eConsult System Research Articles

Laboratory reference intervals influence referral patterns for hemoglobin abnormalities in the Ontario virtual care system.

This retrospective cross-sectional study investigates the impact of laboratory-specific hemoglobin reference intervals on electronic consultation (eConsult) referral patterns for suspected anemia and elevated hemoglobin at a tertiary care center in London, Ontario that serves Southwestern Ontario. The study analyzed referrals through the Ontario Telemedicine Network's eConsult platform for hemoglobin abnormalities, excluding patients under 18 years old, between July 1, 2019, and June 30, 2023.The main outcome measures were influence of hemoglobin reference intervals on the referral patterns for suspected anemia and elevated hemoglobin, as well as the extent of pre-referral laboratory testing. Of the 619 eConsults reviewed, 251 referrals for suspected anemia and 93 for elevated hemoglobin were analyzed. Referral patterns showed significant variance in hemoglobin levels based on different laboratory thresholds. Referrals for suspected anemia in females from laboratories whose lower limit was 120 g/L or greater had a hemoglobin concentration 7.5 g/L greater than referrals that used laboratories with a threshold lower than 120 g/L. The study also identified potential areas for improvement in pre-referral investigations; 44% of eConsults did not provide a ferritin level, 53% were missing a B12 level, and 81% were missing a reticulocyte count. In conclusion, laboratory reference intervals for hemoglobin significantly influence referral patterns for suspected hemoglobin abnormalities in Ontario's eConsult system. There is a need for standardized reference intervals and comprehensive pre-referral testing to avoid unnecessary medicalization and referrals. We propose an anemia management algorithm to guide primary care providers in the pre-referral investigation process.

Impact of an Evidence-Based Prioritization System and Electronic Consultation in Early Diagnosis of Colorectal Cancer.

(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.

Improving Access to Specialty Pediatric Care: Innovative Referral and eConsult Technology in a Specialized Acute Care Hospital.

Background: The COVID-19 pandemic has exacerbated wait times for pediatric specialty care. Transformative technologies such as electronic referral (eReferral-automation of patient information) and electronic consultations (eConsult-asynchronous request for specialized advice by primary care providers) have the potential to increase timely access to specialist care. The objective of this study was to present an overview of the current state and characteristics of referrals directed to a pediatric ambulatory medical surgery center, with an emphasis on the innovative use of an eConsult system and to indicate key considerations for system improvement. Methods: This cross-sectional study was conducted at a specialized pediatric acute care hospital in Ottawa, Ontario. Secondary data were obtained over a 2-year period during the COVID-19 pandemic (2019-2022). To gain insights and identify areas of improvement related to the factors pertaining to referrals and eConsults at the process and system levels, quality improvement (QI) methodologies were employed. Descriptive statistics provide a summary of the trends and characteristics of referrals and the utilization of eConsult. Results: Among the 113,790 referrals received, 31,430 were denied. Most common reasons for referral denial were other/null (e.g., unspecified) (29.3%), inappropriate referrals (12.6%), and duplicate referrals (12.4%). Four clinics (e.g., endocrinology, cardiology, neurology, and neurosurgery) reported a total of 277 eConsults, with endocrinology accounting for 95.0% of all eConsults. QI findings revealed the need for standardized workflows among specialties and ensuring that eConsult options are accessible and integrated within the electronic medical record (EMR). Conclusions: Refining the pediatric referral management process and optimizing eConsult through existing clinical systems have the potential to improve the timeliness and quality of specialty care. The results inform future research initiatives targeting improved access to pediatric specialty care and serve as a benchmark for hospitals utilizing EMRs and eConsult.

