation Between Primary Care Providers and Radiologists.

OBJECTIVE. The purpose of this study was to assess the use of an electronic consultation platform to connect primary care providers and radiologists and provide opportunities for valuable consultation regarding diagnostic imaging in patients, as well as to identify opportunities for targeted education surrounding high-yield radiology topics. MATERIALS AND METHODS. A retrospective review was performed of consultations conducted using the electronic platform from September 2012 to January 2017. Consultations were classified by subspecialty (neuroradiology, thoracic, abdominal, musculoskeletal, or pediatric radiology), question type (workup, surveillance, education, specialist referral query, discharge, or other), anatomy, and pathology. Feedback surveys were completed by primary care providers after each consultation to evaluate timeliness, value, and impact on patient care. RESULTS. A total of 302 consultations were reviewed. Subspecialty breakdown was as follows: abdominal, 94/302 (31%); neuroradiology, 74/302 (25%); musculoskeletal, 61/302 (20%); thoracic, 56/302 (19%); and pediatric, 17/302 (6%). The majority of consultations pertained to patient workup (112/302 [37%]), surveillance of imaging findings (95/302 [31%]), and provider education (48/302 [16%]). Cystic lesions (38/302 [13%]), pain (24/302 [8%]), and bone lesions (21/302 [7%]) were the most queried conditions. Patient management was altered in 167 cases (55%), and unnecessary testing was avoided in 84 (28%). Providers rated the perceived value of the electronic consultation system as excellent in 227 cases (75%). CONCLUSION. The electronic consultation system allowed primary care providers to easily consult with radiologists, was perceived as high value by primary care providers, resulted in altered patient management, and avoided unnecessary imaging tests. We identified follow-up imaging of cystic lesions and imaging workup of pain in patients as opportunities for continuing medical education for primary care providers.

Insights into Specialists' Participation and Self-Reported Billing Times in a Multispecialty eConsult Service: Correlating Response Length with Outcomes and Satisfaction.

Background: Electronic consultation (eConsult) services have been shown to reduce the need for face-to-face consultations. The largest expense is remunerating the specialist. Introduction: The Champlain BASE™ eConsult service remunerates specialists based on their self-reported billing time. It is important for funders of eConsult systems to understand and plan for specialist remuneration. This study examined specialists' time commitments pertaining to eConsult, identified factors that affect their self-reported billing time, and determined if self-reported billing time is associated with changes in primary care provider (PCP) behavior. Methods: A cross-sectional study of eConsults was completed between January 1 and December 31, 2017. Data were collected automatically by the service and through mandatory closeout surveys. Logistic regressions identified associations between specialists' self-reported billing time and volume of cases completed, PCP characteristics, specialty group, impact on PCP behaviors, and PCP satisfaction. Results: A total of 11,985 cases met inclusion criteria. Self-reported billing time was <5 min in 18.3% of cases, 5-10 min in 35.6%, 10-15 min in 27.3%, 15-20 min in 11.3%, and >20 min in 7.5%. Self-reported billing time demonstrated significant variation between specialty groups. Cases with higher self-reported billing time were more likely to lead to new/additional course of action for PCPs (p ≤ 0.0001), resulted in fewer referrals (p ≤ 0.0001), and received higher rankings for helpfulness and educational value (p ≤ 0.0001). Discussion: A thorough understanding of when and how specialists respond to eConsult cases is critical to ensuring the service's long-term sustainability. Examining these factors and their impact on PCP behaviors helps us to better understand the service's overall value and serve to inform the structure of its remuneration process. Conclusions: Specialists' self-reported billing time varies by specialty group and is associated with changes in PCP behavior and satisfaction. Further research is needed to identify what factors influence self-reported billing time and how eConsult can be best incorporated into clinicians' workflows.

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

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

Toll-like receptors signaling network in pre-eclampsia: An updated review.

Toll-like receptors (TLRs) are innate immune cells receptors. They are expressed on leukocytes, epithelial cells, and more particularly on placental immune cells and chorion trophoblast. Upregulation of innate immune response occurs during normal pregnancy, but its excessive activity is involved in the pathology of pregnancy complications including pregnancy-induced hypertension and pre-eclampsia (PE). The recent studies about the overmuch inflammatory responses and aberrant placentation are associated with increased expression of TLRs in PE patients. This review has tried to focus on the relationship between some activities of TLRs and the risk of preeclampsia development.

Specialist Perspectives on Ontario Provincial Electronic Consultation Services.

