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Objectives: Delays in the evaluation and treatment of iron deficiency can lead to increased disease‐related morbidity and mortality. Electronic consultation (e‐consult) is a referral modality that allows providers quicker access to recommendations from a specialist based on electronic chart review. While the use of e‐consult is expanding in classical hematology, gaps exist in the understanding of patient outcomes related to its use for iron deficiency. Methods: We randomly selected 200 e‐consults and 200 traditional referrals from 3,336 hematology referrals for iron deficiency at a single center. The primary outcomes of the retrospective analysis were: time to completion of the referral, and time to treatment with intravenous iron. Secondary outcomes included recurrence of iron deficiency, need for repeat e‐consult, conversion to in‐person evaluation, and assessment of whether the etiology of iron deficiency was addressed. Results: E‐consults significantly reduced the time from referral to intravenous iron repletion (e‐consult, 33 days; traditional referral, 68 days; p <.05). Assessment of the underlying etiology occurred in 70.7% of the e‐consult encounters compared to 92.5% of traditional referrals (p <.05). Conclusions: These findings highlight advantages of e‐consults in improving care delivery in iron deficiency, and identifying gaps that can be improved through practice standardization to ensure equitable, high‐value care. [ABSTRACT FROM AUTHOR]

ABSTRACT Background/Objective Methods Results Conclusions The demand for pediatric dermatology services in the U.S. is high, especially at large academic healthcare centers. eConsultation programs provide a solution to poor in‐person access by offering diagnostic and management support to primary care providers (PCPs). To determine the real‐world utility of eConsultation in pediatric dermatology within a closed system at a major academic center, we assessed the outcomes, diagnostic and management concordance, and predictors of eConsult completion of an asynchronous provider‐to‐provider pediatric dermatology eConsult program.Retrospective cohort study of 900 consecutive outpatient pediatric dermatology eConsult referrals from PCPs at a tertiary academic center from 2017 to 2021.Of 900 eConsult referrals, 621 (69%) were completed without the need for in‐person dermatology follow‐up. 46 (5%) were completed but required follow‐up. 233 eConsult referrals (26%) were declined, primarily due to medical complexity. Thirty referrals (3%) were declined because of inadequate clinical photos. The PCP communicated eConsult recommendations to the patient/family on an average of 1.6 days (SD 3) after receiving the completed eConsult. eConsults for adolescents were less likely to be completed compared to infants (p = 0.03). Diagnostic and management concordance between PCP and dermatologist was 78% and 67%, respectively.Provider‐to‐provider eConsultation provides rapid speciality guidance to PCPs managing low‐complexity skin conditions in pediatric outpatients. The lower rate of management plan concordance compared to diagnostic concordance suggests that eConsultation improves outpatient skin management by PCPs. [ABSTRACT FROM AUTHOR]

Abstract Background Many patients with diabetic kidney disease (DKD) do not receive evidence-based, guideline-recommended treatment shown to reduce DKD progression and complications. Proactive electronic consultations (e-consults) are an emerging intervention strategy that could potentially allow nephrologists to provide timely and evidence-based guidance to primary care providers (PCPs) engaged in early DKD care. Methods The objective of this study was to explore perspectives about potential barriers and facilitators associated with a proactive e-consult program to improve DKD care delivery. We conducted semi-structured qualitative interviews with PCPs across three different health systems. Interview transcripts were reviewed in a rapid qualitative analysis approach to iteratively identify, refine, and achieve consensus on a final list of themes and subthemes. Results A total of 18 interviews were conducted. PCPs across all sites identified similar challenges to delivering guideline-recommended DKD care. PCPs were supportive of the proactive e-consult concept. Three major themes emerged surrounding (1) perceived potential benefits of proactive e-consults, including educational value and improved specialist access; (2) concerns about the proactive nature of e-consults, including the potential to increase PCP workload and the possibility that e-consults could be seen as documenting substandard care; and (3) leveraging of care teams to facilitate recommended DKD care, such as engaging clinic-based pharmacists to implement specialist recommendations from e-consults. Conclusion In this pre-implementation qualitative study, PCPs noted potential benefits and identified concerns and implementation barriers for proactive e-consults for DKD care. Strategies that emerged for promoting successful implementation included involving clinic support staff to enact e-consult recommendations and framing e-consults as a system improvement effort to avoid judgmental associations.

Background: Many patients with diabetic kidney disease (DKD) do not receive evidence-based, guideline-recommended treatment shown to reduce DKD progression and complications. Proactive electronic consultations (e-consults) are an emerging intervention strategy that could potentially allow nephrologists to provide timely and evidence-based guidance to primary care providers (PCPs) engaged in early DKD care. Methods: The objective of this study was to explore perspectives about potential barriers and facilitators associated with a proactive e-consult program to improve DKD care delivery. We conducted semi-structured qualitative interviews with PCPs across three different health systems. Interview transcripts were reviewed in a rapid qualitative analysis approach to iteratively identify, refine, and achieve consensus on a final list of themes and subthemes. Results: A total of 18 interviews were conducted. PCPs across all sites identified similar challenges to delivering guideline-recommended DKD care. PCPs were supportive of the proactive e-consult concept. Three major themes emerged surrounding (1) perceived potential benefits of proactive e-consults, including educational value and improved specialist access; (2) concerns about the proactive nature of e-consults, including the potential to increase PCP workload and the possibility that e-consults could be seen as documenting substandard care; and (3) leveraging of care teams to facilitate recommended DKD care, such as engaging clinic-based pharmacists to implement specialist recommendations from e-consults. Conclusion: In this pre-implementation qualitative study, PCPs noted potential benefits and identified concerns and implementation barriers for proactive e-consults for DKD care. Strategies that emerged for promoting successful implementation included involving clinic support staff to enact e-consult recommendations and framing e-consults as a system improvement effort to avoid judgmental associations. [ABSTRACT FROM AUTHOR]

