Search

Background: Electronic consultation (eConsult) programs are crucial components of modern healthcare that facilitate communication between primary care providers (PCPs) and specialists. eConsults between PCPs and specialists. They also provide a unique opportunity to use real-world patient scenarios for reflective learning as part of professional development. However, tools that guide and document learning from eConsults are limited. The purpose of this study was to develop and pilot two eConsult reflective learning tools (RLTs), one for PCPs and one for specialists, for those participating in eConsults., Methods: We performed a four-phase pragmatic mixed methods study recruiting PCPs and specialists from two public health systems located in two countries: eConsult BASE in Canada and San Francisco Health Network eConsult in the United States. In phase 1, subject matter experts developed preliminary RLTs for PCPs and specialists. During phase 2, a Delphi survey among 20 PCPs and 16 specialists led to consensus on items for each RLT. In phase 3, we conducted cognitive interviews with three PCPs and five specialists as they applied the RLTs on previously completed consults. In phase 4, we piloted the RLTs with eConsult users., Results: The RLTs were perceived to elicit critical reflection among participants regarding their knowledge and practice habits and could be used for quality improvement and continuing professional development., Conclusion: PCPs and specialists alike perceived that eConsult systems provided opportunities for self-directed learning wherein they were motivated to investigate topics further through the course of eConsult exchanges. We recommend the RLTs be subject to further evaluation through implementation studies at other sites., (© 2023. The Author(s).)

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., Competing Interests: Conflict of Interest C.L. and E.K. are cofounders of the Champlain BASE eConsult Service, but they have no commercial interest in the service and do not retain any proprietary rights. As Coexecutive Directors of the Ontario eConsult Centre of Excellence, they receive salary support from the Ontario Ministry of Health. E.K. answers occasional electronic consultations (less than 1 per month) as a specialist through the service for which she is reimbursed. All other authors report no conflicts of interest., (Copyright © 2022 American College of Medical Genetics and Genomics. Published by Elsevier Inc. All rights reserved.)

Background: Increasing strain on public health resources in Canada, in particular with respect to accessing specialist care, necessitates the exploration of alternative models of care. The aim of this study was to assess the efficacy of electronic consultation (eConsult) in providing orthopedic surgery specialist service to patients in the Champlain Local Health Integration Network (LHIN) of Ontario., Methods: This was a cross-sectional review of all 564 Champlain LHIN orthopedic surgery referral requests received via the Champlain Building Access to Specialist service through the eConsult (BASE) system in 2017. Primary outcome measures were impact on primary care provider (PCP) referral pattern and time to receive orthopedic consultation., Results: eConsult prevented unnecessary in-person consultation 64% of the time, while PCP referral decisions were modified 51% of the time. Of all eConsults, 94% were rated as valuable to PCPs in their practice and 97% of eConsults resulted in actionable advice. eConsults took an average of 14.5 minutes of specialist time to complete, and the mean time from referral to response was 3.7 days., Conclusion: The eConsult system spares unnecessary consultation to orthopedic surgery; catches important referrals that would have otherwise been missed; saves time for patients, PCPs and orthopedic surgeons; and improves efficiency in a socialized health care system., Competing Interests: Competing interests: Erin Keely reports employment as the co-executive director of the Ontario eServices team, which is funded by the Ontario Ministry of Health, for oversight into eConsult programs. Dr. Keely uses the system and receives compensation, approximately once per month. Clare Liddy and Erin Keely are co-executive directors of the Ontario eServices program. No other competing interests were declared., (© 2022 CMA Impact Inc. or its licensors.)

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.

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., (© The Author(s) 2021. Published by Oxford University Press on behalf of International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Electronic consultations (eConsults) and referrals (eReferrals) are being implemented to improve access to specialist care. As eConsult and eReferral services rely on a roster of engaged specialists for their success, careful attention must be paid to how the term "specialist" is defined, what criteria inform specialists recruitment, and how quality of specialist responses can be monitored and maintained. Key considerations, informed by our personal experiences, review of best practice documents, international frameworks of specialists roles and competencies and a focused small group discussion among providers, health service planners and researchers for each of these important elements is discussed. Individuals participating in services should receive clear expectations around their role and responsibilities and be provided equitable access assuming they meet the necessary requirements. Training and feedback should be provided to ensure timely, quality responses. Paying attention to these key elements will reduce confusion, frustration and disengagement amongst specialists and ensure high quality responses.

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.

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.

