Abstract
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 Data sources include published and unpublished quantitative data from each electronic consultation database and qualitative data from systems’ end-users.ResultsOrganizational drivers of electronic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.
Highlights
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
Case studies Four case studies were performed, examining electronic consultation implementation in systems that represent different structures of specialty care delivery: a community setting with non-affiliated individual Primary care provider (PCP) and specialty care practices; an integrated tertiary care academic medical center; an urban safety-net system with affiliated PCPs and specialists; and a fully integrated public delivery system (Table 1)
Champlain local health integration network (LIHN) The Champlain BASETM (Building Access to Specialists through eConsultation) program was developed in 2009. It is based in the Champlain health region of Eastern Ontario, Canada, which has a population of 1.3 million individuals, roughly half of whom reside in the city of Ottawa [15]
Summary
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. Two systematic reviews that included international programs have reported that electronic consultation programs are associated with improved access to specialty care and enhanced care coordination, high satisfaction among primary and specialty care providers, and positive patient experience [12, 13]. Despite these data, electronic consultation programs have not achieved widespread use in the United States. We identify gaps in knowledge to promote areas of future study and propose a set of shared evaluation measures to promote future study
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