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

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

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

BackgroundSince the advent of COVID-19, accelerated adoption of systems that reduce face-to-face encounters has outpaced training and best practices. Electronic consultations (eConsults), structured communications between PCPs and specialists regarding a case, have been effective in reducing face-to-face specialist encounters. As the health system rapidly adapts to multiple new practices and communication tools, new mechanisms to measure and improve performance in this context are needed.ObjectiveTo test whether feedback comparing physicians to top performing peers using co-specialists' ratings improves performance.DesignCluster-randomized controlled trial PARTICIPANTS: Eighty facility-specialty clusters and 214 clinicians INTERVENTION: Providers in the feedback arms were sent messages that announced their membership in an elite group of "Top Performers" or provided actionable recommendations with feedback for providers that were "Not Top Performers."Main measuresThe primary outcomes were changes in peer ratings in the following performance dimensions after feedback was received: (1) elicitation of information from primary care practitioners; (2) adherence to institutional clinical guidelines; (3) agreement with peer's medical decision-making; (4) educational value; (5) relationship building.Key resultsSpecialists showed significant improvements on 3 of the 5 consultation performance dimensions: medical decision-making (odds ratio 1.52, 95% confidence interval 1.08-2.14, p

Abstract Aims and Objectives To describe characteristics of service utilization by advanced practice nurses (APNs) employing an electronic consultation (eConsult) service in their care for older adults. Background Canada's aging population is projected to place unprecedented demands on the healthcare system. APNs, which include clinical nurse specialists (CNSs) and nurse practitioners (NPs), are nurses with advanced knowledge who can independently provide age‐appropriate care. eConsult is a secure web‐based platform enabling asynchronous, provider‐to‐provider communication. APNs can send and receive eConsults to address patient‐specific concerns. Methods This is a retrospective analysis of eConsult utilization and user survey data for cases completed in 2019, reported in line with the STROBE guidelines. Eligible eConsults included those that had APN involvement (as a referrer or responder) and were concerning an older patient (≥65 years). Descriptive statistics were used to analyse service utilization and survey response data. Results Of 430 eligible eConsults, 421 (97.9%) were initiated by NPs and the rest by physicians. 23 (5.3%) were received by a CNS, of which 14 (3.3%) involved an NP‐to‐CNS exchange. Median specialist response interval was 0.9 days. 53% of eConsults was for dermatology, haematology, cardiology, gastroenterology and endocrinology. 73% of eConsults avoided a face‐to‐face referral after the consultation. In 90% of eConsults, APNs rated the service as helpful and/or educational. Conclusions Through eConsult, APNs can collaborate with each other and physicians to access and provide a breadth of advice facilitating timely specialist‐informed care for older patients, thus helping to alleviate some of the demands placed on the healthcare system. Relevance to Clinical Practice There is an opportunity for APNs to further adopt eConsult into their clinical practice, and this can, in turn, support the integration of the APN role in the health workforce. Patient or Public Contribution Current APN eConsult users were involved in the study design and interpretation of results.

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]

BackgroundExpanding 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.MethodsWe 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.ResultsThis 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.ConclusionsEfforts 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.

BackgroundCardiovascular electronic consultation is a new service line in consultative medicine and enables care without in-person office visits. We aimed to evaluate accessibility and time saved as measures of efficiency, determine the safety of cardiology electronic consultations, and assess satisfaction by responding cardiologists.MethodsUsing a mixed-methods approach and a modified time-driven, activity-based, costing framework, we retrospectively analysed cardiology electronic consultations. A random subset of 500 electronic consultations referred between 2013-2017 were reviewed. Accessibility was determined based upon increased number of patients served without the need for an in-person clinic visit. To assess safety, medical records were reviewed for emergency room visits or hospital admission at six months from the initial electronic consultation date. Responding cardiologist satisfaction was assessed by voluntary completion of an online survey.ResultsThe majority of electronic consultations were related to medication advice, clearance for surgery, evaluation of images, or guidance after abnormal testing. Recommendations included echo (10.8%), stress testing (5.0%), other imaging (4.0%) and other subspecialist referrals (3.8%). Electronic consultations were completed within 0.7±0.5 days of the request, with a time to completion of 5-30 min. Over a six-month follow-up, 13.9% of patients had an in-person visit and 2.2% of patients were hospitalised, but none were directly related to the electronic consultation question. Satisfaction by responding cardiologists was modest.ConclusionIn conclusion, within a single-payer system, cardiology electronic consultations represent a convenient and safe alternative for providing consultative cardiovascular care, but further optimization is necessary to minimise electronic consultation fatigue experienced by cardiologists.

Abstract 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

Abstract Aims e‐consults are asynchronous, clinician‐to‐clinician exchanges that answer focused, non‐urgent, patient‐specific questions using the electronic medical record. We instituted an e‐consultation programme (2013–2019) for all general practitioners (GPs) referrals to cardiologists that preceded patients' in‐person consultations when considered. In our study, we aimed to analyse the clinical characteristics, 1 year prognosis and the prognostic determinants of patients with a previous diagnosis of HF referred for an e‐consult, categorized by their previous HF‐related hospitalization status (recent hospitalization, 1 year before or never been hospitalized because of HF), and to analyse the impact of reducing the time elapsed between e‐consultation and response by the cardiologist in terms of prognosis. Methods and results Epidemiological and clinical data were obtained from 4851 HF patients referred by GPs to the cardiology department for an e‐consultation 2013 and 2020. The delay of time to e‐consults were solved was 8.6 + 8.6 days with 84.3% solved in