The Performance of Electronic Consultation in Non-Malignant Hematology in a Fee-for-Service Care Delivery Model

Background: Electronic consultation (e-consultation) refers to asynchronous electronic communication between a consulting provider and a consulted specialist. Recommendations are formulated by medical record review and communicated via medical record documentation without direct contact between the specialist and patient. There is a current shortage of non-malignant hematologists and hence a need to optimize the efforts of the existing workforce. E-consultation holds promise by allowing simpler consults to be answered quickly, reserving face-to-face (FTF) encounters for complex hematologic questions and therefore allowing hematologists to serve a larger number of patients. Additional benefits of e-consultation include faster response to consultation questions and decreased travel burden for patients. However, due to lower financial incentives for e-consultation compared to FTF in fee-for-service reimbursement models, adoption has been limited. Here, we report the experience with e-consultation in non-malignant hematology in a fee-for-service model at a large academic medical center and compare that experience to published reports in three medical centers with non-fee-for-service models. Methods: On March 1, 2021, the outpatient clinic of the University of Alabama at Birmingham (UAB), implemented e-consultation for non-malignant hematology. E-consults could be initiated by any provider within the UAB system through electronic order entry. Three non-malignant hematologists reviewed and responded to all e-consults and these hematologists, along with an advanced practice provider, conducted all FTF encounters. Retrospective analysis of e-consultation practices, 1 year after implementation was performed. Variables collected included the reason for consultation, date and time of response, the time between e-consult and response, time to review and respond, frequency of conversion to an FTF encounter, and follow-up communication. Results: Over the 1-year study period, 214 e-consults were requested, of which 183 (86%) had an e-consult completed and 31 (14%) were converted to an FTF encounter due to complexity. The frequency of e-consults ordered and completed (i.e., not converted to an FTF encounter) by month is presented in Figure 1. The most common diagnoses prompting consultation included anemia (21%), thrombosis (19%), leukopenia (12%), and thrombocytopenia (11%). There was more than one diagnostic question in 29 e-consults (14%). The average time to review and respond to an e-consult was 8.6 minutes (range 2-20 minutes). The median time from the e-consult request to completion was 2 hours and 34 minutes (IQR 9 hours and 46 minutes). Additional workup, including laboratory testing and/or imaging, was recommended in 56% of e-consults and was performed by the consulting provider. Subsequent communication between the consulting provider and non-malignant hematology provider within 30 days of the e-consult was required in 13% of e-consults. The total number of FTF new patient encounters scheduled in the study year increased to 2,642/year from 1,708/year in the year before e-consult implementation. The average wait time for a physician FTF new patient appointment also increased from 56 days to 88 days. Table 1 presents a comparison of the performance of reported e-consultation systems in non-malignant hematology. Low cell counts (anemia, thrombocytopenia, and leukopenia) were the most common reason for consultation in all systems. Our e-consult system demonstrated a shorter time to complete the consult and a shorter time to respond. A consistent percentage (14-17%) of e-consults were converted to FTF encounters. In the two programs that measured influence on consult volume, both reported a similar increase in total consult volume after e-consult implementation. Conclusions: In a large fee-for-service medical center, the implementation of e-consultation for non-malignant hematologic care did not decrease consult volume, and consulting provider uptake was low. However, when used, e-consultation facilitated rapid delivery of non-malignant hematologic expertise and performed similarly to reported experiences in non-fee-for-service models. Further investigation is needed to determine how e-consultation can be best utilized to maximize access to expertise in non-malignant hematology. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Access to orthopedic specialist service in Ontario via eConsult.

Background:Increasing strain on public health resources in Canada, in particular with respect to accessing specialist care, necessitates the exploration of alternative models of care. The aim of this study was to assess the efficacy of electronic consultation (eConsult) in providing orthopedic surgery specialist service to patients in the Champlain Local Health Integration Network (LHIN) of Ontario.Methods:This was a cross-sectional review of all 564 Champlain LHIN orthopedic surgery referral requests received via the Champlain Building Access to Specialist service through the eConsult (BASE) system in 2017. Primary outcome measures were impact on primary care provider (PCP) referral pattern and time to receive orthopedic consultation.Results:eConsult prevented unnecessary in-person consultation 64% of the time, while PCP referral decisions were modified 51% of the time. Of all eConsults, 94% were rated as valuable to PCPs in their practice and 97% of eConsults resulted in actionable advice. eConsults took an average of 14.5 minutes of specialist time to complete, and the mean time from referral to response was 3.7 days.Conclusion:The eConsult system spares unnecessary consultation to orthopedic surgery; catches important referrals that would have otherwise been missed; saves time for patients, PCPs and orthopedic surgeons; and improves efficiency in a socialized health care system.