Objective: To calculate patient wait times for specialist care using data from primary care clinics across Canada., Design: Retrospective chart audit., Setting: Primary care clinics., Participants: A total of 22 primary care clinics across 7 provinces and 1 territory., Main Outcome Measures: Wait time 1, defined as the period between a patient's referral by a family physician to a specialist and the visit with said specialist., Results: Overall, 2060 referrals initiated between January 2014 and December 2016 were included in the analysis. The median national wait time 1 was 78 days (interquartile range [IQR] of 34 to 175 days). The shortest waits were observed in Saskatchewan (51 days; IQR = 23 to 101 days) and British Columbia (59 days; IQR = 29 to 131 days), whereas the longest were in New Brunswick (105 days; IQR = 43 to 242 days) and Quebec (104 days; IQR = 36 to 239 days). Median wait time 1 varied substantially among different specialty groups, with the longest wait time for plastic surgery (159 days; IQR = 59 to 365 days) and the shortest for infectious diseases (14 days; IQR = 6 to 271 days)., Conclusion: This is the first national examination of wait time 1 from the primary care perspective. It provides a picture of patient access to specialists across provinces and specialty groups. This research provides decision makers with important context for developing programs and policies aimed at addressing the largely ignored stage of the wait time continuum from the time of referral to eventual appointment time with the specialist., (Copyright© the College of Family Physicians of Canada.)

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.

Introduction: Poor communication between health professionals can compromise patient safety, yet specialists rarely receive feedback on their written communication. Although worldwide implementation of electronic consultation (eConsult) services is rising rapidly, little is known about the features of effective communication when specialists provide online advice to primary care providers (PCP). To inform efforts to ensure and maintain high-quality communication via eConsult, we aim to identify features of high-quality eConsult advice to incorporate into an assessment tool that can provide specialists with feedback on their correspondence., Methods: Initial items for the tool were generated by PCPs and specialists using the nominal group technique (NGT). Invited PCPs were above-median eConsult users between July 2016 and June 2017. Specialists were purposively recruited to represent the range of available specialties. Participants individually wrote down items they felt should be included in the tool. A moderator with consensus group expertise then led a round-robin discussion for each item. Items were ranked anonymously and included if highly-ranked by over 70% of participants., Results: Eight PCPs (six family physicians, two nurse practitioners) and three specialists (dermatology, hematology, pediatric orthopedics) produced 49 items that were refined to 14 after group discussion and two rounds of ranking. Highly-ranked items encompassed specific, up-to-date, patient-individualized, and practical advice that the PCP could implement., Discussion: Features of high-quality eConsult correspondence derived from consensus methods highlight similarities and differences between face-to-face consultation letters and eConsult. Our findings could be used to inform feedback and education for eConsult specialists on their advice to PCPs.

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.

With the rising demand for clinical genetics services, it is a challenge for clinical geneticists to meet the needs of patients and referring primary care providers in a timely way, using current models of genetics health care delivery. One method of providing primary care providers with greater access to clinical genetics expertise is through an electronic consultation (eConsult) service. We describe here a pilot project of a clinical genetics eConsult service that our genetics centre in Eastern Ontario, Canada provided, using the Champlain Building Access to Specialists through eConsultation (BASE) TM web-based application. We analyzed 111 genetics eConsults submitted by primary care providers to a single clinical geneticist over a 28-month time period. More than half (54%) of the eConsult questions were regarding (1) hereditary cancer and (2) genetic syndromes, with the remainder encompassing a wide variety of clinical genetics topics. We avoided a referral to the Genetics clinic for an in-person appointment for 30% of the eConsult cases, based on a contemplated referral rate to Genetics clinic of 72% prior to eConsult and a planned referral rate to Genetics clinic of 42% following all eConsults. Primary care providers rated the eConsult service of high value to themselves and also to their patients. This pilot service supports the potential of an eConsultation service to create a stronger and more dynamic link between clinical genetics and primary care providers, which may lead to better patient care.