Asynchronous electronic consultations (e-consults) can be a useful tool for the screening of cutaneous lesions, but may offer a malpractice risk. We characterized factors affecting initial eConsult office follow-up in a cohort of patients with documented neoplasm of uncertain behavior. Patients with an ICD 10 code of neoplasm with uncertain behavior (D48.5) at The Ohio State University that received an E-consult order from May 2017 to May 2021 were queried. Information collected included patient demographics, status of follow-up in-office appointment, referral status, and health care utilization. In-office follow-up appointments were defined as completed, cancelled/no-show or no-contact. 667 patients with a diagnosis of D48.5 were identified as having completed an eConsult. 427 (64%) patients had a documented phone/electronic message notifying the patient of the results of the eConsult. Year of encounter (0.88 [0.79–0.97]) and number of previously completed ambulatory visits (0.86 [0.77–0.96]) were significantly associated with documentation of phone/electronic message in the univariate and multivariate model. 429 (84%) patients had a dermatology office follow-up encounter while 82 (16%) had no appointment scheduled. Language spoken, referral status and race were significant in the univariate model, though race was the only significant variable in the multivariate model (P < 0.003). Asynchronous electronic consults to assess possible cutaneous neoplasms is an important tool for population screening of skin cancer. Dermatologists and health systems implementing an eConsult model for screening purposes should be aware of risk factors for loss of follow-up. Additional systems need to be implemented to ensure minorities and non-native English speakers are obtaining adequate dermatologic care. [ABSTRACT FROM AUTHOR]

Aims and Objectives: To describe characteristics of service utilization by advanced practice nurses (APNs) employing an electronic consultation (eConsult) service in their care for older adults. Background: Canada's aging population is projected to place unprecedented demands on the healthcare system. APNs, which include clinical nurse specialists (CNSs) and nurse practitioners (NPs), are nurses with advanced knowledge who can independently provide age‐appropriate care. eConsult is a secure web‐based platform enabling asynchronous, provider‐to‐provider communication. APNs can send and receive eConsults to address patient‐specific concerns. Methods: This is a retrospective analysis of eConsult utilization and user survey data for cases completed in 2019, reported in line with the STROBE guidelines. Eligible eConsults included those that had APN involvement (as a referrer or responder) and were concerning an older patient (≥65 years). Descriptive statistics were used to analyse service utilization and survey response data. Results: Of 430 eligible eConsults, 421 (97.9%) were initiated by NPs and the rest by physicians. 23 (5.3%) were received by a CNS, of which 14 (3.3%) involved an NP‐to‐CNS exchange. Median specialist response interval was 0.9 days. 53% of eConsults was for dermatology, haematology, cardiology, gastroenterology and endocrinology. 73% of eConsults avoided a face‐to‐face referral after the consultation. In 90% of eConsults, APNs rated the service as helpful and/or educational. Conclusions: Through eConsult, APNs can collaborate with each other and physicians to access and provide a breadth of advice facilitating timely specialist‐informed care for older patients, thus helping to alleviate some of the demands placed on the healthcare system. Relevance to Clinical Practice: There is an opportunity for APNs to further adopt eConsult into their clinical practice, and this can, in turn, support the integration of the APN role in the health workforce. Patient or Public Contribution: Current APN eConsult users were involved in the study design and interpretation of results. [ABSTRACT FROM AUTHOR]

Rheumatic diseases account for almost 30% of consultations attended in Spanish primary care centres. The main objective was to analyse the demand for rheumatology consultations from Primary Care and their resolution using the electronic consultation system. Retrospective descriptive study of electronic consultations from primary care centres in the health area to the Rheumatology service of a tertiary hospital, between July 2020 and May 2021. The last 500 consecutive consultations were collected. Mean age of patients was 59.5 years; 74.2% were women. Main reasons for consultation were osteoporosis and treatment of patients with rheumatoid arthritis and spondyloarthritis under follow-up by the department. Mean response time was 2 days. Fifty-seven per cent of patients required outpatient appointments. Over 40% of queries were resolved thanks to the electronic consultation system in an average of 2 days, otherwise patients would have been referred to specialized care. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

BackgroundElectronic consultation is an emerging mode of specialty care delivery that allows primary care providers and their patients to obtain specialist expertise without an in-person visit. While studies of individual programs have demonstrated benefits related to timely access to specialty care, electronic consultation programs have not achieved widespread use in the United States. The lack of common evaluation metrics across health systems and concerns related to the generalizability of existing evaluation efforts may be hampering further growth. We sought to identify gaps in knowledge related to the implementation of electronic consultation programs and develop a set of shared evaluation measures to promote further diffusion.MethodsUsing a case study approach, we apply the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) and the Quadruple Aim frameworks of evaluation to examine electronic consultation implementation across diverse delivery systems. Data are from 4 early adopter healthcare delivery systems (San Francisco Health Network, Mayo Clinic, Veterans Administration, Champlain Local Health Integration Network) that represent varied organizational structures, care for different patient populations, and have well-established multi-specialty electronic consultation programs. Data sources include published and unpublished quantitative data from each electronic consultation database and qualitative data from systems' end-users.ResultsOrganizational drivers of electronic consultation implementation were similar across the systems (challenges with timely and/or efficient access to specialty care), though unique system-level facilitators and barriers influenced reach, adoption and design. Effectiveness of implementation was consistent, with improved patient access to timely, perceived high-quality specialty expertise with few negative consequences, garnering high satisfaction among end-users. Data about patient-specific clinical outcomes are lacking, as are policies that provide guidance on the legal implications of electronic consultation and ideal remuneration strategies.ConclusionA core set of effectiveness and implementation metrics rooted in the Quadruple Aim may promote data-driven improvements and further diffusion of successful electronic consultation programs.