Classifying unstructured electronic consult messages to understand primary care physician specialty information needs.

Electronic consultation (eConsult) content reflects important information about referring clinician needs across an organization, but is challenging to extract. The objective of this work was to develop machine learning models for classifying eConsult questions for question type and question content. Another objective of this work was to investigate the ability to solve this task with constrained expert time resources. Our data source is the San Francisco Health Network eConsult system, with over 700000 deidentified questions from the years 2008-2017, from gastroenterology, urology, and neurology specialties. We develop classifiers based on Bidirectional Encoder Representations from Transformers, experimenting with multitask learning to learn when information can be shared across classifiers. We produce learning curves to understand when we may be able to reduce the amount of human labeling required. Multitask learning shows benefits only in the neurology-urology pair where they shared substantial similarities in the distribution of question types. Continued pretraining of models in new domains is highly effective. In the neurology-urology pair, near-peak performance is achieved with only 10% of the urology training data given all of the neurology data. Sharing information across classifier types shows little benefit, whereas sharing classifier components across specialties can help if they are similar in the balance of procedural versus cognitive patient care. We can accurately classify eConsult content with enough labeled data, but only in special cases do methods for reducing labeling effort apply. Future work should explore new learning paradigms to further reduce labeling effort.

Efficacy of an eConsult service to cure hepatitis C in primary care.

In 2016, an eConsult service was developed within a safety net health system to expand access to hepatitis C (HCV) treatment in the primary care setting. The eConsult system provides individualized treatment recommendations from specially trained primary care pharmacists and primary care physicians to primary care providers with less experience in the rapidly changing treatment of HCV. Since its launch, this service has had a large impact in expanding care to a largely homeless and low-income urban population within our health system. We now aim to evaluate its efficacy in curing HCV. In this retrospective cohort study, we describe rates of sustained virologic response 12weeks after treatment completion (SVR12) for those who received primary care-based HCV treatment through the eConsult system with those who were treated in primary care independent of an eConsult from 2017 to 2019. We found there was no significant difference in the proportion of patients who achieved SVR12 between the two groups. Overall, >90% of patients who received treatment achieved SVR12. Approximately 40% of patients treated for HCV received an eConsult, suggesting utility of the eConsult in expanding access and coordinating treatment for patients within our network.

HbA1c-Triggered Endocrinology Electronic Consultation for Type 2 Diabetes Management.

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). To develop and implement a system to provide unsolicited endocrinology eConsult for T2DM patients with HbA1c 8.5-10.5% managed by PCPs. Cluster-randomized matched cohort study with implementation evaluation. PCPs affiliated with Massachusetts General Hospital (MGH). Unsolicited endocrinology eConsultation. 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. 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. 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. Clinicaltrials.gov registration: NCT03542084.