Objective: To examine the process of implementing an electronic consultation (eConsult) service and evaluate its impact along key metrics outlined by the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework., Design: Cross-sectional study., Setting: Clinics using eConsult in four provinces across Canada: Alberta, Manitoba, Quebec and Newfoundland and Labrador., Participants: All eConsult cases submitted in four participating provinces were included., Intervention: The eConsult service is a secure online application that allows primary care providers and specialists to communicate regarding a patient's care. We measured the impact using system utilisation data and mandatory close-out surveys completed at the end of each eConsult., Main Outcome Measures: Implementation progress and impact were examined using the five categories outlined by the RE-AIM framework: reach, effectiveness, adoption, implementation and maintenance., Results: Four provinces provided data from different periods, ranging from 4 years (Alberta) to 10 months (Manitoba). Total cases completed ranged from 96 (Manitoba) to 6885 (Alberta). Newfoundland had the largest menu of available specialties (n=35), while Alberta and Quebec had the smallest (n=22). The most frequently requested groups varied across provinces, with only endocrinology appearing in the top five for all provinces. The average specialist response time ranged from 3 days (Manitoba) to 16.7 days (Alberta). Between 54% (Newfoundland) and 66% (Manitoba) of cases resulted in new or additional information. Primary care providers avoided completing referrals they had originally considered in 36% (Newfoundland) to 53% of cases (Manitoba), while only between 27 % (Quebec) and 29% (Newfoundland) of cases resulted in a referral. In every province, services demonstrated higher rates of usage in their last quarter of data than their first., Conclusions: eConsult was successfully implemented in four new provinces across Canada. Implementation strategies and scope varied, but services demonstrated substantial consistency on several key metrics, most notably on whether new information was learnt and impact on decision to refer., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Excessive wait times for specialist care are a significant issue in many countries. Electronic consultation (eConsult) services have demonstrated the ability to improve access to specialist care. In this article, we evaluated the implementation of a successful eConsult service in a new jurisdiction to test its generalizability., Methods: We used a multimethod approach to evaluate the Champlain Building Access to Specialists through eConsultation eConsult service's implementation in the South East Local Health Integration Network of Ontario, Canada. Our quantitative analysis drew on use data collected automatically by the service and survey responses completed between February 1, and June 15, 2017. For our qualitative analysis, we conducted a thematic analysis of 3 focus groups with primary care providers and specialists participating in the pilot study., Results: Forty-nine out of the potential 219 primary care providers in Kingston submitted 301 cases to 24 specialty groups during the study period. Monthly case volume grew from 15 in February to 90 in May. The most frequently requested specialties included dermatology (n = 59), cardiology (n = 27), and gastroenterology (n = 26). Specialists responded in a median of 2 days, and a referral was originally contemplated but ultimately avoided in 40% of cases. Providers spoke positively of the service, citing high levels of satisfaction, enhanced collegiality, increased trust, and improved patient flow., Conclusions: Adoption of the eConsult service in the South East Local Health Integration Network was successful. The service exceeded all adoption targets, and the number of completed cases demonstrated a consistently upward trend, suggesting continued growth beyond the study's duration. The service's rate of adoption, high levels of satisfaction, and use data similar to other regions all demonstrate eConsult's generalizability., Competing Interests: Conflict of interest: none declared., (© Copyright 2019 by the American Board of Family Medicine.)

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., (©Justin Joschko, Erin Keely, Rachel Grant, Isabella Moroz, Matthew Graveline, Neil Drimer, Clare Liddy. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 21.12.2018.)

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.

Wait times for many chronic pain programs in Canada range from 6 months to 2 years. This project sought to determine the interest of primary care providers (PCPs) in using an electronic consult system for patient(s) waiting for a pain consultation. This cross-sectional study was conducted at the pain clinic of a Canadian tertiary academic health sciences center. Participants were PCPs who had submitted a referral to this clinic. Referrals received between April 1, 2012, and March 31, 2014, were reviewed to determine their appropriateness for eConsult, and a letter providing information about eConsult and encouraging its use was sent to the referring PCP. Of the 585 referrals that were reviewed, 227 were appropriate for eConsult. Fifty-one (26%) of the 194 PCP responses received were positive. Technologies like eConsult may help address the growing demand for specialist advice. In addition to facilitating response to specific questions, the bidirectional nature of eConsult permits its use for educating PCPs about chronic pain treatment. Given that almost one third of responding PCPs indicated an interest in eConsult, its potential reach is vast. Additional study is needed to understand barriers to PCP acceptance and use of eConsult and the uptake of advice given.

Background: This study explores the effectiveness of an electronic consultation (eConsult) service between primary care providers and psychiatry, and the types and content of the clinical questions that were asked., Methods: This is a retrospective eConsult review study. All eConsults directed to Psychiatry from July 2011 to January 2015 by Primary care providers were reviewed. Response time and the amount of time reported by the specialist to answer each eConsult was analyzed. Each eConsult was also categorized by clinical topic and question type in predetermined categories. Mandatory post-eConsult surveys for primary care providers were analyzed to determine the number of traditional consults avoided and to gain insight into the perceived value of eConsults., Results: Of the 5597 eConsults, 169 psychiatry eConsults were completed during the study period. The average response time for a specialist to a primary care provider was 2.3 days. Eighty-seven percent of clinical responses were completed by the psychiatrist in less than 15 min. The primary care providers most commonly asked clinical questions were about depressive and anxiety disorders. 88.7% of PCPs rated the eConsult service a 5 (excellent value) or 4., Conclusions: This study indicates that an eConsult psychiatry service has tremendous potential to improve access to psychiatric advice and expand the capacity to treat mental illness in primary care. Future research may include follow-up with PCPs regarding the implementation of specialist advice.