ObjectiveTo understand patient, primary care clinician (PCC), and subspecialist perspectives on potential, unexplored roles for patients in electronic consultation and referral (eCR) systems.Data sourcesPrimary focus group and survey data collected April-November 2015. Zuckerberg San Francisco General Hospital (ZSFG) is part of an integrated public health delivery system. Its mature eCR system was first implemented in 2005.Study designThis mixed-methods study synthesizes patient, subspecialist, and PCC perspectives through two patient focus groups in English, Spanish, and Cantonese (n = 6); subspecialist focus groups (n = 2); and an electronic survey of all PCCs (n = 222/634, 35 percent response).Data collection/extraction methodsFocus groups were audio-recorded and transcribed. Two researchers coded the transcripts to identify recurrent themes. Survey data were analyzed using summary and bivariate statistics.Principal findingsPatients expressed minimal desire to directly engage in eCR, instead of emphasizing their PCC's role in advocating, informing, and finding health solutions. Subspecialists requested more consistent communication to patients about the electronic consultation process. Most PCCs (52 percent) supported patient engagement in the eCR process, particularly patient ability to track consult status and securely message with subspecialists.ConclusionsResults suggest a continuum of opportunities for patients and their caregivers to engage in eCR systems.

Our study evaluates the impact of feedback sent to specialists participating in eConsult services. eConsult Specialists from two eConsult services in Ontario, Canada, received feedback on their use of eConsult via bi-annual specialist reports. An 11-item survey was developed to evaluate the impact, content, and distribution process of these specialist reports. We distributed 742 specialist reports in March 2021 and surveyed the specialists in July 2021. Our findings show that specialists largely felt that the feedback received validated their efforts (83%) and that receiving the report made them more likely to continue to participate in the eConsult service (59%). Most did not feel judged (74%) or distressed (79%) by the reports, and 72% said that reporting the median self-reported billing time did not impact their own billing times. Overall, eConsult services can capture, report and aggregate data valuable to specialists and is useful for Continuing Professional Development. Benefits and lack of risk implementing this type of feedback should encourage other services to consider similar processes. [ABSTRACT FROM AUTHOR]

Aims: e‐consults are asynchronous, clinician‐to‐clinician exchanges that answer focused, non‐urgent, patient‐specific questions using the electronic medical record. We instituted an e‐consultation programme (2013–2019) for all general practitioners (GPs) referrals to cardiologists that preceded patients' in‐person consultations when considered. In our study, we aimed to analyse the clinical characteristics, 1 year prognosis and the prognostic determinants of patients with a previous diagnosis of HF referred for an e‐consult, categorized by their previous HF‐related hospitalization status (recent hospitalization, <1 year before; remote hospitalization, >1 year before or never been hospitalized because of HF), and to analyse the impact of reducing the time elapsed between e‐consultation and response by the cardiologist in terms of prognosis. Methods and results: Epidemiological and clinical data were obtained from 4851 HF patients referred by GPs to the cardiology department for an e‐consultation 2013 and 2020. The delay of time to e‐consults were solved was 8.6 + 8.6 days with 84.3% solved in <14 days. For the 1 year prognosis evaluation after the e‐consult were assessed the cardiovascular hospitalizations, HF‐related hospitalizations, HF‐related mortality, cardiovascular mortality, and all‐cause mortality. Compared with the group without a previous hospitalization, patients with recent and remote HF hospitalization were at higher risk of a new HF‐related hospitalization (OR: 19.41 [95% CI: 12.95–29.11]; OR: 8.44 [95% CI: 5.14–13.87], respectively), HF‐related mortality (OR: 2.47 [95% CI: 1.43–4.27]; OR: 1.25 [95% CI: 0.51–3.06], respectively), as well as cardiovascular hospitalizations and mortality and all‐cause mortality. Reduction in the time elapsed because e‐consultation was solved was associated with lower risk of HF‐related mortality (OR: 0.94 [95% CI: 0.89–0.99]), cardiovascular mortality (OR: 0.96 [95% CI: 0.93–0.98]), and all‐cause mortality (OR: 0.98 [95% CI: 0.97–1.00]). Conclusions: A clinician‐to‐clinician e‐consultation programme between GPs and cardiologists in patients with HF allows to solve the demand of care in around 25% e‐consults without an in‐person consultation; the patients with a previous history of HF‐related hospitalization showed a worse 1 year outcome. A reduction in the time elapsed because e‐consultation was solved was associated with a mortality reduction. [ABSTRACT FROM AUTHOR]

Our study evaluates the impact of feedback sent to specialists participating in eConsult services. eConsult Specialists from two eConsult services in Ontario, Canada, received feedback on their use of eConsult via bi-annual specialist reports. An 11-item survey was developed to evaluate the impact, content, and distribution process of these specialist reports. We distributed 742 specialist reports in March 2021 and surveyed the specialists in July 2021. Our findings show that specialists largely felt that the feedback received validated their efforts (83%) and that receiving the report made them more likely to continue to participate in the eConsult service (59%). Most did not feel judged (74%) or distressed (79%) by the reports, and 72% said that reporting the median self-reported billing time did not impact their own billing times. Overall, eConsult services can capture, report and aggregate data valuable to specialists and is useful for Continuing Professional Development. Benefits and lack of risk implementing this type of feedback should encourage other services to consider similar processes.