MP23-16 HEMATURIA IN PRACTICE: LEVERAGING TELEMEDICINE TO EVALUATE 2020 AUA GUIDELINE FEASIBILITY IN THE SAFETY NET

You have accessJournal of UrologyHealth Services Research: Practice Patterns, Quality of Life and Shared Decision Making III (MP23)1 Sep 2021MP23-16 HEMATURIA IN PRACTICE: LEVERAGING TELEMEDICINE TO EVALUATE 2020 AUA GUIDELINE FEASIBILITY IN THE SAFETY NET Desiree Sanchez, Josiah Low, Alvin Kwong, Waheed Baqai, Sajid Ahmed, and Stanley Frencher Desiree SanchezDesiree Sanchez More articles by this author , Josiah LowJosiah Low More articles by this author , Alvin KwongAlvin Kwong More articles by this author , Waheed BaqaiWaheed Baqai More articles by this author , Sajid AhmedSajid Ahmed More articles by this author , and Stanley FrencherStanley Frencher More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002014.16AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Hematuria can portend urologic malignancy but often does not receive complete evaluation, particularly in underserved settings. Safety net populations face resource limitations that may impede evaluation. Telemedicine services like electronic consultation (eConsult) increase urologic access by enabling asynchronous web-based consults and patient co-management between primary care providers and urologists. Using eConsult data, we evaluated patterns of hematuria and assessed feasibility of the new 2020 AUA microhematuria guidelines in California’s largest community-based Medicaid network, the Inland Empire Health Plan (IEHP). METHODS: We performed a retrospective chart review of all IEHP hematuria eConsults. Rates of documented imaging types (ultrasound (US), CT urogram (CTU), other cross sectional imaging) were calculated. Those with sufficient data capture were assigned a risk level per the new 2020 guidelines. Feasibility of guideline-based risk stratified management pathway was assessed according to differences in US and CTU received. Chi-square and Wilcoxon rank-sum tests were used to compare categorical and continuous variables respectively. RESULTS: There were 106 hematuria eConsults from 5/2018-8/2020. See table for demographics. Thirty (28%) patients had a documented US, 3 (3%) had both US and CTU, and 61 (58%) had neither; the difference was significant (p=0.009). Twelve (11%) had other cross sectional imaging. More low/intermediate-risk patients received renal US and CTU than high risk patients, 55.6% and 11.1% versus 26.7% and 3.3%, respectively; these differences were not statistically significant. Whether imaging was obtained and documented did not differ between physician versus midlevel, p=0.422. CONCLUSIONS: An eConsult system reveals that past AUA guidelines dictating universal CTU rarely translated to real life imaging in a diverse community Medicaid setting, whereas the risk stratification and associated imaging (US or CTU) adopted by the new 2020 guidelines more realistically aligns with imaging availability in this population. The large gap between those high risk patients without indicated CTU and those who actually receive it represents a key opportunity for reducing morbidity and mortality for safety net patients. Source of Funding: H&H Lee Surgical Research Grant © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e408-e408 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Desiree Sanchez More articles by this author Josiah Low More articles by this author Alvin Kwong More articles by this author Waheed Baqai More articles by this author Sajid Ahmed More articles by this author Stanley Frencher More articles by this author Expand All Advertisement Loading ...

The Development and Implementation of a Novel Electronic Consult System by a Laboratory Medicine Service: Experience From the First 2 Years of Use.

A novel electronic consult (e-consult) system for a pathology and laboratory medicine service (PLMS) was implemented in 2015 at a high-complexity Veterans Administration health care facility. Consults were previously made through direct provider communication without documentation in the medical record. To evaluate the utilization trends of the laboratory e-consult system at the Department of Veterans Affairs Connecticut facility during the first 2 years since inception. E-consultation involves pathology and laboratory medicine resident review followed by attending pathologist review and cosignature. E-consults to the pathology and laboratory medicine service from 2015 to 2017 were reviewed to record type of consult, requesting department, patient location, and turnaround time. The pathology and laboratory medicine service received 351 e-consults from 2015 to 2017. The volume varied by subsection: hematology and coagulation (215 of 351; 61%), chemistry (109 of 351; 31%), blood bank (19 of 351; 6%), and microbiology/virology (8 of 351; 2%). Hematology and coagulation consults were entirely for peripheral blood smear review (215 of 215; 100%). Chemistry consults were placed for toxicology/drugs of abuse (81 of 109; 74%), test utilization (17 of 109; 16%), or nontoxicology (11 of 109; 10%). Three services placed the majority of consults: primary care (279 of 351; 80%), hematology/oncology (39 of 351; 11%), and psychiatry (27 of 351; 8%). The median turnaround time for completion of e-consults was 1.2 days. Since e-consult implementation, the mean number of consults increased from 8.6/mo in 2015 to 18.1/mo in 2017, peaking in the last quarter of analysis in 2017 with a mean of 25.3 consults/mo. This novel e-consult system improved accessibility to and documentation of answers to laboratory questions and increased the visibility of the pathology and laboratory medicine service. Future goals include development of outcomes-based measures to better assess the clinical impact of e-consults.