Background: Health technology solutions are too often implemented without a true understanding of the system-level problem they seek to address, resulting in excessive costs, poor adoption, ineffectiveness, and ultimately failure. Before implementing or adopting health care innovations, stakeholders should complete a thorough assessment to ensure effectiveness and value. In this article, we describe how to evaluate the impact of a health technology innovation through the 4 dimensions of care outlined by the Quadruple Aim Framework, using our experience with the Champlain Building Access to Specialists through eConsultation (BASE) eConsult service as a case example., Methods: A descriptive overview of data was collected between April 1, 2011, and August 31, 2017, using 4 dimensions of care outlined by the Quadruple Aim Framework: patient experience, provider experience, costs, and population health. Findings were drawn from use data, primary care provider closeout surveys, surveys/interviews with patients and provider, and costing data., Results: Overall, patients have received access to specialist advice within days and find the advice useful in 86% of cases. Provider experience is very positive, with satisfaction ratings of high/very high value in 94% of cases. The service cost a weighted average of $47.35/case, compared with $133.60/case for traditional referrals. In total, 1,299 primary care providers have enrolled in the service, completing 28,838 cases since 2011. Monthly case volumes have grown from an average of 13 cases/month in 2011 to 969 cases/month in 2016., Conclusions: The eConsult service has been widely adopted in our region and is currently expanding to new jurisdictions across Canada. However, although we successfully demonstrated eConsult's impact on patient experience, provider satisfaction, and reducing costs, we met several challenges in evaluating its impact on population health. More work is needed to evaluate eConsult's impact on key population health metrics (eg, mortality, morbidity, and system use). Efforts to conduct such evaluations are underway., Competing Interests: Conflict of interest: none declared., (© Copyright 2018 by the American Board of Family Medicine.)

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 Author 2017. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: To describe the use and benefits of an innovative eConsult service to improve access to rheumatologists., Methods: There were 225 eConsults directed to rheumatology that were categorized by type of question and effect on face-to-face referral rates., Results: The median response time by the rheumatologists was 1.9 days. Clinical questions included drug treatment (34%), diagnosis (26%), or management (14%). Osteoporosis was the most common diagnosis (22%), followed by pain in multiple joints (11%), and polyarthritis (10%). A face-to-face referral was avoided in 38% of cases., Conclusion: There are clinical questions that can be answered quickly by an eConsult, improving access to rheumatologists.

Introduction: Excessive wait times for chronic pain are associated with significant reductions in quality of life and worse health outcomes. The Champlain BASE ™ (Building Access to Specialists through eConsultation) eConsult service can improve access to specialist care for patients with chronic pain by facilitating electronic communication between primary care providers (PCPs) and specialists. We explored the content of eConsult cases sent to chronic pain specialists to identify the major themes emerging from exchanges between PCPs and specialists regarding patients with chronic pain., Methods: We conducted a thematic analysis of eConsult cases submitted to chronic pain specialists between April 1, 2011 and October 31, 2014, using a constant comparison approach., Results: PCPs submitted 128 cases to chronic pain specialists during the study period. The study team coded 48 cases before data saturation was reached. PCPs sought advice for treating patients with chronic pain arising from a range of medical problems, and who frequently struggled with issues of mental health, substance dependence, and social complexity. Specialists responded with advice on pain management and treatment, directed PCPs to published guidelines and community resources, and validated the PCPs' frustration or concerns. Specialists provided instruction on safe opioid prescribing and how to identify and manage potential cases of substance dependence., Conclusion: Providing care to patients with chronic pain is a challenge for PCPs, who often experience frustration at their inability to provide a definitive solution for patients. Specialists offered invaluable feedback not only through guidance and advice, but also with sympathy and encouragement., Competing Interests: Conflict of interest: none declared., (© Copyright 2017 by the American Board of Family Medicine.)

Objective: To identify the proportion and evaluate the content of eConsults (electronic consultations) in which the Champlain BASE (Building Access to Specialists through eConsultation) eConsult process prompted a referral to a specialist that was not originally contemplated by the primary care provider (PCP)., Design: Cross-sectional study of all eConsults submitted between April 15, 2011, and January 31, 2015., Setting: Champlain Local Health Integration Network, a large health region in eastern Ontario., Participants: Primary care providers registered to use the Champlain BASE eConsult service., Main Outcome Measures: Answers from a close-out survey-completed by PCPs at the conclusion of each eConsult-stating that specialist referral was not originally contemplated but that the eConsult process had prompted referral. The logs containing the communication exchanged between the PCPs and the specialists were reviewed, and each prompted referral case was categorized by the type of question asked, if pharmaceutical advice was given, if the referral was redirected to a different specialty group, and if the referral was urgent., Results: A total of 188 (3.4%) of 5601 eConsults completed during the study period were cases in which PCPs stated that they had originally not contemplated referring the patient to a specialist but that the Champlain BASE eConsult process had prompted referral. Prompted referrals were most often directed to cardiologists (10.6%), dermatologists (10.6%), infectious disease specialists (9.0%), hematologists (9.0%), and urologists (8.5%). The most common questions were about diagnosis (34.0%), drug treatment (18.0%), and management (15.0%). Pharmaceutical advice was given in 28.0% of prompted referral cases, and in 26.0% of cases, the face-to-face referral was redirected to another specialty group. In 5.0% of cases, the specialist stated the referral was urgent. The median specialist response time was 0.96 days (interquartile range 0.17 to 3.80 days)., Conclusion: By providing PCPs with increased access to specialists, the Champlain BASE eConsult service serves an important role in identifying and preventing the potential detrimental consequences of delayed medical referrals across specialty groups., (Copyright© the College of Family Physicians of Canada.)