BackgroundElectronic consultation (eConsult) systems have enhanced access to specialty expertise and enhanced care coordination among primary care and specialty care providers, while maintaining high primary care provider (PCP), specialist and patient satisfaction. Little is known about their impact on the efficiency of specialty care delivery, in particular surgical yield (percent of ambulatory visits resulting in a scheduled surgical case).MethodsRetrospective cohort of a random selection of 150 electronic consults from PCPs to a safety-net general surgery clinic for the three most common general surgery procedures (herniorrhaphy, cholecystectomy, anorectal procedures) in 2014. Electronic consultation requests were reviewed for the presence/absence of consult domains: symptom acuity/severity, diagnostic evaluation, concurrent medical conditions, and attempted diagnosis. Logic regression was used to examine the association between completeness of consult requests and scheduling an ambulatory clinic visit. Surgical yield was also calculated, as was the percentage of patients requiring unanticipated healthcare visits.ResultsIn 2014, 1743 electronic consultations were submitted to general surgery. Among the 150 abstracted, the presence of consult domains ranged from 49% to 99%. Consult completeness was not associated with greater likelihood of scheduling an ambulatory visit. Seventy-six percent of consult requests (114/150) were scheduled for a clinic appointment and surgical yield was 46%; without an eConsult system, surgical yield would have been 35% (p=0.07). Among patients not scheduled for a clinic visit (n=36), 4 had related unanticipated emergency department visits.ConclusionEconsult systems can be used to safely optimize the surgical yield of a safety-net general surgery service.

PURPOSE COVID-19 has increased the need for innovative virtual care solutions. Electronic consultation (eConsult) services allow primary care practitioners to pose clinical questions to specialists using a secure remote application. We examined eConsult cases submitted to a COVID-19 specialist group in order to assess usage patterns, impact on response times and referrals, and the content of clinical questions being asked. METHODS This was a mixed-methods analysis of eConsult cases submitted between March and September 2020 in Ontario, Canada to 2 services. We performed a descriptive analysis of the average response time and the total time spent by the specialist for eConsults. Primary care practitioners completed a post-eConsult questionnaire that asked about the outcome of the eConsult. We performed an inductive and deductive content analysis of a subset of cases to identify common themes among the clinical questions asked. RESULTS A total of 208 primary care practitioners submitted 289 eConsult cases. The median specialist response time was 0.6 days (range = 3 minutes to 15 days); the average time spent by specialists per case was 16 minutes (range = 5 to 59 minutes). In 69 cases (24%), the eConsult enabled avoidance of a face-to-face referral. Content analysis of 51 cases identified 5 major themes: precautions for high-risk and special populations, diagnostic clarification and/or need for COVID-19 testing, guidance on self-isolation and return to work, guidance on personal protective equipment, and management of chronic symptoms. CONCLUSIONS This study demonstrates the considerable potential of eConsults during a pandemic as our service was quickly implemented across Ontario and resulted in primary care practitioners' rapid and low-barrier access to specialist input. [ABSTRACT FROM AUTHOR]

High-quality correspondence between healthcare providers is critical for effective patient care. We developed an assessment tool to measure the quality of specialist correspondence to primary care providers (PCPs) via electronic consultation (eConsult), where specialists provide advice without specialist-patient interactions. We incorporated fourteen previously described features of high-quality eConsult correspondence into an assessment tool named the eConsult Specialist Quality of Response (eSQUARE). Six PCPs and two specialists applied the 10-item eSQUARE tool to 30 eConsults of varying quality as informed by PCP survey data. Content, response process, and internal structure validity evidence was gathered. Psychometric properties were calculated using descriptive statistics and generalizability analyses. Mean total score for low-quality eConsults (M = 24 ± 5.6) was significantly lower than moderate-quality eConsults (M = 38 ± 4.7; p<0.001) which was significantly lower than high-quality eConsults (M = 46 ± 3.0; p = 0.002). Reliability measures were high, including generalizability coefficient (0.96), inter-item (≥0.55) and item-total correlations (≥0.68). A decision study demonstrated that a single rater was adequate to achieve a reliability measure of ≥0.70. This study demonstrates initial validity evidence including multiple reliability measures for the eSQUARE. A single rater is adequate to achieve reliability measures for formative feedback. Future studies can apply the eSQUARE when planning educational initiatives aiming to improve specialist-to-PCP correspondence via eConsult. [ABSTRACT FROM AUTHOR]

Background: Electronic consultation (eConsultation) offers a potential mechanism to increase access to specialty care, address knowledge gaps, and overcome therapeutic inertia in patients with type 2 diabetes (T2DM) being managed by primary care physicians (PCPs). Objective: To develop and implement a system to provide unsolicited endocrinology eConsult for T2DM patients with HbA1c 8.5–10.5% managed by PCPs. Design: Cluster-randomized matched cohort study with implementation evaluation. Participants: PCPs affiliated with Massachusetts General Hospital (MGH). Interventions: Unsolicited endocrinology eConsultation. Main Measures: The primary clinical outcome was mean change in HbA1c at 6 months. Secondary process outcomes included referral completion rate, prescription rates of glucose-lowering medications, differences in rate of other management recommendations, change in all glucose-lowering medications, and number of face-to-face endocrinology visits. Key Results: 161 PCPs were randomly assigned to intervention (n=81) and control (n=80) arms. eConsultations were triggered on 130 patients from intervention arm PCPs. Intervention arm patients had a 0.89 (SD 1.45) decrease in HbA1c compared to 0.69 (SD 1.32) decrease in the control arm (p=0.28). There were significant differences in prescribing of glucose-lowering medications between arms. There was a 19.3% increase in patients prescribed GLP-1 RA or SGLT2i in the intervention arm compared to a 6.9% increase in control (p=0.003). There were also significant increases in prescription rates of metformin (3.1% vs −3.1%, p=0.03) and sulfonylureas (1.5% vs −6.9%, p=0.03). At 6-month follow-up, the intervention arm had 13 in-person endocrinology visits compared to 29 (p=0.012) in the control arm. PCPs were more likely to accept recommendations regarding adherence to or dose adjustment of current medications than initiation of new medications. Conclusions: The implementation of an unsolicited endocrinology eConsult system for patients with poorly controlled T2DM is feasible. Unsolicited eConsultation was associated with increased prescribing of glucose-lowering medications without significant difference in HbA1c. Trial Registration: Clinicaltrials.gov registration: NCT03542084 [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]

Abstract 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.