MP02-01 IMPLEMENTATION OF A UROLOGY E-CONSULT SERVICE AT A SAFETY NET COUNTY HOSPITAL

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Practice Patterns, Quality of Life and Shared Decision Making I (MP02)1 Apr 2020MP02-01 IMPLEMENTATION OF A UROLOGY E-CONSULT SERVICE AT A SAFETY NET COUNTY HOSPITAL Nathan Chertack*, Yair Lotan, Christian Mayorga, and Ryan Mauck Nathan Chertack*Nathan Chertack* More articles by this author , Yair LotanYair Lotan More articles by this author , Christian MayorgaChristian Mayorga More articles by this author , and Ryan MauckRyan Mauck More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000816.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: To assess the implementation of an e-consult service at a urology clinic in a safety net county hospital. METHODS: An e-consult system was introduced in 2018 at our institution. All e-consults for 2018 were collected and data analyzed. Patient demographics were recorded. Total consults, clinic referrals, cystoscopy referrals, need to reschedule, and need for follow-up were compared. Time from referral to in-person clinic visit was collected. Reason for e-consult and final visit diagnosis were placed into urologic categories and subcategories. RESULTS: In 2018, 472 e-consults were received for 454 patients. The majority were men (62.3%) with a median age of 55 years (IQR 44-63). The majority (52%) were Hispanic. Most patients (69.1%) were scheduled for an in-person clinic visit, with 23.9% of these patients scheduled for a cystoscopy. Median time from referral to in-person clinic visit was 39.5 days (IQR 33-50). One-fourth of patients did not require further follow-up after initial consultation. The majority of e-consults were for hematuria (24%), renal pathologies (20%), and benign prostatic hyperplasia and lower urinary tract symptoms (17%). CONCLUSIONS: Implementation of a urology e-consult service is feasible and decreases need for in-person clinic visits. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e11-e11 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nathan Chertack* More articles by this author Yair Lotan More articles by this author Christian Mayorga More articles by this author Ryan Mauck More articles by this author Expand All Advertisement PDF downloadLoading ...

Implementation of a Urology E-Consult Service at a Safety Net County Hospital.

We assess the implementation of an e-consult service at a urology clinic in a safety net county hospital. An e-consult system was introduced in 2018 at our institution. All e-consults for January to December 2018 were collected and data analyzed. Patient demographics were recorded. Total consults, clinic referrals, cystoscopy referrals, need to reschedule and need for followup were compared. Time from referral to in-person clinic visit was collected. Reason for e-consult and final visit diagnosis were placed into urological categories and subcategories. In 2018 472 e-consults were received for 454 patients. The majority were men (62.3%) with a median age of 55 years (IQR 44-63). The majority (52%) were Hispanic. Most patients (69.1%) were scheduled for an in-person clinic visit with 23.9% of these patients scheduled for a cystoscopy. Median time from referral to in-person clinic visit was 39.5 days (IQR 33-50). A quarter of the patients did not require further followup after initial in-person consultation. The majority of e-consults were for hematuria (24%), renal pathologies (20%), and benign prostatic hyperplasia and lower urinary tract symptoms (17%). Implementation of a urology e-consult service is feasible and decreases need for in-person clinic visits.

Classifying Electronic Consults for Triage Status and Question Type.