Background: eConsult is a web based service that facilitates communication between primary care providers (PCPs) and specialists, which can reduce the need for face-to-face consultations with specialists. One example is the Champlain BASE (Building Access to Specialist through eConsultation) service with dermatology being the largest specialty consulted., Methods: Dermatology eConsults submitted from July 2011 to January 2015 were reviewed. Post eConsult surveys for PCPs were analyzed to determine the number of traditional consults avoided and perceived value of eConsults. The time it took the PCP to receive a reply and the amount of time reported by the specialist to answer eConsult were proactively recorded and analyzed. A subset of 154 most recent eConsults was categorized for dermatology content and question type (e.g. diagnosis or management) using a validated taxonomy., Results: A total of 965 eConsults were directed to dermatology from 217 unique PCPs. The majority of eConsults (64%) took the specialist between 10 and 15 minutes to answer. The overall value of this service to the provider was rated as very good or excellent in 95% of cases. In 49%, traditional in-person assessments were avoided. In the subset of the most recent cases, diagnosis was the most common question type asked (65.2%) followed by management (29%) and drug treatment (10.6%). The top five subject areas (40%) were: Dermatitis, Infections, Neoplasm, Nevi, and Pruritus., Conclusion: eConsults was feasible and well received by PCPs, which improves access to dermatology care with a potential to reduce wait times for traditional consultation., (© 2017 The International Society of Dermatology.)

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.

Health care reform should be driven by the goals of better patient experience, improved population health, lower per capita costs, and improved provider satisfaction. Electronic consultation (eConsult) services have been adopted by several jurisdictions in the United States, Canada, and Europe to improve access to specialists by primary care providers (PCPs) and are being heralded as a key component for delivery of coordinated care. The primary intent of an eConsult service is to provide PCPs with efficient, timely, direct access to specialist expertise to help guide the management of their patients, reduce the need for unnecessary face-to-face specialty consultations, and improve the quality of the initial face-to-face consultation when needed, through the preconsultative communication.In addition to improving access to care, eConsult services have been praised by PCPs and specialists for their educational value, in particular their ability to enrich practice-based learning. Less recognized, but equally important from the educational perspective, include the abilities of eConsult programs to promote reflection by PCPs and specialists, improve collegiality and professionalism between primary and specialist care, inform continuing professional development activities and maintenance of certification, and enhance training programs' teaching of effective communication and care coordination.As eConsult services become increasingly available, the medical community must leverage the educational opportunities inherent in eConsult programs to further improve the delivery of coordinated specialty care. The educational role of eConsults should be considered as a priority outcome in their evaluation and must be highlighted and optimized in next iterations of eConsult systems design.

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.

Background: By facilitating direct communication of primary care providers (PCPs) with specialists for advice, electronic consult (e-consult) services can reduce the need for patients to wait for and travel to face-to-face consultations with specialists. An association between avoiding face-to-face referrals using an e-consult service and specific content within each e-consult has not been rigorously explored., Materials and Methods: Cases submitted to the Champlain Building Access to Specialists through eConsultation service between April 2011 to May 2013 were evaluated. Factors analyzed include question type (e.g., diagnosis or management), formulation (if interventions or outcomes were specified), and the addressed specialty. An avoided referral was present if the PCP indicated so in a mandatory close-out survey. A discrepancy was present if the PCP made a referral when the specialist did not indicate one was necessary, or if the PCP did not request a referral despite the specialist recommending one., Results: There were 426 (40%) avoided referrals among 1,055 cases analyzed. Questions associated with the highest avoided referral rates included ones pertaining to diagnosis (44%), nonspecific requests for direction (44%), questions without specified interventions or outcomes (47%), and dermatology cases (49.5%). Specialists agreed on the need for a referral in 82% of cases, with most discrepancies due to the PCP making a referral without the specialist recommending one., Conclusions: Referral outcomes are associated with the type of question being asked, the formulation of each question, and the specialty being addressed. Discrepancies among PCPs and specialists regarding which patients require face-to-face referrals may help identify knowledge gaps and guide professional development.

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., (©2015 American Association of Nurse Practitioners.)