Keywords: atrial fibrillation; coordinated care; electronic consultation; oral anticoagulation; primary care EN atrial fibrillation coordinated care electronic consultation oral anticoagulation primary care 1 3 3 02/14/23 20230301 NES 230301 The past decades have seen substantial technological advances and improvements in the diagnosis and treatment of a wide range of medical conditions, such as atrial fibrillation (AF), which, along with the multimorbid aging population, adds complexity to the process of care. Optimal AF management therefore requires coordinated care across multidisciplinary teams, as recommended in the 2020 ESC Guidelines for the diagnosis and management of AF.[2] Since AF is often diagnosed in the primary care setting, referral from the primary care physician to a cardiologist is a common initial step in integrated AF management. [Extracted from the article]

Digitalization of health has introduced critical changes into the clinical setting. Electronic Health Records and other Information Technology tools have been used to improve data management, communication, and healthcare in general. However, changes in the clinical settings have not been without a cost. Patients and doctors agree that the introduction of the computer into the examination room has a generally positive effect, but some concerns were raised about the proper use of the technology and its possible effects in the clinical consultation. The purpose of this study is to review the literature about the effects of the use of EHR in the doctor-patient relationship and the outcomes for quality of care. A literature review was conducted using the method proposed by Arksey and O'Malley. Papers from PubMed, Scopus, and IEEE Xplore were selected from a range of keyword combinations that reflect the topic of doctor-patient relationships since the introduction of the computer into the clinical setting. The selected articles were reviewed, and a summary of their most relevant results is presented. The literature shows that while the benefits of digitalization exist, the effects on doctor-patient communication could lead to poor patient outcomes. Overall, it has been observed that the introduction of the computer into the examination room has impacted the relationship of doctors and patients by introducing a new partner into the relationship, and more work needs to be done to understand this impact while putting a focus on how systems could be designed for better health outcomes. There seems to be a need to deepen the understanding of the effects of the introduction of the computer in the doctor-patient setting, but more so regarding facilitating an effective EHR design, and an adoption model that allows for an improved doctor-patient relationship and positive health outcomes. [ABSTRACT FROM AUTHOR]

Abstract 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.

Aim: This work aims to evaluate whether electronic consultations (e-consults) are a clinically useful, safe tool for assessing patients between primary care and internal medicine., Methods: This is a retrospective cohort study of all e-consults ordered by the Primary Care Department to the Internal Medicine Department between September 2019 and December 2023. The results of initial consultations, emergency department visits and subsequent admissions, and survival were assessed and complaints and claims filed were reviewed., Results: A total of 11,434 e-consults were recorded (55.4% women) with a mean age of 62.1 (SD19.4) years and a wide range (15-102 years). The mean response time was 2.55 (SD 1.6) days. As a result of the e-consults, 5645 patients (49.4%) were given an in-person appointment. For the remaining 5789 (50.6%), a written response was provided. Among those given appointments, the time between the response and in-person appointment was less than five days (95% of cases). Compared to those not given appointments, in-person appointments were older (p < 0.0001), visited the emergency department more times (one month: p = 0.04; three months: p = 0.001), were admitted to the hospital more times (one month: p = 0.0001; three months: p = 0.0001), and had higher mortality at one year (12.7% vs. 9.8% p = 0.0001). In the Cox analysis, only in-person appointments (RR = 1.11; p = 0.04)) and age (RR = 1.09; p < 0.01) were independent factors of mortality. No complaints or claims of any kind were registered., Conclusions: These data suggest that e-consults are a clinically useful, safe tool for assessing patients referred from primary care to internal medicine departments., (Copyright © 2024 Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI). All rights reserved.)

BackgroundAccess to specialty care remains a challenge for primary care providers and patients. Implementation of electronic referral and/or consultation (eCR) systems provides an opportunity for innovations in the delivery of specialty care. We conducted key informant interviews to identify drivers, facilitators, barriers and evaluation metrics of diverse eCR systems to inform widespread implementation of this model of specialty care delivery.MethodsInterviews were conducted with leaders of 16 diverse health care delivery organizations between January 2013 and April 2014. A limited snowball sampling approach was used for recruitment. Content analysis was used to examine key informant interview transcripts.ResultsElectronic referral systems, which provide referral management and triage by specialists, were developed to enhance tracking and operational efficiency. Electronic consultation systems, which encourage bi-directional communication between primary care and specialist providers facilitating longitudinal virtual co-management, were developed to improve access to specialty expertise. Integrated eCR systems leverage both functionalities to enhance the delivery of coordinated, specialty care at the population level. Elements of successful eCR system implementation included executive and clinician leadership, established funding models for specialist clinician reimbursement, and a commitment to optimizing clinician workflows.ConclusionseCR systems have great potential to streamline access to and enhance the coordination of specialty care delivery. While different eCR models help solve different organizational challenges, all require institutional investments for successful implementation, such as funding for program management, leadership and clinician incentives.

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Abstract 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.