Electronic consult (eConsult) systems allow specialists more flexibility to respond to referrals more efficiently, thereby increasing access in under-resourced healthcare settings like safety net systems. Understanding the usage patterns of eConsult system is an important part of improving specialist efficiency. In this work, we develop and apply classifiers to a dataset of eConsult questions from primary care providers to specialists, classifying the messages for how they were triaged by the specialist office, and the underlying type of clinical question posed by the primary care provider. We show that pre-trained transformer models are strong baselines, with improving performance from domain-specific training and shared representations.

Protocol: Improving Access to Specialist Nephrology Care Among Rural/Remote Dwellers of Alberta: The Role of Electronic Consultation in Improving Care for Patients With Chronic Kidney Disease.

Background:As the burden of chronic kidney disease (CKD) continues to increase, many geographically dispersed Canadians have limited access to specialist nephrology care, which tends to be centralized in major urban areas. As a result, many rural/remote-dwellers in Canada experience poor quality of care and related adverse outcomes. It is imperative to develop alternative care delivery mechanisms to ensure optimal health outcomes for all Canadians.Objective:To investigate the feasibility and effectiveness of electronic consultation (eConsult) as a new model for interactions between specialists and primary care providers (PCPs) to improve access to care for patients with CKD.Design:This is a sequential, mixed methods study that will be conducted in 3 phases.Setting:The study will be conducted across the entire province of Alberta, supported by Alberta Kidney Care (formerly, Northern and Southern Alberta Renal Programs [NARP/SARP]).Patients:Patients suffering from CKD will be included in the study.Measurements:We will assess the barriers and enablers of implementation and adoption of an e-consultation protocol to facilitate access to care for patients with CKD in Alberta with a focus on rural/remote-dwellers with CKD. We will also evaluate the impact of the eConsult system (eg, improved access to specialist care, reduction in care gaps), assess the feasibility of province-wide implementation, and compare eConsult with practice facilitation versus eConsult alone in terms of access to specialist care, quality of care, and related outcomes.Methods:The study will be conducted in 3 phases. In phase 1, we will assess the perceptions of stakeholders (ie, PCPs, nephrologists, patients, policymakers, and other care providers) to improve CKD care delivery, quality, and outcomes in Alberta with focus groups and semistructured interviews. Phase 2 will engage specific family physicians for their input on key factors and logistical issues affecting the feasibility of implementing eConsult for the care of patients with CKD. Phase 3 will provide academic detailing including practice facilitation to clinics in Alberta to assess how eConsult with practice facilitation compares with eConsult alone in terms of access to specialist care, quality of care, and related outcomes.Results:We will assess stakeholder perceptions about potential barriers to and enablers of a new eConsult and decision support system strategy, focusing on elements that are most important for the design of a feasible and implementable intervention. We will develop, pilot test, and assess the impact of the eConsult model in improving access to specialist nephrology care and the feasibility of province-wide implementation. The final phase of the project will address key challenges for optimal care for patients with CKD living in rural, remote, and underserved areas of Alberta, particularly timely referral and disease management as well as the cost-effective benefits of eConsult.Limitations:Lack of high-speed Internet in many rural and remote areas of Alberta may lead to more time spent in completing the eConsult request online versus faxing a referral the traditional way. Allied health care staff (referral coordinators, administrative staff) require training to the eConsult system, and physicians at many remote sites do not have adequate staff to handle eConsult as an added task.Conclusions:Implementation of eConsult can favorably influence referral patterns, access to care, care quality, patient outcomes, and health care costs for people with CKD. Results of this study will inform the optimization of care for rural/remote-dwellers with CKD and will facilitate future partnerships with policymakers and provincial renal programs in Alberta to ensure optimal kidney health for all residents.Trial registration:Not required.

Implementation of an EConsult System with Patient Navigation.