Objectives: We have improved access to specialist care and decreased wait times in our region through the development and implementation of the Champlain BASE (Building Access to Specialists through eConsultation) service. This secure, web-based tool allows primary care providers (PCPs) quick access to specialist advice for their patients and often helps to avoid the need for a face-to-face referral. Our successful implementation of eConsult in our region provides a unique opportunity to examine PCPs' satisfaction and overall perspective on using the service., Methods: Following the closure of each case, PCPs completed a short survey with multiple-choice and open-ended questions regarding the eConsult. All eConsults submitted between April 15, 2011, and December 31, 2013, were analyzed. We calculated satisfaction scores from the survey and conducted a constant-comparison thematic analysis on those cases where the PCP elected to leave a text response., Results: We analyzed 2,052 eConsults completed during the study period. In 91% and 93% of eConsults, PCPs reported a high value for their patients and themselves, respectively. In 554 eConsults, PCPs elected to leave a written response. Three major themes emerged: PCP appreciation of the eConsult service, perceived benefits for the quality of patient care, and attitudes towards using a new health technology. High satisfaction was expressed with quick response times, helpfulness of responses, and reassurance reported. Most PCPs felt eConsult had a positive impact on patient care by also providing reassurance to patients, reducing burden of time and travel, and offering educational opportunities to PCPs applicable to future cases., Conclusion: PCPs showed a high level of satisfaction with eConsult's quick turnaround time and quality of specialist advice. Our results illustrate the advantages of using asynchronous virtual platforms to increase access to specialty care from a PCP perspective., (© Copyright 2015 by the American Board of Family Medicine.)

Electronic consultation can improve access to specialist care. However, specialists have been identified as less likely to adopt electronic solutions in clinical settings. We conducted an online survey to explore the perspectives of specialists who use the Champlain BASE eConsult service in Eastern Ontario, Canada. Specialists were asked their opinions on experience with the service, their current consult/referral practices, recommendations for change and expansion of the service, and compensation models. We tabulated descriptive statistics from the multiple choice and Likert scale responses and performed a content analysis with an emergent code strategy for open-text responses. Specialists (n=34, 77% response rate) agreed that the Champlain BASE eConsult service is a feasible way to improve access to specialist care (94%), improves communication between specialists and primary care providers (PCPs) (94%), has educational value for PCPs (91%), and is user friendly (82%). A majority of specialists (88%) felt the service should be expanded provincially and 67% felt it should allow specialist-to-specialist consultation. 88% of specialists agreed that the current compensation process is best. This study provides an in-depth look at the perspective of the specialist physicians who use the Champlain BASE eConsult service. Specialists stated specific recommendations for change that will allow us to ensure the service remains sustainable.

Background: Timely access to specialist care remains a barrier for both patients with type 2 diabetes and their primary care physicians. To improve access to specialists for new patients, an efficient and appropriate discharge process is required. Consideration of patient perspectives is central to developing a smooth care transition, and currently, research in this area is limited. The aim of this study was to explore patients' expectations and experiences surrounding discharge from a specialized diabetes centre back to primary care., Methods: A qualitative approach was used involving data from one-to-one semistructured interviews. Participants were 12 patients with type 2 diabetes who had been discharged from the Tertiary Care Diabetes Referral Centre in Ottawa, Canada., Results: Participants were uncertain in their initial expectations of specialist care duration. Patients expressed that an explicit discussion of the discharge process had not occurred, and many were unclear about the reason for discharge and plans for appropriate primary care physician follow up. Patients' psychological preparedness for discharge existed on a spectrum from low to high readiness. Many articulated a desire for improved communication surrounding the discharge plan, and some wished to have input into the discharge decision. Although most described their primary care physician positively, some expressed concern over cessation of specialist care., Conclusions: It is important to prepare patients for discharge from care, and to recognize that individual patients have varying needs and preferences. Further research is warranted to develop effective interventions for improving the discharge process for patients., (Copyright © 2014 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.)

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.

The epidemic of diabetes has increased pressure on the whole spectrum of the healthcare system including specialist centres. The authors' own specialist centre at The Ottawa Hospital has 20,000 annual visits for diabetes, 80% of which are follow-up visits. Since it is a tertiary facility, managers, administrators and clinicians would like to increase their ability to see newly referred patients and decrease the number of follow-up visits. In order to discharge appropriate diabetes patients, the authors decided it was essential to strengthen the transition process to decrease both the pressure on the centre and the risk for discontinuity of diabetes care after discharge.