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

Objectives/Hypothesis: To determine the impact of electronic consultation on the otolaryngology clinic workflow at our high‐volume public hospital. Study Design: Retrospective Observational Study. Methods: This is a retrospective observational analysis study. Operational data regarding clinic volume, referral patterns, and scheduling efficiency were assessed over a 9‐month period in 2018 prior to implementation of electronic consultation. The same data were collected for the 9‐month period immediately following implementation of electronic consultation in 2019. Results: During the pre‐implementation (pre‐EC) period, 3,243 otolaryngology referrals were made as compared to 4,249 post‐implementation (post‐EC). 86% of referrals were scheduled for a clinic appointment pre‐EC, compared to 61% post‐EC (P <.00001) 24.5% of patients were evaluated within 30 days pre‐EC compared to 53.6% post‐EC (P <.00001). The average time to be seen by an otolaryngology provider declined from 60.8 days pre‐EC to 42.8 days post‐EC (P =.0029). There was a 50% decline in the percentage of appointments canceled by patients in the post‐EC period as compared to pre‐EC. Conclusions: In our experience, implementation of electronic consultation significantly reduced both wait times for a clinic appointment and the percentage of no‐show or canceled appointments. Electronic consultation may be a valuable tool in improving the efficiency and yield of the modern otolaryngology clinic. Level of Evidence: 4 Laryngoscope, 131:E1792–E1796, 2021 [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]

Introduction: The electronic consultation service, eConsult, is an asynchronous web-based platform for provider-to-provider consultation with specialists. This study described the utilization of eConsult by primary care providers to obtain specialist opinion in gynaecologic malignancy screening, with a specific focus on pathology-related inquiries.Methods: This is a cross-sectional retrospective review of eConsults submitted to obstetrics/gynaecology between September 2011 and December 2016. All questions pertaining to gynaecologic cancer screening and their pathologies were included. Each question was classified based on a pre-determined taxonomy. The mandatory primary care providers' exit surveys were analysed to determine eConsult's influence on patient care, primary care providers' referral patterns, primary care providers' satisfaction and educational value.Results: In total, 1,357 electronic consultations were submitted to the obstetrics and gynaecology service during the study period, of which 329 met inclusion criteria. Indications for a screening test based on patient risk factors made up 36% of consults pertaining to gynaecologic malignancy screening and 17% were inquiries about test intervals based on previous results. Primary care providers pointed out gaps in current screening guidelines. In total, 38% of primary care providers reported the eConsult service helped avoid a specialist referral, whereas 47% of primary care providers received new or additional courses of action. Pathology report interpretation accounted for 5% of eConsults and 6% of primary care providers wished for clarification of incidental pathology findings.Conclusion: This study uncovered areas of uncertainty among primary care providers regarding gynaecologic cancer screening and gaps in current clinical guidelines. Furthermore, the role of pathology consultants in an eConsult platform is explored and may be extrapolated into practice. [ABSTRACT FROM AUTHOR]

Background: Electronic consultation (eConsult) is an eHealth service that allows primary care providers (PCPs) to electronically consult specialists regarding their patients' medical issues. Many studies have demonstrated that eConsult services improve timely access to specialist care; prevent unnecessary referrals; improve PCPs', specialists', and patients' satisfaction; and therefore have a large impact on costs. However, no studies have evaluated PCPs' and specialists' acceptance of eConsult services in Quebec, Canada, and worldwide., Objective: This exploratory study aims to identify factors affecting eConsult service acceptance by PCPs and specialists in urban and rural primary care clinics across 3 regions in the province of Quebec, Canada, by integrating the Unified Theory of Acceptance and Use of Technology and Task-Technology Fit (TTF) models and user satisfaction. This research was designed to broaden and assist in scaling up this effective eHealth service innovation across the province., Methods: A cross-sectional web-based survey was sent to all PCPs (n=263) and specialists (n=62) who used the eConsult Quebec Service between July 2017 and May 2021. We proposed a unified model integrating the Unified Theory of Acceptance and Use of Technology model and TTF model and user satisfaction by endorsing 11 hypotheses. The partial least squares was used to investigate factors influencing the acceptance of the eConsult Quebec Service., Results: Of the 325 end users, 136 (41.8%) users responded (PCPs: 101/263, 38.4%; specialists: 35/62, 57%). The results of the analysis with partial least squares method indicate that 9 of our 11 hypotheses are supported. The direct relationships uniting the various constructs of the model highlighted the importance of several key constructs and predominant correlations. The results suggest that satisfaction is the key driver behind the use of the eConsult Quebec Service. Performance expectancy (P<.001) and effort expectancy (P=.03) can have a positive impact on behavioral intention (BI), and BI (P<.001) can impact adoption. TTF has an influence on performance expectancy (P<.001), adoption (P=.02), and satisfaction (P<.001). However, the results show that there is no direct effect between social influence (P=.38) and BI or between facilitating conditions (P=.17) and adoption., Conclusions: This study provides a better understanding of the factors influencing PCPs' and specialists' intention to adopt the eConsult Quebec Service. Furthermore, this study tests a research model and a technology that have never been explored in Quebec until now. On the basis of the results, the service is a good fit to meet the users' need to improve access to specialized medical advice. Therefore, the results of our study have made a valuable contribution to the implementation of the service by policy makers in order to maximize acceptance, use, adoption, and success across the province of Quebec. Moreover, after 4 successful years, the eConsult Quebec pilot project is now the Conseil Numérique digital consultation service., (©Véronique Nabelsi, Annabelle Lévesque-Chouinard. Originally published in JMIR Formative Research (https://formative.jmir.org), 30.05.2024.)