Community and academic partners in New Haven, Connecticut designed and implemented a system whereby patients with Medicaid insurance at a community health center received electronic specialty consultation from academic medical center physicians as well as navigation to follow-up tests and face-to-face appointments. Specialty access was improved, but some patients reported being burdened by a lack of coordination for their overall care.

The Development and Implementation of a Novel Electronic Consult (E-Consult) System by a Laboratory Medicine Service: Experience From the First 2 Years of Use

The Development and Implementation of a Novel Electronic Consult (E-Consult) System by a Laboratory Medicine Service: Experience From the First 2 Years of Use

Primary Care Practitioners’ Perceptions of Electronic Consult Systems

Safety-net health systems across the country are implementing electronic consult (eConsult) systems in which primary care practitioners (PCPs) submit all requests for specialty assistance electronically to be reviewed and discussed with specialists. Evidence suggests that eConsult systems can make significant improvements in specialty access, but the outcomes of these systems for frontline PCPs is poorly understood. To understand PCP perceptions of the results of eConsult initiation on PCP workflow, specialist access, and patient care. Qualitative interviews were conducted from December 1, 2016, to April 15, 2017, with 40 safety-net PCPs in Los Angeles County who use the Los Angeles County Department of Health Services (DHS) eConsult system. Interviewees were recruited to include diversity in PCP type, practice setting, and employer (DHS employed vs DHS affiliated). Participants were interviewed about their perceptions of clinical workflow, access to specialists, relationships with specialists, and referral decision making. Perceptions of the results of eConsult, including positive and negative themes and remaining perceived gaps in specialty care. Of the 40 participants, 27 (68%) were women; 24 (60%) PCPs performed 5 or more eConsults per week. Primary care practitioners' perceptions of eConsult clustered around 4 main themes: access and timeliness of specialty care, shift of work to PCPs, relationships with specialists, and eConsult interface issues. Many PCPs praised the improved timeliness of specialist input with eConsult, as well as the added clinical and educational value of dialogue with specialists, particularly compared with the limitations of the prior referral process. However, PCPs also consistently perceived that eConsult shifted some of the work of specialty care to them. Many PCPs believed that this extra burden was worth the effort given the benefits of eConsult, such as improved timeliness of care and ability to manage specialty conditions. In contrast, others were frustrated by the increased administrative burden, broadened clinical responsibility, and restructuring of specialty care delivery. While associated with improved specialty care access, eConsult systems simultaneously created new challenges for PCPs, such as an increased burden of work in providing specialty care. Primary care practitioners varied in their enthusiasm for these workflow changes with diverging perceptions of the same processes. Our findings provide insights on challenges future primary care transformation efforts may face.

PD52-07 BUILDING ACCESS TO UROLOGY SPECIALIST CARE THROUGH E-CONSULTATION IN MEDICALLY UNDERSERVED PATIENTS IN AREAS OF TENSION AND CONFLICT