Background: The growing prevalence of diabetes and heightened awareness of the benefits of early and intensive disease management have increased service demands and expectations not only of primary care physicians but also of diabetes specialists. While research has addressed issues related to referral into specialist care, much less has been published about the transition from diabetes specialists back to primary care. Understanding the concerns of family physicians related to discharge of diabetes care from specialist centers can support the development of strategies that facilitate this transition and result in broader access to limited specialist services. This study was undertaken to explore primary care physician (PCP) perspectives and concerns related to reassuming responsibility for diabetes care after referral to a specialized diabetes center., Methods: Qualitative data were collected through three focus groups. Sessions were audio-taped and transcribed verbatim. Data were coded and sorted with themes identified using a constant comparison method. The study was undertaken through the regional academic referral center for adult diabetes care in Ottawa, Canada. Participants included 22 primary care physicians representing a variety of referral frequencies, practice types and settings., Results: Participants described facilitators and barriers to successful transition of diabetes care at the provider, patient and systems level. Major facilitators included clear communication of a detailed, structured plan of care, ongoing access to specialist services for advice or re-referral, continuing education and mentoring for PCPs. Identified provider barriers were gaps in PCP knowledge and confidence related to diabetes treatment, excessive workload and competing time demands. Systems deterrents included reimbursement policies for health professionals and inadequate funding for diabetes medications and supplies. At the PCP-patient interface, insufficient patient confidence or trust in PCP's ability to manage diabetes, poor motivation and "non-compliance" emerged as potential patient barriers to transition. Incongruence between PCP attitudes and expectations related to diabetes self-management and those of patients who had attended a multidisciplinary specialist center was also observed., Conclusion: This study underlines the breadth of PCP concerns related to transition of diabetes care and the importance of this topic to them. While tools that promote timely information flow and care planning are cornerstones to successful transition, and may be sufficient for some practitioners, appropriately resourced decision support and education strategies should also be available to enhance PCP capacity and readiness to resume diabetes care after referral to a specialist center. Characteristics of the patient-care provider relationship that impact discharge were identified and are worthy of further research.

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. [ABSTRACT FROM AUTHOR]

This paper reports on a multimethod cross-sectional study of the Ontario electronic consultation (eConsult) service. Utilization and closeout survey data from July 2018 through June 2020 were analyzed using the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework. Requesting clinicians submitted 60,474 eConsults, and monthly cases increased from 1,487 in July 2018 to 4,179 in June 2020. The median specialist response time was 1 day. An originally contemplated referral was avoided in 51% of cases. Ontario eConsult showed successful uptake across Ontario, demonstrating continued spread and scale, and offering a template for trailblazers looking to implement digital health innovations in their own jurisdictions. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Access to transgender care in Canada is poor. Although primary care providers are ideally positioned to initiate care, many feel uncomfortable providing transgender care. This study aimed to explore the impact of an electronic consultation (eConsult) service between primary care providers and transgender care specialists on access to care and to explore the content of clinical questions that were asked. Methods: This was a retrospective mixed methods analysis of 62 eConsults submitted between January 2017 and December 2018 by primary care providers to specialists in transgender care in a health region in eastern Ontario, Canada. A descriptive analysis was conducted to assess the average response time and the total time spent by the specialist for the eConsults. An inductive and deductive content analysis was carried out to identify common themes of clinical questions being asked to transgender specialists. A post-eConsult survey completed by primary care providers was assessed to gain insight into avoided face-to-face referrals and overall provider satisfaction. Results: The median specialist response time was 1.2 days (range: 1 h to 5 days) and the average time spent by specialists per eConsult was 18 min (range: 10 to 40 min). The qualitative analysis identified six major themes: 1) interpretation/management of abnormal bloodwork, 2) change in management due to lack of desired effect/hormone levels not a target, 3) initiation of hormone therapy/initial work up, 4) management of adverse effects of hormone therapy, 5) transition related surgery counseling and post-op complications, and 6) management of patients with comorbidities. Approximately one-third of eConsults resulted in an avoided face-to-face referral and 95% of primary care providers rated the value of their eConsult as a 5 (excellent value) or 4. Conclusions: This study demonstrated that a transgender eConsult service has potential to significantly improve access to care for transgender patients. Given the importance that timely access has on improving mental health and reducing suicide attempts, eConsult has the potential to make a substantial clinical impact on this population. Identified themes of eConsult questions provides insight into potential gaps in knowledge amongst primary care providers that could help inform future continuing education events. [ABSTRACT FROM AUTHOR]

