Abstract
BackgroundElectronic consultation (eConsult) services are secure online applications facilitating provider-to-provider communication. They have been found to improve access to specialist care. However, little is known about eConsult’s impact on family physicians’ referral rates to specialty care. The objective of this study was to assess the impact of a multispecialty eConsult service on referral rates from primary care.MethodsIn this parallel-arm, randomized controlled trial, we recruited primary care providers across Ontario not previously enrolled with eConsult. We randomly assigned participants to intervention and control arms. Participants in the intervention arm received access to eConsult for a period of 1 year while those in the control arm received no access to eConsult. The main outcome was specialist referral rate, expressed as the total number of referrals to (1) specialties available through eConsult, and (2) all medical specialties, per 100 patients seen. Multivariable negative binomial regression analysis was used to evaluate the effect of the intervention before and after adjusting for provider characteristics, using health administrative data.ResultsOne hundred and thirteen participants were randomized (56 to control and 57 to intervention). For the primary outcome (referrals to eConsult specialties), the results show a statistically significant reduction in the number of referrals in both arms (control-arm Rate Ratio (RR), 0.85, 95% CI 0.79 to 0.91; intervention-arm RR, 0.80, 95% CI 0.74 to 0.85; unadjusted and adjusted RR values almost identical), as compared to the baseline data collected during the 12-month period before randomization, with a non-statistically significant 6% greater reduction in referrals in the intervention arm, compared to the control arm (unadjusted RR 0.94, 95% CI 0.85 to 1.03; adjusted RR 0.93, 95% CI 0.85 to 1.03).ConclusionsOur randomized controlled trial of a multispecialty eConsult service demonstrated inconclusive results in terms of the impact of eConsult on physician referral rates. Findings are discussed in light of important limitations associated with conducting randomized controlled trials (RCTs) of complex interventions in the primary care context with intent to inform the design and analysis of future trials.Trial registrationClinicaltrials.gov, ID: NCT02053467. Registered prospectively on 3 February 2014.
Highlights
Electronic consultation services are secure online applications facilitating provider-toprovider communication
In 2009 our team began developing, implementing, and evaluating an innovative eHealth solution called the Champlain Building – Access to Specialists through eConsultation (BASETM) (Building Access to Specialists through eConsultation) eConsult service [6]. eConsult is a form of asynchronous communication whereby primary care providers (PCP) and specialists can communicate directly about a patient through a secure web-based application
They can reply to the question, request additional information, or recommend a referral, and advise the PCP on other matters such as medication changes, additional tests, or other critical actions to be completed before the face-to-face specialty care appointment
Summary
Electronic consultation (eConsult) services are secure online applications facilitating provider-toprovider communication They have been found to improve access to specialist care. PCPs can submit a patient question (usually for a patient who would otherwise have been referred) to one of over 100 specialty services via a web-based portal. They can attach any additional information (e.g., photos, test results, Electronic Medical Record-generated letter). Specialists are expected to provide an answer within 1 week They can reply to the question, request additional information, or recommend a referral, and advise the PCP on other matters such as medication changes, additional tests, or other critical actions to be completed before the face-to-face specialty care appointment. Specialists are compensated on a pro-rated hourly basis [6, 7]
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