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Practice Patterns, Quality of Life & Shared Decision Making III1 Apr 2018PD52-07 BUILDING ACCESS TO UROLOGY SPECIALIST CARE THROUGH E-CONSULTATION IN MEDICALLY UNDERSERVED PATIENTS IN AREAS OF TENSION AND CONFLICT Sataa Sallami, Sana Abou El Makarim, Anwar Chalbak, Abdelwahab Abou Soua, and Ali Massoud Jornaz Sataa SallamiSataa Sallami More articles by this author , Sana Abou El MakarimSana Abou El Makarim More articles by this author , Anwar ChalbakAnwar Chalbak More articles by this author , Abdelwahab Abou SouaAbdelwahab Abou Soua More articles by this author , and Ali Massoud JornazAli Massoud Jornaz More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.2359AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Since the «official» end of the civil war, Libya is in total anarchy. The roads are cut off and the militias enforce their laws. The western region of Libya (Nafusa mountains)is often cut off from the capital and other major cities and Tunisian borders are also often closed. The civilian population was then in a deadly trap. One of the common public health problems were urological affections, thus urological care was urgent and mandatory. For all these reasons, we developed an e-consultation system between three PCPs in this region and an urologist surgeon in the north of Tunisia. This system was based on a secure web-based means, as an alternative to direct consultations. In this study we evaluated the use of an "ask-the-expert" e-consultation service in order to assess whether the service is efficient and useful. METHODS We prospectively collected all e-consultations submitted from April 2016 to October 2017 from 3 community health centers with mainly medically underserved patients. Collected data included number of e-consultations submitted, patient′s epidemiological data, specialist response, and time required for the specialist to complete the e-consultation. Perceived benefit to the PCPs and their patients and impact on care delivery were analyzed. RESULTS Three PCPs participated in the study, had referred a total of 390 patients. They were 247 men and 143 women. Their ages range from 3 months to 91 years. They were children (≤10 years old) in 51 cases. The total number of e-consultations was 747 (1 to 5 by patient). The percentage of e-consult patients grew by ≈ 22% every 6 months. The specialist provided an answer without requesting further information in 28,7% of cases, with ≥90% of cases taking ≤15 min for the specialist to complete. Eighty-nine percent of cases were answered within 48 hours. The service was perceived as highly beneficial to providers and patients in 75,9% of patients / parents. The e-consult rate was highest in benign prostatic hypertrophy (20%), urolithiasis (19,5 %), and urinary infection (13,3%). Only 18,4% of the referrals (n=72) had required face-to-face visit and follow-up. Of them, 11 underwent complementary explorations (cystoscopy, prostatic biopsy) or surgical intervention. For e-consult patients, the average potential miles needed to travel was 195.1 miles (148 - 430) per patient. The mean travel reimbursement cost was 144 dollars per patient with a total of 107.568 dollars. CONCLUSIONS The present study showed high levels of satisfaction of e-consultation system, improvement in the access to specialist advice in a much more timely manner than the traditional referral-consultation process that may be impossible in areas of conflict. Moreover, e-consult system may decrease travel burden/ risks and direct travel costs for patients with avoidance of unnecessary specialist visits and investigations. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e983-e984 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Sataa Sallami More articles by this author Sana Abou El Makarim More articles by this author Anwar Chalbak More articles by this author Abdelwahab Abou Soua More articles by this author Ali Massoud Jornaz More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

A cohort study of a general surgery electronic consultation system: safety implications and impact on surgical yield

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.

Improving access to otolaryngology-head and neck surgery expert advice through eConsultations.

Prolonged wait times have become common. Electronic consultations (eConsults) have been shown in previous studies to reduce unnecessary face-to-face consultations to specialists, but no prior study has investigated the feasibility or efficacy of eConsults in an otolaryngology-head and neck surgery (OTO-HNS) practice. Prospective observational study. The Champlain BASE eConsult system is a secure web portal allowing primary care physicians (PCPs) to communicate asynchronously with specialists about a patient, without requiring a formal face-to-face consult. The data from all eConsults sent through this portal to OTO-HNS practices between July 2011 and January 2015 were collected and analyzed. Response time was rapid; over 40% of eConsults received a response within 24 hours, and nearly all eConsults were answered within 7 calendar days. The median response time was nearly 29 times faster than traditional face-to-face consultation. Unnecessary face-to-face referrals were avoided in 33.4% of all eConsults, and in nearly 50% of cases where the PCP initially planned a formal referral. PCPs reported adopting a new or additional course of action over 50% of the time following an eConsult. Eighty-eight percent of PCPs reported the service to be valuable for their patients, and 92% found it valuable for themselves. eConsults require only a limited time commitment from specialists, with over 75% taking less than 10 minutes to complete. eConsultation is a cost-effective system that can lead to decreased wait times, improved communication between PCPs and otolaryngologists, and help guide the development of targeted continuing professional development modules for PCPs. 4. Laryngoscope, 128:350-355, 2018.