Background:Effective communication between primary care providers (PCPs) and specialists plays a key role in providing high-quality patient care. A high-quality referral process should involve referral letters containing all information that is necessary to support shared care between primary and specialty care. Introduction:There is no consensus on the optimal components of specialist-to-PCP communication after a face-to-face patient encounter or in the context of the emerging field of electronic consultations (eConsult). In this study, we aimed at synthesizing the evidence on key components of a traditional consultation letter and at determining whether they can be applied to eConsult replies. Methods:We conducted a systematic review by using a narrative synthesis approach. We searched Pubmed and Embase from inception to January/March 2016 (English). Included studies focused on features of specialists' responses to PCPs. We extracted components of a consultation letter that were identified to be of importance to PCPs and attempted to relate their applicability to eConsult replies. Results:The search revealed 744 potentially relevant citations, of which 65 were deemed eligible for full-text review. Forty-one papers were excluded on full-text review, resulting in 24 studies included in the final synthesis. Important components of consultation letters that were applicable to eConsults included: answering a direct question, providing a diagnosis, providing treatment options, providing education around the case, providing a prognosis, and arranging follow-up, clarity, and organization. Key differences between traditional and eConsult replies included the history and physical investigations, impression, plan, and rationale for plan/education. Conclusion:When seeking to improve the quality of specialist reply letters in both traditional and eConsult replies, one should consider differences in how information is collected and accessed, the role of each provider, and factors that impact specialist-to-PCP communication. [ABSTRACT FROM AUTHOR]

Introduction: Continuing professional development (CPD) offerings should address the educational needs of health care providers. Innovative programs, such as electronic consultations (eConsults), provide unique educational opportunities for practicebased needs assessment. The purpose of this study is to assess whether CPD offerings match the needs of physicians by coding and comparing session content to clinical questions asked through eConsults. Methods: This study analyzes questions asked by primary care providers between July 2011 and January 2015 using a service that allows specialists to provide consultation over a secure web-based server. The content of these questions was compared with the CPD courses offered in the area in which these primary care providers are practicing over a similar period (2012-2014). The clinical questions were categorized by the content area. The percentage of questions asked about each content area was calculated for each of the 12 specialties consulted. CPD course offerings were categorized using the same list of content areas. Percentage of minutes dedicated to each content area was calculated for each specialty. The percentage of questions asked and the percentage of CPD course minutes for each content area were compared. Results: There were numerous congruencies and discrepancies between the proportion of questions asked about a given content area and the CPD minutes dedicated to it. Discussion: Traditional needs assessment may underestimate the need to address topics that are frequently the subject of eConsults. Planners should recognize eConsult questions as a valuable source of practice-associated challenges that can identify professional development needs of physicians. [ABSTRACT FROM AUTHOR]

Background: In many countries, the referral-consultation process faces a number of challenges from inefficiencies and rising demand, resulting in excessive wait times for many specialties. We collected referral data from a sample of family doctors across the province of Ontario, Canada as part of a larger program of research. The purpose of this study is to describe referral patterns from primary care to specialist and allied health services from the primary care perspective. Methods: We conducted a prospective study of patient referral data submitted by primary care providers (PCP) from 20 clinics across Ontario between June 2014 and January 2016. Monthly referral volumes expressed as a total number of referrals to all medical and allied health professionals per month. For each referral, we also collected data on the specialty type, reason for referral, and whether the referral was for a procedure. Results: PCPs submitted a median of 26 referrals per month (interquartile range 11.5 to 31.8). Of 9509 referrals eligible for analysis, 97.8% were directed to medical professionals and 2.2% to allied health professionals. 55% of medical referrals were directed to non-surgical specialties and 44.8% to surgical specialties. Medical referrals were for procedures in 30.8% of cases and non-procedural in 40.9%. Gastroenterology received the largest share (11.2%) of medical referrals, of which 62.3% were for colonoscopies. Psychology received the largest share (28.3%) of referrals to allied health professionals. Conclusion: We described patterns of patient referral from primary care to specialist and allied health services for 30 PCPs in 20 clinics across Ontario. Gastroenterology received the largest share of referrals, nearly two-thirds of which were for colonoscopies. Future studies should explore the use of virtual care to help manage non-procedural referrals and examine the impact that procedural referrals have on wait times for gastroenterology. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objective. To describe the impact of the Champlain BASE (Building Access to Specialists through eConsultation) eConsult service on access to specialist care for patients with chronic pain. Design. A cross-sectional descriptive study Setting. The Champlain Local Health Integration Network, comprising Ottawa, Canada, and the surrounding region. Subjects. All eConsult cases submitted to chronic pain specialists by primary care providers between April 15, 2011 and June 30, 2015. Methods. Usage data and provider responses to a mandatory closeout survey were analyzed to determine response times, case outcomes, and provider satisfaction. Results. Ninety-three primary care providers submitted 199 eConsults to four chronic pain specialists during the study period. Submitted cases had median response times of 1.9 days. Thirty-six percent of cases resulted in an unnecessary referral being avoided, and over 90% of cases were rated by primary care providers as being of high or very high value for their patients and themselves. Conclusion. The eConsult service improved access to specialist care for patients with chronic diseases. By facilitating prompt communication between primary care providers and specialists, eConsult can help mitigate the negative effects of long wait times experienced by patients with chronic pain. [ABSTRACT FROM AUTHOR]