BACKGROUND: Wait times to access specialist care remain a huge frustration for patients and providers. In Ontario, two electronic consultation (eConsult) services provide prompt, secure access to specialist advice: The Champlain Building Access to Specialists through eConsultation (BASE™) eConsult-managed service, and the Ontario Telemedicine Network (OTN). INTRODUCTION: To gain a broader understanding of specialists' perspectives providing eConsult services, we surveyed all specialists actively participating in either platform. METHODS: A 34-item web questionnaire focused in four key areas (experience with the service, ideas for provincial expansion, recommendations for enhancements to the service, and specialist demographics) was sent to all specialists who had completed at least one eConsult on either service. RESULTS: There was a 66% (114/172) response rate for BASE and a 47% (61/130) response rate for OTN. The most frequent motivations for participating in eConsult were innovative patient care (58% and 69%), opportunity to reduce wait times (45% and 54%), and opportunity to communicate directly with primary care providers (41% and 51%). Most specialists agreed that eConsult is feasible, results in improved communication between providers, and can be integrated into their clinical workflow without difficulty. Fifty-two percent of OTN specialists and 49% of BASE specialists agreed that they were appropriately compensated for answering eConsults. DISCUSSION: Specialists participate in eConsult services to improve communication with primary care, provide innovative care, and reduce wait times. CONCLUSIONS: As eConsult services expand across regions and provinces, the provider perspectives and experiences should be used to evaluate the benefits of eConsult and impact on provider satisfaction.

Nanocurcumin restores aberrant miRNA expression profile in multiple sclerosis, randomized, double-blind, placebo-controlled trial.

In the current study, we aimed to identify nanocurcumin effects on microRNAs (miRNAs) in the peripheral blood of patients with relapsing-remitting multiple sclerosis (RRMS). We intended to investigate the expression pattern of these miRNAs in experimental settings in vivo. The expression levels of the selected 27 miRNAs known to be involved in the regulation of immune responses were analyzed in 50 RRMS patients and 35 healthy controls. The miRNA expression profiles were investigated by quantitative PCR (qPCR) at baseline and after 6 months of nanocurcumin therapy. Our data revealed that the expression of a number of microRNAs including miR-16, miR-17-92, miR-27, miR-29b, miR-126, miR-128, miR-132, miR-155, miR-326, miR-550, miR-15a, miR-19b, miR-106b, miR-320a, miR-363, miR-31, miR-150, and miR-340 is regulated by nanocurcumin. The results of the current work indicate that nanocurcumin is able to restore the expression pattern of dysregulated miRNAs in MS patients. We discovered that some miRNAs are deregulated in untreated patients compared with healthy controls and nanocurcumin-treated patients. This is a new finding that might represent the potential contribution of these miRNAs to MS pathogenesis. Taken together, these data provide novel insights into miRNA-dependent regulation of the function of B and T cells in MS disease and enrich our understanding of the effects mediated by a therapeutic approach that targets B and T cells.

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.

Just a click away: exploring patients' perspectives on receiving care through the Champlain BASETM eConsult service.

Background: Excessive wait times for specialist care can have a substantial negative impact on health outcomes. The Champlain BASETM (Building Access to Specialists through eConsultation) eConsult service based in Ottawa, Canada has demonstrated the ability to improve patients' access to specialist care. Objective: We interviewed patients who were treated using eConsult in order to explore their attitudes towards the service and their experiences of receiving care via the service. Methods: We conducted a thematic analysis of patient interviews using a constant comparative approach. Patients whose primary care providers used the eConsult service in their care were contacted by telephone between June 2015 and January 2016 and completed 15-min semi-structured interviews. Results: Of 43 contacted participants, 30 completed interviews (70%). Over half of all respondents (n = 16) reported receiving a follow-up call or appointment within 1 week, and 26 stated that eConsult was useful in their case. Participants unanimously agreed that eConsult was an acceptable way to access specialist care, and 29 stated that they would ask their primary care provider to use eConsult on their behalf in the future. Three themes emerged from the thematic analysis of patient comments: access, acceptability of eConsult and strengthened role of the primary care provider. Conclusions: Patients expressed acceptance for eConsult as a model for improving access to specialist care, had largely positive experiences with it as a model of care delivery, and supported its use in their future care.

The use of electronic consultations is associated with lower specialist referral rates: a cross-sectional study using population-based health administrative data.

Background: The referral-consultation process can be difficult to navigate. Electronic consultations (eConsults) can help streamline referrals by facilitating inter-provider communication. Objective: We evaluated the potential effect of eConsult on specialist referral rates in Ontario among family physicians providing comprehensive care. Methods: We conducted a retrospective 1:3 matched cohort study examining total referrals and referrals to all available medical specialties from primary care providers between 1 April 2014 and 31 March 2015. We used multivariable random effects Poisson regression analysis to compare referral rates between eConsult and non-eConsult users while adjusting for relevant patient and provider characteristics. Referral rates were expressed per physician, per 100 patients and per 100 patient encounters. Results: There were 113197 referrals across all medical specialties made by 119 eConsult physicians and 352 matched controls. Referral rates per physician were significantly lower in the eConsult group for all specialty groupings [unadjusted rate ratio (RR) = 0.87, 95% confidence interval (CI) = 0.80-0.95; adjusted RR = 0.92, 95% CI = 0.85-1.00]. Referral rates per patient were lower among eConsult physicians (unadjusted RR = 0.91, 95% CI = 0.84-0.98) but this difference was not statistically significant after adjustment (adjusted RR = 0.96, 95% CI = 0.90-1.02). No statistically significant difference was observed when referrals were expressed per 100 patient encounters. Conclusion: This is the first Canadian study to examine the potential effect of eConsult on overall referrals at a population level. Our findings demonstrate that using eConsult service is associated with fewer referrals from primary to specialist care, with considerable potential for cost savings to our single-payer system.