Background: Limiting in-person contact was a key strategy for controlling the spread of the highly infectious novel coronavirus (COVID-19). To protect patients and staff from the risk of infection while providing continued access to necessary health care services, we implemented a new electronic consultation (e-consult) service that allowed referring providers to receive subspecialty consultations for patients who are hospitalized and do not require in-person evaluation by the specialist., Objective: We aimed to assess the impact of implementing e-consults in the inpatient setting to reduce avoidable face-to-face referrals during the COVID-19 pandemic., Methods: This quality improvement study evaluated all inpatient e-consults ordered from July 2020 to December 2022 at the University of California Irvine Medical Center. The impact of e-consults was assessed by evaluating use (eg, number of e-consults ordered), e-consult response times, and outcome of the e-consult requests (eg, resolved electronically or converted to the in-person evaluation of patient)., Results: There were 1543 inpatient e-consults ordered across 11 participating specialties. A total of 53.5% (n=826) of requests were addressed electronically, without the need for a formal in-person evaluation of the patient. The median time between ordering an e-consult and a specialist documenting recommendations in an e-consult note was 3.7 (IQR 1.3-8.2) hours across all specialties, contrasted with 7.3 (IQR 3.6-22.0) hours when converted to an in-person consult (P<.001). The monthly volume of e-consult requests increased, coinciding with surges of COVID-19 cases in California. After the peaks of the COVID-19 crisis subsided, the use of inpatient e-consults persisted at a rate well above the precrisis levels., Conclusions: An inpatient e-consult service was successfully implemented, resulting in fewer unnecessary face-to-face consultations and significant reductions in the response times for consults requested on patients who are hospitalized and do not require an in-person evaluation. Thus, e-consults provided timely, efficient delivery of inpatient consultation services for appropriate problems while minimizing the risk of direct transmission of the COVID-19 virus between health care providers and patients. The service also demonstrated its value as a tool for effective inpatient care coordination beyond the peaks of the pandemic leading to the sustainability of service and value., (©Anna S Aledia, Amish A Dangodara, Aanya A Amin, Alpesh N Amin. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 16.05.2024.)

Abstract Background Electronic consultation is an emerging mode of specialty care delivery that allows primary care providers and their patients to obtain specialist expertise without an in-person visit. While studies of individual programs have demonstrated benefits related to timely access to specialty care, electronic consultation programs have not achieved widespread use in the United States. The lack of common evaluation metrics across health systems and concerns related to the generalizability of existing evaluation efforts may be hampering further growth. We sought to identify gaps in knowledge related to the implementation of electronic consultation programs and develop a set of shared evaluation measures to promote further diffusion. Methods Using a case study approach, we apply the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) and the Quadruple Aim frameworks of evaluation to examine electronic consultation implementation across diverse delivery systems. Data are from 4 early adopter healthcare delivery systems (San Francisco Health Network, Mayo Clinic, Veterans Administration, Champlain Local Health Integration Network) that represent varied organizational structures, care for different patient populations, and have well-established multi-specialty electronic consultation programs. Data sources include published and unpublished quantitative data from each electronic consultation database and qualitative data from systems’ end-users. Results Organizational drivers of electronic consultation implementation were similar across the systems (challenges with timely and/or efficient access to specialty care), though unique system-level facilitators and barriers influenced reach, adoption and design. Effectiveness of implementation was consistent, with improved patient access to timely, perceived high-quality specialty expertise with few negative consequences, garnering high satisfaction among end-users. Data about patient-specific clinical outcomes are lacking, as are policies that provide guidance on the legal implications of electronic consultation and ideal remuneration strategies. Conclusion A core set of effectiveness and implementation metrics rooted in the Quadruple Aim may promote data-driven improvements and further diffusion of successful electronic consultation programs.

Abstract 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: Insurance, racial, and socioeconomic health disparities continue to pose significant challenges for access to dermatologic care. Studies applying teledermatology to increase access to underinsured individuals and ethnic minorities are limited.Objective: To determine how the implementation of a teledermatology program affects access to health care and patient outcomes.Methods: A cross-sectional evaluation was performed of all ambulatory dermatology referrals and electronic dermatology consultations (eConsults) at Ohio State University within a 25-month period.Results: Compared with ambulatory referrals, eConsults served more nonwhite patients (612 of 1698 [36.0%] vs 4040 of 16,073 [25.1%]; P < .001) and more Medicaid enrollees (459 of 1698 patients [27.0%] vs 3266 of 16,073 [20.3%]; P < .001). In addition, ambulatory referral patients were significantly less likely to attend their scheduled appointment compared with eConsult patients, as either "no-shows" (246 of 2526 [9.7%] vs 3 of 62 [4.8%]) or cancellations (742 of 2526 [29.4%] vs 8 of 62 [12.9%]; P = .003). There were fewer median days to extirpation for eConsult patients compared with ambulatory referral patients (interquartile range; 80.7 ± 79.8 vs 116.9 ± 86.6 days; P = .004).Conclusion: Integrating dermatologic care through a telemedicine system can result in improved access for underserved patients through improved efficiency outcomes. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Abstract Background Electronic consultation (eConsult) systems have enhanced access to specialty expertise and enhanced care coordination among primary care and specialty care providers, while maintaining high primary care provider (PCP), specialist and patient satisfaction. Little is known about their impact on the efficiency of specialty care delivery, in particular surgical yield (percent of ambulatory visits resulting in a scheduled surgical case). Methods Retrospective cohort of a random selection of 150 electronic consults from PCPs to a safety-net general surgery clinic for the three most common general surgery procedures (herniorrhaphy, cholecystectomy, anorectal procedures) in 2014. Electronic consultation requests were reviewed for the presence/absence of consult domains: symptom acuity/severity, diagnostic evaluation, concurrent medical conditions, and attempted diagnosis. Logic regression was used to examine the association between completeness of consult requests and scheduling an ambulatory clinic visit. Surgical yield was also calculated, as was the percentage of patients requiring unanticipated healthcare visits. Results In 2014, 1743 electronic consultations were submitted to general surgery. Among the 150 abstracted, the presence of consult domains ranged from 49% to 99%. Consult completeness was not associated with greater likelihood of scheduling an ambulatory visit. Seventy-six percent of consult requests (114/150) were scheduled for a clinic appointment and surgical yield was 46%; without an eConsult system, surgical yield would have been 35% (p=0.07). Among patients not scheduled for a clinic visit (n=36), 4 had related unanticipated emergency department visits. Conclusion Econsult systems can be used to safely optimize the surgical yield of a safety-net general surgery service.