eCONSULTS TO ENDOCRINOLOGISTS IMPROVE ACCESS AND CHANGE PRIMARY CARE PROVIDER BEHAVIOR.

OBJECTIVE: To describe the impact of an eConsult service on access to endocrinologists along with its influence on changing primary care provider (PCP) course of action and referral behaviors. METHODS: Established in 2011, the Champlain BASE (Building Access to Specialist Care via eConsult) service allows PCPs to access specialist care in lieu of traditional face-to-face referrals. We conducted a cross-sectional study of eConsult cases submitted to endocrinologists by PCPs between April 15, 2011 and January 31, 2015. Usage data and PCP responses to a mandatory closeout survey were analyzed to determine eConsult response times, PCP practice behavior, referral outcomes, and provider satisfaction. Each eConsult was coded according to clinical topic and question type based on established taxonomies. RESULTS: A total of 180 PCPs submitted 464 eConsults to endocrinology during the study period. Specialist median response time was 7 hours, with 90% of responses occurring within 3 days. PCPs received a new or additional course of action in 62% of submitted cases. An unnecessary face-to-face referral was avoided in 44% of all eConsults and in 67% of cases where the PCP initially contemplated requesting a referral. Over 95% of cases were rated at least 4 out of 5 in value for PCPs and their patients. CONCLUSION: The use of eConsult improves access to endocrinologists by providing timely, highly rated practice-changing clinical advice while reducing the need for patients to attend face-to-face office visits. ABBREVIATIONS: BASE = Building Access to Specialist Advice through eConsult PCP = primary care physician UCSF = University of California San Francisco.

Utilization, benefits, and impact of an e-consultation service across diverse specialties and primary care providers.

BACKGROUND: Access to specialist advice remains a barrier for primary care providers (PCPs) and their patients. Virtual consultations have been used to expedite access. There are few studies demonstrating the utilization and impact of such services. We established a regional e-consultation service that was used across a wide range of specialty services and PCPs. MATERIALS AND METHODS: We prospectively collected all e-consultations submitted from April 1, 2011 to June 30, 2012. Utilization data collected included number of e-consultations submitted, specialist response, and time required for the specialist to complete the e-consultation. Perceived benefit to the PCPs and their patients and the impact on care delivery were determined from a close-out survey. RESULTS: Fifty-nine PCPs submitted 406 e-consultations to 16 specialty services. The specialist provided an answer without requesting further information in 89% of cases, with >90% of cases taking <15 min for the specialist to complete. Seventy-five percent of cases were answered in <3 days. The service was perceived as highly beneficial to providers and patients in>90% of cases. In 43% of submitted cases a traditional referral was originally contemplated but was now avoided. CONCLUSIONS: We successfully implemented an e-consultation service across diverse PCPs and specialty services that was highly valued. Almost half of referrals submitted would have required a face-to-face consultation if the service had not been available. Thus e-consultation has tremendous potential for improving access to specialist advice in a much more timely manner than the traditional referral-consultation process.

Ten steps to establishing an e-consultation service to improve access to specialist care.

There is dissatisfaction among primary care physicians, specialists, and patients with respect to the consultation process. Excessive wait times for receiving specialist services and inefficient communication between practitioners result in decreased access to care and jeopardize patient safety. We created and implemented an electronic consultation (e-consultation) system in Eastern Ontario to address these problems and improve the consultation process. The e-consultation system has passed through the proof-of-concept and pilot study stages and has effectively reduced unnecessary referrals while receiving resoundingly positive feedback from physician-users. Using our experience, we have outlined the 10 steps to developing an e-consultation service. We detail the technical, administrative, and strategic considerations with respect to (1) identifying your partners, (2) choosing your platform, (3) starting as a pilot project, (4) designing your product, (5) ensuring patient privacy, (6) thinking through the process, (7) fostering relationships with your participants, (8) being prepared to provide physician payment, (9) providing feedback, and (10) planning the transition from pilot to permanency. In following these 10 steps, we believe that the e-consultation system and its associated improvements on the consultation process can be effectively implemented in other healthcare settings.